AHH联合CLCVP在脊柱后路手术中应用的安全性和有效性

Safety and efficacy of acute hypervolemic hemodilution combined with controlled low central venous pressure in posterior spinal surgery

目的探讨急性高容量血液稀释(AHH)联合控制性低中心静脉压(CLCVP)在脊柱后路手术中应用的安全性和有效性。方法选取2021年2月至2022年1月该院收治的择期行脊柱后路手术患者60例,均为美国麻醉医师协会分级Ⅰ~Ⅱ级。采用随机数字表法分为C组(AHH联合CLCVP)和F组(常规输液),每组30例。2组患者入室后均在局部麻醉下行桡动脉穿刺置管监测有创动脉压及中心静脉穿刺置管行中心静脉压(CVP)监测。常规麻醉诱导,采用CLCVP麻醉技术管理围手术期输液及用药。记录2组患者输液量、出血量、尿量、输血量、手术时间、硝酸甘油用量等,以及麻醉诱导前(T_(0))、切皮开始时(T_(1))、手术开始后2 h(T_(2))、创面完全止血完成时(T_(3))、手术结束30 min时(T_(4))、术后第1天(T_(5))各时间点平均动脉压、心率、脉搏血氧饱和度、血红蛋白(Hb)、血细胞比容(Hct)和CVP、血糖、血乳酸、血凝指标[包括凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原和血小板计数]、血气分析[包括pH、二氧化碳分压、氧分压、动脉血氧饱和度和碱剩余(BE)],以及围手术期不良反应、并发症发生情况,苏醒期steward评分等。结果C组患者手术时间短于F组,硝酸甘油用量高于F组,但差异均无统计学意义(P>0.05);C组患者输液量、尿量均明显高于F组,出血量、血浆、悬浮红细胞均明显少于F组,差异均有统计学意义(P<0.05)。与T_(0)时比较,2组患者T_(1)~T_(3)时平均动脉压均明显降低,心率均明显减慢,C组患者T_(1)~T_(4)时Hb、Hct均明显降低,T_(1)~T_(3)时CVP、血小板计数均明显降低,PT、APTT均明显延长,F组患者T_(2)~T_(5)时Hb均明显降低,T_(3)~T_(4)时Hct均明显降低,差异均有统计学意义(P<0.05)。与F组比较,C组患者T_(1)时Hb明显降低,T_(5)时Hb明显增加,T_(1)时Hct、T_(1)~T_(3)时CVP均明显降低,T_(1)~T_(3)时PT、APTT均明显延长,差异均有统计学意义(P<0.05)。2组患者围手术期不良反应、并发症发生情况及苏醒期steward评分比较,差异均无统计学意义(P>0.05)。结论AHH联合CLCVP可安全用于脊柱后路手术,具有良好的血液保护效应,能显著减少术中出血量及异体输血量,术中维持血流动力学平稳及内环境稳定,苏醒期平稳,不会增加围手术期不良反应及并发症发生率,同时,CLCVP有利于提供清晰的手术视野,缩短手术时间。

Objective To investigate the safety and efficacy of acute hypervolemic hemodilution(AHH)combined with controlled low central venous pressure(CLCVP)in posterior spinal surgery.Methods From February 2021 to January 2022,a total of 60 patients who underwent elective posterior spinal surgery in this hospital were selected,and the American Association of Anesthesiologists classified them as GradeⅠ-Ⅱ.They were randomly divided into group C(AHH combined with CLCVP)and group F(routine infusion),with 30 cases in each group using the randomized numerical table method.After entering the room,the patients in both groups were monitored by radial artery puncture and central venous puncture(CVP)under local anesthesia.Routine anesthesia was induced,and perioperative infusions and medications were managed using CLCVP anesthesia techniques.The infusion volume,bleeding volume,urine volume,blood transfusion volume,operation time and nitroglycerin dosage of the two groups were recorded.And the mean arterial pressure(MAP),heart rate(HR),pulse oxygen saturation(SpO 2),hemoglobin(Hb),hematocrit(Hct),CVP,blood glucose,blood lactate,Hemagglutination indexes[including prothrombin time(PT),activated partial thromboplastin time(APTT),fibrinogen(Fg)and platelet count(Plt)],blood gas analysis[including pH,partial pressure of carbon dioxide(PCO_(2)),partial pressure of oxygen(PO 2),arterial oxygen saturation(SaO 2)and alkali residue(BE)]at each time point before anesthesia induction(T_(0)),at the beginning of skin incision(T_(1)),at the beginning of operation(T_(2)),at the end of operation(T_(3)),at the end of operation(T_(4))and at the first day after operation(T_(5))were recorded.Perioperative adverse reactions,complications and steward score during recovery also were recorded.Results The operation time in group C was shorter than that in group F and the dosage of nitroglycerin was higher than that in group F,but the differences were not statistically significant(P>0.05).The infusion volume and urine volume in group C were significantly higher than those in group F,and the bleeding volume,plasma and suspended red blood cells were significantly lower than those in group F,with statistical significances(P<0.05).Compared with T_(0),the average arterial pressure and heart rate in the two groups were significantly decreased from T_(1)to T_(3),the Hb and Hct in group C were significantly decreased from T_(1)to T_(4),the CVP and platelet count were significantly decreased,and the PT and APTT were significantly prolonged from T_(1)to T_(3).The Hb in group F was significantly decreased from T_(2)to T_(5),and the Hct was significantly decreased from T_(3)to T_(4),with statistical significances(P<0.05).Compared with group F,the Hb in group C decreased significantly at T_(1),increased significantly at T_(5),the Hct at T_(1),CVP decreased significantly from T_(1)to T_(3),the PT and APTT prolonged significantly from T_(1)to T_(3),with statistical significances(P<0.05).There were no significant differences in perioperative adverse reactions,complications and steward score between the two groups(P>0.05).Conclusion AHH combined with CLCVP can be safely used in posterior spinal surgery which has a good blood protection effect.It can significantly reduce the amount of intraoperative bleeding and allogeneic blood transfusion,maintain the stability of hemodynamics and internal environment during operation,and keep stable recovery period,without increasing perioperative adverse reactions and complications.At the same time,CLCVP is conducive to providing a clear surgical field and shorten the operation time.