Effects of Acute Normovolemic Hemodilution on Perioperative Coagulation and Fibrinolysis in Elderly Patients Undergoing Hepatic Carcinectomy

Objective To observe the effects of acute normovolemic hemodilution （ANH） on coagulation function and fibrinolysis in elderly patients undergoing hepatic carcinectomy. Methods Thirty elderly patients （aged 60-70 years） with liver cancer （American Society of Anesthesiologists physical status I-II） scheduled for hepatic carcinectomy from February 2007 to February 2008 were randomly divided into ANH group （n= 15） and control group （n= 15）. After tracheal intubation, patients in ANH group and control group were infused with 6% hydroxyethyl starch （HES） （130/0.4）, and basic liquid containing 6% HES and routine Ringer＇s solution, respectively. In all the studied patients, blood samples were drawn at five different time points： before anesthesia induction （T1）, 30 minutes after ANH （T2）, 1 hour after start of operation （T3）, immediately after operation （T4）, and 24 hours after operation （Ts）. Then co- agulation function, soluble fibrin monomer complex （SFMC）, prothrombin fragment （F1＋2）, and platelet membrane glycoprotein （activated GPIIb/GPIIIa and P-selectin） were measured. Results The perioperative blood loss was not significantly different between the two groups （P〉 0.05）. The volume of allogeneic blood transfusion in ANH group was significantly smaller than that in control group （350.5±70.7 mL vs. 457.8±181.3 mL, P〈0.01）. Compared with the data ofT1, prothrombin time （PT） and activated partial thromboplastin time in both groups prolonged significantly after T3 （P〈0.05）, but still within normal range. There were no significant changes in thrombin time and D-dimer between the two groups and between different time points in each group （all P〉0.05）. SFMC and F1 ＋2 increased in both groups, but without statistical significance. P-selectin expression on the platelet surface of ANH group was significantly lowered atT2 andT3 compared with the level atT1 （P〈 0.05）. Compared with control group, P-selectin was sig-nificantly lower in ANH group atT2-T3 （all P〈0.05）. Conclusions In elderly patients undergoing resection of liver cancer, ANH may not hamper fibri- nolvsis and coagulation function. It coukt therefore be safe to largely reduce allogeneic blood transfusion.

Dynamics of vascular volume and hemodilution of lactated Ringer’s solution in patients during induction of general and epidural anesthesia

Objective： To investigate the dynamics of vascular volume and the plasma dilution of lactated Ringer＇s solution in patients during the induction of general and epidural anesthesia. Methods： The hemodilution of i.v. infusion of 1000 ml of lactated Ringer＇s solution over 60 min was studied in patients undergoing general （n=31） and epidural （n= 22） anesthesia. Heart rate, arterial blood pressure and hemoglobin （Hb） concentration were measured every 5 rain during the study. Surgery was not started until the study period had been completed. Results： General anesthesia caused the greater decrease of mean arterial blood pressure （MAP） （mean 15% versus 9%; P〈0.01） and thereby followed by a more pronounced plasma dilution, blood volume expansion （VE） and blood volume expansion efficiency （VEE）. A strong linear correlation between hemodilution and the reduction in MAP （r=-0.50;P〈0.01） was found. At the end of infusion, patients undergoing general anesthesia retained 47% （SD 19%） of the infused fluid in the circulation, while epidural anesthesia retained 29% （SD 13%） （P〈0.001）. Correspondingly, a fewer urine output （mean 89 ml versus 156 ml; P〈0.05） and extravascular expansion （454 ml versus 551 ml; P〈0.05） were found during general anesthesia. Conclusion： We concluded that the induction of general anesthesia caused more hemodilution, volume expansion and volume expansion efficiency than epidural anesthesia, which was triggered only by the lower MAP.

