腹膜后肿瘤切除术中大量输血患者围手术期凝血功能的管理

Management of perioperative coagulation dysfunction in patients with massive blood transfusion during retroperitoneal tumor resection

目的探讨腹膜后肿瘤切除术中大量输血患者围手术期凝血功能变化及管理。方法回顾性分析2016年1月至2021年12月收治于北京大学国际医院实施腹膜后肿瘤切除术24 h内输血超过20 U的47例患者的术前和术后第1、3、5天凝血功能变化情况,并对出血、输血及预后情况进行分析。结果47例患者术中出血3000~25800 ml,其中10例患者出血量≥10000 ml。术中输注红细胞(25.3±9.9)U,血浆(2720±1369)ml。术中6例患者输注血小板,平均为(2.4±3.3)U;45例患者术中补充白蛋白,平均为(79.5±46.5)g;47例患者术中补充纤维蛋白原,平均为(2.3±1.3)g;45例患者术中补充凝血酶原复合物,平均为(1205±807)U。术前患者血红蛋白与术毕、术后第1、3、5天血红蛋白相比差异均有统计学意义(W=1790,P<0.001;W=1672,P<0.001;W=1704,P<0.001;W=1486,P=0.004);术前患者血小板与术后第1、3、5天血小板相比差异均有统计学意义(W=2153,P<0.001;W=2092,P<0.001;W=1732,P<0.001);术前患者血清白蛋白与术后第1、3天血清白蛋白相比差异均有统计学意义(W=1568,P<0.001;W=1578,P<0.001,);术前患者血清纤维蛋白原与术后第1天血清纤维蛋白原相比差异有统计学意义(W=1964,P<0.001);患者术前PT、APTT正常,术后第1、3天PT、APTT延长,与术前相比差异均有统计学意义(W=628,P<0.001;W=804,P=0.023)(W=661,P<0.001;W=796,P=0.02)。患者术前血清纤维蛋白降解产物和D-二聚体高于正常值范围,术后第3、5天与术前相比均增高(W=498,P<0.001;W=345,P<0.001)。结论腹膜后肿瘤手术大量输血患者在围手术期会发生凝血功能紊乱,实施大量输血方案时应考虑患者具体情况,至少在术后1~3 d定时监测患者的凝血功能以及血小板计数,进行有效干预,避免出现严重凝血功能障碍。

Objective To investigate the perioperative alterations and management of coagulation function in patients of massive blood transfusion during retroperitoneal tumor(RT)resection.Methods Fourty-seven RT patients at Peking University International Hospital from Jan 2016 to Dec 2021 undergoing resection with massive blood transfusion more than 20 U within 24 h were reviewed for coagulation function before and after surgery.Results Intraoperative bleeding was 3000-25800 ml,10 patients had blood loss≥10000 ml.During the operation,(25.3±9.9)U of red blood cells were transfused,(2720±1369)ml plasma transfused,and(2.4±3.3)U platelets were transfused in 6 patients.Fourty-five patients received intraoperative albumin of(79.5±46.5)g;All 47 patients received fibrinogen of(2.3±1.3)g;Prothrombin complex was given in 45 patients(1205±807)U.Preoperative hemoglobin was statistically different compared to postoperatively and days 1,3 and 5(W=1790,P<0.001;W=1672,P<0.001;W=1704,P<0.001;W=1486,P=0.004);As with platelets,the difference was also statistically significant compared to postoperative days 1,3,and 5(W=2153,P<0.001;W=2092,P<0.001;W=1732,P<0.001);Preoperative albumin was different compared to postoperative days 1 and 3(W=1568,P<0.001;W=1578,P<0.001,);Preoperative fibrinogen was different compared to postoperative day 1(W=1964,P<0.001).PT and APTT were prolonged on postoperative days 1 and 3(W=628,P<0.001,W=804,P=0.023)(W=661,P<0.001,W=796,P=0.02).Patient's preoperative fibrin degradation products and D-dimer were above the normal value and were higher on postoperative days 3 and 5(W=498,P<0.001,W=345,P<0.001).Conclusions Coagulation disorders occur perioperatively in patients with massive transfusion while undergoing surgery for RT.The implementation of ratiional transfusion strategy and close postoperative survey and management of coagulation dysfunction help avoid the coagulation related morbidities.