不同液体复苏对低血容量性休克患者肾及凝血功能的影响

Impacts of fluid resuscitation regimens on renal and coagulation function in patients with hypovolemic shock

目的:探讨不同液体复苏对低血容量性休克患者肾及凝血功能的影响。方法:将295例术后8 h内出现低血容量性休克的患者随机分为3组:平衡液组(醋酸林格液)、0.9%氯化钠溶液组、6%羟乙基淀粉氯化钠(HES) 130/0.4组。结果:羟乙基淀粉组AKI发病率(12.5%)相较于生理盐水(7.3%)、醋酸林格组(6.3%)有升高趋势,但差异无统计学意义(P>0.05);其中泌尿外科患者AKI发病率(11.1%)相较于肝胆外科(5.6%)、胃肠外科(6.5%)及其他科室(7.7%)升高(P<0.05);泌尿外科患者中,羟乙基淀粉组AKI发生率(17.5%)相较于生理盐水组(8.9%)、醋酸林格组(8%)升高(P<0.05);羟乙基淀粉组凝血功能示:入室6 h时APTT与0 h(入室时)、24 h相较均有显著延长,有统计学差异,(P<0.05);入室6 h及24 h时DD二聚体均较0 h(入室时)显著升高,有统计学差异,(P<0.05)。生理盐水组凝血功能示:入室24 h时PT与0 h(入室时)相较显著延长,有统计学差异(P<0.05);入室6 h羟乙基淀粉组PT与APTT均较醋酸林格组显著延长,有统计学差异,(P<0.05);入室6 h生理盐水组PT较醋酸林格组显著延长,有统计学差异,(P<0.05);入室6 h羟乙基淀粉组DD二聚体较醋酸林格组显著升高,有统计学差异,(P<0.05)。羟乙基淀粉组、醋酸林格、生理盐水组术后活动性出血率无统计学差异。结论:1.外科术后低血容量性休克患者使用羟乙基淀粉氯化钠溶液及生理盐水扩容补液,并未增加患者肾损害的风险;2.外科术后低血容量性休克患者使用羟乙基淀粉氯化钠溶液及生理盐水扩容补液对凝血功能有一定影响,但未导致术后出血风险增加;3.泌尿外科术后低血容量性休克患者急性肾损伤(AKI)风险较其他外科术后低血容量性休克患者高,且使用羟乙基淀粉溶液增加泌尿外科手术后低血容量性休克患者发生AKI的风险。

Objective:To investigate the impacts of fluid resuscitation regimens on renal and coagulation function in patients with hypovolemic shock.Methods:Included in this study were 295 patients with hypovolemic shock which occurred within 8 h after surgery,randomized into three groups:balanced solution group(Ringer’s acetate solution,RAS),0.9%sodium chloride(NS)group,and 6%hydroxyethyl starch(HES)sodium chloride130/0.4 group.Results:The incidence of AKI in the HES group(12.5%)appeared to be higher than those in the NS group(7.3%)and RAS group(6.3%),but the difference was not statistically significant(P>0.05).The incidence of AKI in patients after urological surgery(11.1%)was higher than those after hepatobiliary surgery(5.6%),gastrointestinal surgery(6.5%)and other surgeries(7.7%)(P<0.05).Among patients after urological surgery,the incidence of AKI with HES(17.5%)was higher than those with NS(8.9%)and RAS(8%)(P<0.05).Coagulation function test showed that:in the HES group,the 6 h APTT was significantly prolonged compared with 0 h(at the time of ICU admission)and 24 h APTT with statistical differences(P<0.05),and the 6 h and 24 h D-dimer levels were significantly higher than the 0 h D-dimer level with statistical differences(P<0.05);in the NS group,the 24 h PT was significantly prolonged compared with the 0 h PT with statistical difference(P<0.05).The 6 h PT and 6 h APTT in the HES group were significantly prolonged compared with those in the RAS group with statistical differences(P<0.05).The 6 h PT in the NS group was significantly prolonged compared with that in the RAS group with statistical difference(P<0.05).The 6 h D-dimer level in the HES group was significantly higher compared with the RAS group with statistical difference(P<0.05).There was no significant difference in the incidence of active bleeding among the HES,NS and RAS groups.Conclusion:1.Fluid replacement in hypovolemic shock after surgery using HES or NS does not increase the risk of renal impairment.2.Fluid replacement in hypovolemic shock after surgery using HES or NS may somehow interfere with the coagulation function but does not lead to increased risk of postoperative bleeding.3.The risk of AKI in patients with hypovolemic shock after urological surgery is higher compared with those after other surgeries;moreover,use of HES in patients with hypovolemic shock after urological surgery may be associated with higher risk of AKI.