Effects of different plasma expanders on rats subjected to severe acute normovolemic hemodilution

Background:Plasma expanders are widely used for acute normovolemic hemodilution(ANH).However,existing studies have not focused on large-volume infusion with colloidal plasma expanders,and there is a lack of studies that compare the effects of different plasma expanders.Methods:The viscosity,hydrodynamic radius(Rh)and colloid osmotic pressure(COP)of plasma expanders were determined by a cone-plate viscometer,Zetasizer and cut-off membrane,respectively.Sixty male rats were randomized into five groups with Gelofusine(Gel),Hydroxyethyl Starch 200/0.5(HES200),Hydroxyethyl Starch 130/0.4(HES130),Hydroxyethyl Starch 40(HES40),and Dextran 40(Dex40),with 12 rats used in each group to build the ANH model.ANH was performed by the withdrawal of blood and simultaneous infusion of plasma expanders.Acid-base,lactate,blood gas and physiological parameters were detected.Results:Gel had a lower intrinsic viscosity than HES200 and HES130(P<0.01),but at a low shear rate in a mixture of colloids,red cells and plasma,Gel had a higher viscosity(P<0.05 or P<0.01,respectively).For hydroxyethyl starch plasma expanders,the COP at a certain concentration decreases from 11.1 mmHg to 6.1 mmHg with the increase of Rh from 10.7 nm to 20.2 nm.A severe ANH model,with the hematocrit of 40%of the baseline level,was established and accompanied by disturbances in acid-base,lactate and blood gas parameters.At the end of ANH and 60 min afterward,the Dex40 group showed a worse outcome in maintaining the acid-base balance and systemic oxygenation compared to the other groups.The systolic blood pressure(SBP),diastolic blood pressure(DBP),and mean arterial pressure(MAP)decreased significantly in all groups at the end of ANH.The DBP and MAP in the Dex40 group further decreased 60 min after the end of ANH.During the process of ANH,the Dex40 group showed a drop and recovery in SBP,DBP and MAP.The DBP and MAP in the HES200 group were significantly higher than those in the other groups at some time points(P<0.05 or P<0.01).Conclusions:Gel had a low intrinsic viscosity but may increase the whole blood viscosity at low shear rates.Rh and COP showed a strong correlation among hydroxyethyl starch plasma expanders.Dex40 showed a worse outcome in maintaining the acid-base balance and systemic oxygenation compared to the other plasma expanders.During the process of ANH,Dex40 displayed a V-shaped recovery pattern for blood pressure,and HES200 had the advantage in sustaining the DBP and MAP at some time points.

Acute Normovolemic Hemodilution: A Practical Approach

Justifications: Perioperative allogeneic blood transfusion can be reduced or even completely avoided by using a set of different strategies: meticulous hemostasis, the use of pharmaceutical agents that assist in the process of coagulation/ fibrinolysis, the use of blood substitutes, induced hypotension, preoperative autologous blood donation, collection and reinfusion of autologous blood during the operation, as well as from acute normovolemic hemodilution (ANH). Contents: ANH consists of taking a percentage of the patient’s blood volume and a concurrent infusion of acellular fluids in order to maintain normovolemia. As a consequence, a hemodiluted patient will lose less blood cells for each blood volume that is lost during the surgical procedure. The aim of this study is to clarify doubts and provide practical information relative to the procedure of ANH through the author’s own experiences as well as literary examples. Conclusions: ANH is an easy and cheap technique performed during the intraoperative period useful to reduce the use of hemoderivatives.

Evaluation of modified hemodilution combined therapy in the treatment of acute ischemic stroke in the elderly

BACKGROUND： Thrombolysis therapy is not suitable for the elderly patients with acute ischemic stroke who delayed to be diagnosed for more than 3 hours, but traditional medicine is also not very ideal. OBJECTIVE： To observe the clinical therapeutic effect of modified hemodilution combined therapy applied in elderly patients with acute cerebral thrombosis and analyze the mechanism of this therapeutic method. DESIGN： 1：1 paired grouping according to gender and controlled observation SETTING： Department of Internal Medicine, Chengzhanyuan District, First Hospital Affiliated to Zhejiang University. PARTICIPANTS： Totally 90 elderly patients with acute ischemic stroke who received the treatment in the Cadre Ward and Mental Ward, Department of Internal Medicine, Chengzhanyuan District, First Hospital Affiliated to Zhejiang University from March 1996 to June 2004 were recruited. They all met the diagnosis criteria revised by the Fourth Academic Conference of National Cerebrovascular Diseases in 1995 and were diagnosed as acute ischemic stroke by skull CT. They were informed of therapeutic plan and detected items. According to 1：1 paired principle in gender, 90 enrolled patients were assigned into treated group （n=45） and control group （n=45）. There were 39 male and 6 female in the treatment group, and they were aged （76±6）years, ranging from 71 to 84 years, and hospitalized at the 14^th to 76^th hours after onset. There were 39 male and 6 female in the control group, and they were aged （76±6）years , ranging from 70 to 82 years, and hospitalized at the 16^th to 72^th hours after onset. METHODS： Therapeutic method： Patients of treated group received modified hemodilution combined therapy. 200 mL whole blood of patients was exchanged with 500 mL dextran-40 （including 20 mL danshen parenteral solution and 32 mg heparin） at the beginning of therapy; From the 2^nd day, compound huangqi tea bag （Huangqi mainly, including danshen, honghua, chuanxiong, shishao and a little acetyl salicylic acid） was made, twice a day, 1 bag once. At the same time, the above-mentioned dextran-40 liquid of 500 mL was intravenously injected, once a day, 14 days in total; On the 6^th day after therapy, the above-mentioned aseptic autoblood stored in refrigerator at 4℃ was transfused back into the patients following pre-treatment of high-concentration oxygenation and ultraviolet irradiation by light quantum instrument. Patients of control group were intravenously injected of 0.4 g venoruton（Traditional Chinese medicine compound parenteral solution for promoting blood circulation and removing blood stasis ） and 50 g/L glucose of 500 mL, 75 mg acetosal was taken orally, once a day, 14 days in total. ② Measurement and observation of index： Blood coagulation index, change of platelet aggregation rate and change of hemorrheology of patients in two groups were monitored before and after therapy. The level of blood lipid of patients in two groups was measured with American Beckman automatic biochemistry analyzer. Blood flow rate of middle cerebral artery of resting electrocardiogram were measured with American HP SONOS 2500 sonoscope. Neuro-dysfunction score revised in the national conference （1995） was used to evaluate the recovery of neurological function of the patients in two groups at the 3rd, 5^th, 7^th and 14^th days after therapy. ③Therapeutic effect and adverse effect were observed at the same time. MAIN OUTCOME MEASURES ： ① Changes of coagulation index, blood lipid level and hemorheology; ② Blood flow rate of middle cerebral artery and NDS of patients with acute ischemic stroke in two groups; ③Adverse effect of drug. RESULTS： Totally 90 patients were enrolled in the experiment. One patient from treated group died of hyperosmolar nonketotic diabetic coma of complicated diabetes mellitus. One patient from control group died of severe pulmonary infection. The rest 88 patients entered the stage of result analysis. ① Change of coagulation index and platelet aggregation rate： prothrombin time （PT）, activated partial thromboplastin time （APTT） and thrombin time （TT） of patients after therapy were significantly longer than those before therapy in the treated group and those after therapy in control group [After therapy in treated group： （18.4±1.9）, （41.8±2.1）, （19.7±1.7） s, Before therapy in treated group： （13.4±1.3）, （35.8±1.3）, （12.5±0.9） s, After therapy in control group： （16.9±1.5）, （39.1±1.1）, （11.9±2.1） s, P〈 0.05]：Concentration of fibrinogen （Fbg） after therapy was significantly lower than that before therapy in the treated group and that after therapy in control group[After therapy in treated group： （3.4±0.4） g/L; Before therapy in treated group： （4.3±0.7） g/L; After therapy in control group：（4.0±0.6） g/L; P 〈 0.05]. Platelet aggregation rate decreased from （37.92 ±0.85）% before therapy to （26.42±1.01）% after therapy （P 〈 0.01）. ②Change of blood lipid level： Levels of total cholesterol （TC）, triacylglycerol（TG） and low density lipoprotein cholesterol （LDL-C） of patients after therapy were significantly lower than those before therapy in treated group and those after therapy in control group [After therapy in treated group： （5.2±0.9）, （1.9±0.9）, （2.08±1.1） mmol/L, before therapy in treated group： （5.9±1.2）, （2.8±0.9）, （3.94±0.5） mmol/L, After therapy in control group： （6.0±1.1）, （2.6±0.8）, （3.84±0.9） mmol/L, P 〈 0.05]. ③Change of hemorheology index： Hematocrit of patients of treated group was significantly lower after therapy than before therapy [Before therapy： （43.84±4.55）% ;After therapy： （40.48±4.02）%;P 〈 0.05]. Blood flow rate of middle cerebral artery of patients of treated group was significantly lower before therapy than after therapy [（90±1.2）, （97±2.1） cm/s,P〈 0.01]. ⑤NDS of patients in treated group was significantly lower than of control group 14 days after therapy. The total effective rate after therapy was significantly higher in the treated group than in the control group （93%,78%, P 〈 0.05）. ⑥There was no obvious adverse effect. CONCLUSION： Modified hemodilution combined therapy can improve hemorheology, decrease hematocrit, increase blood flow rate of middle cerebral artery, so as to improve the impaired clinical neurological function of elderly patients with acute cerebral thrombosis through anticoagulation and antiplatelet aggregative activity as well as regulating blood lipid.

Safety and efficacy of acute normovolemic hemodilution during liver surgery: a Meta-analysis

Objective The aim of this study was to evaluate the safety and efficacy of acute normovolemic hemodilution(ANH) during liver surgery.Methods Structured searches of the Pub Med,Chinese Biological Medicine Database,and Cochrane Library electronic databases were performed,followed by a meta-analysis of outcomes,including intraoperative blood transfusion(s),intraoperative bleeding,postoperative hematocrit(Hct) levels,postoperative prothrombin time(PT),and number of patients who underwent transfusions during liver surgery.Results In total,14 eligible studies were included in the meta-analysis,which revealed that ANH for liver resection was associated with a reduction in intraoperative blood transfusions [weighted mean difference(WMD)-1.99;95% confidence interval(CI)-2.82 to -1.16;P<0.00001].The ANH group experienced less intraoperative bleeding(WMD -72.81;95% CI -136.12 to -9.50;P<0.00001) and exhibited a lower postoperative Hct level(WMD -3.38;95% CI -7.14 to -0.67;P<0.00001) than the control group.Moreover,meta-analysis revealed that postoperative prothrombin time was not affected by ANH(WMD -0.02;95% CI -0.18 to -0.32;P=0.65).Finally,the number of patients requiring allogeneic transfusion was significantly smaller in the ANH group than in the control group(odds ratio 0.13;95% CI 0.09 to 0.18;P=0.24).Conclusion Results of the present meta-analysis indicated that ANH can reduce intraoperative bleeding and the need for blood transfusions.In addition,ANH did not negatively affect the coagulation system after surgery;therefore,ANH appears to be safe and effective during liver surgery.

Transoesophageal echo-doppler hemodynamic monitoring during preoperative acute hypervolemic hemodilution

Using transesophageal echo-Doppler, it is demonstrated that preoperative acute hypervolemic hemodilution(HHD) with 6% hydroxyethel starch(HES) significantly increased in intravascular volume, DO2, CO, SV and CI, markedly decreased in SVR and remained stable in MAP and HR, which indicates HES infused at 20 ml*kg-1 is safe in patient without cardiac disease.

Effect of Hemodilution on Fluctuation of Cerebral Oxygen Saturation during Cardiopulmonary Bypass in Children with Cyanotic Congenital Heart Disease

Background:In patients with cyanotic congenital heart disease(CHD),cerebral oxygenation may be maintained by elevations in hematocrit(Hct).Hemodilution accompanying cardiopulmonary bypass(CPB),however,can disrupt cerebral oxygen balance,leading to fluctuations in cerebral oxygen saturation(ScO_(2)).The present study investigated the effects of Hct changes on the fluctuation of ScO_(2)during CPB in cyanotic CHD using performance measurement(PM).Methods:Children with CHD(51 acyanotic and 46 cyanotic)who had undergone cardiac surgery using CPB were enrolled.Median performance error(MDPE),median absolute performance error(MDAPE),and wobble parameters of ScO_(2)were calculated before(reference value),during,and after CPB.Correlations of PM parameters with Hct and reductions in Hct(ΔHct)were also evaluated.Results:Before CPB,patients with cyanotic CHD had lower MDPE and larger wobble than those with acyanotic CHD,although mean ScO_(2)did not differ significantly between the two groups.During CPB,ScO_(2)of acyanotic CHD increased asΔHct increased,but PM variables were not associated withΔHct.In cyanotic CHD,MDPE(r=−0.324,p=0.032)and MDAPE(r=0.339,p=0.024)correlated significantly withΔHct during CPB.After CPB,MDPE(r=0.574,p=0.025)and MDAPE(r=−0.543,p=0.036)were significantly correlated with Hct in children with cyanotic CHD who underwent palliative surgery.Conclusion:Therefore,ScO_(2)fluctuation during CPB in children with cyanotic CHD may be affected by the decrease in Hct,suggesting that excessive hemodilution can negatively influence the maintenance of cerebral oxygenation in these patients.

The role of acute normovolemic hemodilution in reducing allogeneic blood transfusion in glioblastoma surgery:a case-control study

Background Acute normovolemic hemodilution(ANH)was first introduced in glioblastoma surgery,and its role in reducing allogeneic blood transfusion was investigated in this study.Methods This study enrolled supratentorial glioblastoma patients who received total resection.In the ANH group,the patients were required to draw blood before the operation,and the blood will be transfused back to the patient during the operation.The association between ANH and clinical features was investigated.Results Sixty supratentorial glioblastoma patients were enrolled in this study,25 patients were allocated in the ANH group,and another 35 patients were included in the control group.ANH dramatically reduced the need for allogeneic blood transfusion(3[12%]vs 12[34.3%],P=0.049),and the blood transfusion per total of patients was dramatically decreased by the application of ANH(0.40±1.15 units vs 1.06±1.59 units,P=0.069).Furthermore,ANH also markedly reduced the requirement of fresh frozen plasma(FFP)transfusion(2[8%]vs 11[31.4%],P=0.030)and the volume of FFP transfusion per total of patients(32.00±114.46 mL vs 115.71±181.00 mL,P=0.033).The complication rate was similar between the two groups.Conclusions ANH was a safe and effective blood conservation technique in glioblastoma surgery.

Combined effect of hypothermia and crystalloid hemodilution on the solubility of volatile anesthetics in human blood

OBJECTIVE: To determine the combined effect of hypothermia and crystalloid hemodilution on blood solubility of volatile anesthetics. METHODS: Two hundred and thirty ml blood samples obtained from each of twelve healthy male volunteers were adjusted to a hematocrit of 40% and then diluted with normal saline to hematocrits of 36%, 32%, 28%, 24%, and 20%. Blood/gas partition coefficients of desflurane, sevoflurane, isoflurane, enflurane and halothane were measured at 37 degrees C,33 degrees C, 29 degrees C, 25 degrees C, 21 degrees C and 17 degrees C using a two-stage headspace double equilibration method. RESULTS: As the temperature decreased, the logarithm of the blood/gas partition coefficient increased linearly (P

Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis

Background Hemoconcentration may be an important factor that determines the progression of severe acute pancreatitis （SAP）. In addition, it has been proposed that biomarkers may be useful in predicting subsequent necrosis in SAP. However, it is still uncertain whether hemodilution in a short term can improve outcome. We aimed to investigate the effect of rapid hemodilution on the outcome of patients with SAP. Methods One hundred and fifteen patients were admitted prospectively according to the criteria within 24 hours of SAP onset. Patients were randomly assigned to either rapid hemodilution （hematocrit （HCT） 〈35%, n=56） or slow hemodilution （HCT 〉35%, n=-59） within 48 hours of onset. Balthazar CT scores were calculated on admission, day 7, and day 14, after onset of the disease. Time interval for sepsis presented, incidence of sepsis within 28 days and in-hospital survival rate were determined. Results The amount of fluid used in rapid hemodilution was significantly more than that used in slow hemodilution （P 〈0.05） on the admission day, the first day, and the second day. There were significant differences between the rapid and slow hemodilution group in terms of hematocrit, oxygenation index, pH values, APACHE II scores and organ dysfunction at different time during the first week. There were significant differences in the time interval to sepsis in rapid hemodilution （（7.4±1.9） days） compared with the slow hemodilution group （（10.2±2.3） days）, and the incidence of sepsis （78.6%） was higher in the rapid group compared to the slow （57.6%） in the first 28 days. The survival rate of the slow hemodilution group （84.7%） was better than the rapid hemodilution （66.1%. P 〈0.05）. Conclusions Rapid hemodilution can increase the incidence of sepsis within 28 days and in-hospital mortality. Hematocrit should be maintained between 30%-40% in the acute response stage.

Responsiveness of stroke volume variation and central venous pressure during acute normovolemic and hypervolemic hemodilution

Background Stroke volume variation （SW） is a robust indicator of fluid responsiveness during volume change. We compared the sensibility of SW by Vigileo/Flotrac to central venous pressure （CVP） when volume changes in patients undergoing intraoperative acute normovolemic hemodilution （ANH） and acute hypervolemic hemodilution （AHH）. Methods Forty patients were randomly divided into an ANH group （n=20） and an AHH group （n=20）. All patients received general anesthesia and were mechanically ventilated. Data were collected from 7 different time-points in the ANH group： baseline, after withdrawal of 5%, 10%, and 15% of the estimated blood volume （EBV） and after replacement with an equal volume of 6% hydroxyethyl starch 130/0.4 （HES） in 5% EBV increments to baseline. There were four time points in the AHH group： baseline, after 5%, 10%, and 15% expansion of the EBV with 6% HES. At each time-point, CVP, SW and other hemodynamic parameters measurements were obtained. Results After removal of 10% and 15% EBV, SVV significantly increased from 10.9±3.0 to 14.1±3.4 and 10.9±3.0 to16.0±3.3 （P 〈0.01）, and returned to a final value of 10.6±3.4 after volume replacement. The CVP value was unchanged after removal and replacement of 15% of the EBV. There were no significant changes in SW after 5%, 10% whereas there was a significant reduction after 15% （8.2±1.7） expansion of the EBV compared with baseline （9.9±1.8） （P=0.033）. However, there was a significant increase in CVP after10% （10.3±2.4）, 15% （11.3±2.2） expansion of the EBV compared with baseline （8.2±2.7） （P 〈0.01）. Conclusion SW is a more sensitive parameter for volume than CVP during hypovolemia, on the contrary CVP is more sensitive than SW during hypervolemia.

Prolonged hypervolemic hemodilution decreases functional capillary density of ileal mucosa in pigs revealed by sidestream dark-field imaging

Objective： Hemodilution changes the physical properties of blood by reducing its hematocrit and blood viscosity. We tested whether prolonged hypervolemic hemodilution （HHD） impairs functional capillary density （FCD） of ileal mucosa in healthy mechanically-ventilated pigs and if there is any correlation between changes in FCD of ileal and sublingual mucosas during HHD. Methods： Sixteen domestic female pigs were anesthetized, mechanically-ventilated, and randomly assigned to the HHD （20 ml/（kg.h） Hartmann＇s solution for 3 h） or fluid restrictive （5 ml/（kg-h） Hartmann＇s solution for 3 h） group. Microcirculations of sublingual and ileal mucosas via ileostomy were visualized using sidestream dark-field （SDF） imaging at baseline conditions （t=0 h） and at selected time intervals of fluid therapy （t=-l, 2, and 3 h）. Results： A significant decrease of ileal FCD （285 （278-292） cm/cm^2） in the HHD group was observed after the third hour of HHD when compared to the baseline （360 （350-370） cm/cm2） （P〈0.01）. This trend was not observed in the restrictive group, where the ileal mucosa FCD was significantly higher after the third hour of fluid therapy as compared to the HHD group （P〈0.01）. No correlation between microhemodynamic parameters obtained from sublingual and ileal mucosas was found throughout the study. Conclusions： Prolonged HHD established by crystalloid solution significantly decreased ileal villus FCD when compared to restrictive fluid regimen. An inappropriate degree of HHD can be harmful during uncomplicated abdominal surgery.

急性等容血液稀释对部分肝脏切除术患者肝功能及凝血功能的影响

目的探讨急性等容血液稀释(ANH)对部分肝脏切除术患者肝功能及凝血功能的影响。方法选取我院收治的行部分肝脏切除术的患者64例,采用随机数字表法分为试验组和对照组(ANH组)各32例,对照组行常规麻醉,试验组行ANH。比较两组患者麻醉诱导前(T1)、血液稀释后30 min(T2)、术毕(T3)、术后24 h(T4)、术后72 h(T5)的肝功能、凝血功能及肾功能指标变化。结果试验组异体输血量、异体输血患者数少于对照组(P<0.05),两组总失血量比较差异无统计学意义(P>0.05);与T1时比较,两组谷草转氨酶(AST)、谷丙转氨酶(ALT)均上升,总蛋白(TP)下降,试验组白蛋白(ALB)于T4时上升,对照组ALB于T3时上升,两组比较差异有统计学意义(P<0.05);两组纤维蛋白原(FIB)下降、活化部分凝血酶原时间(APTT)上升(P<0.05);试验组凝血酶原时间(PT)上升,凝血酶时间(TT)则在T4时下降,试验组T2~T3时的PT、TT高于对照组(P<0.05);两组T1、T4、T5时的肾功能指标比较差异无统计学意义(P>0.05)。结论ANH可在一定程度上减少患者异体输血量,对于行部分肝脏切除术的患者肝功能及凝血功能无显著负面影响,可用于临床推广。

急性等容血液稀释联合术中血液回收对强直性脊柱炎后凸畸形截骨矫正术患者血液保护作用

目的:探究急性等容血液稀释(ANH)联合术中血液回收(IBS)对强直性脊柱炎后凸畸形截骨矫正术患者血液的保护作用。方法:选取87例强直性脊柱炎后凸畸形截骨矫正术患者为研究对象,按照干预方式不同分为ANH组、IBS组和ANH联合IBS组,每组各29例。比较各组患者在麻醉诱导10 min后(T0)、放血10 min后(T1)、自体血回输前(T2)、回输血结束后30 min(T3)围术期血流动力学、凝血指标、肾功能指标,记录术中血液保护情况。结果:T1时刻,ANH组和ANH联合IBS组MAP值相较于T0均下降(P<0.05),且两组MAP值均低于IBS组(P<0.05);T2时刻,IBS组MAP值较T0下降(P<0.05),ANH联合IBS组MAP高于IBS组(P<0.05),三组CVP值均低于T0(P<0.05);在T2和T3时,各组患者PT和APTT值较T0时刻均上升(P<0.05);在T3时,ANH组和ANH联合IBS组PT和APTT值均低于IBS组(P<0.05),但ANH组和ANH联合IBS组间无统计学差异(P>0.05);ANH联合IBS组异体红细胞输注量低于ANH组和IBS组(P<0.05)。结论:ANH联合IBS应用于强直性脊柱炎后凸畸形截骨矫正术中,可以有效减少异体输血需求,对血流动力学、凝血功能和肾功能影响较小。

AHH程度对老年髋关节置换术中凝血功能、内脏灌注的影响

目的 探讨急性高容量血液稀释(acute hypervolemic hemodilution,AHH)程度对老年髋关节置换术患者术中凝血功能、内脏灌注的影响。方法 选取2021年1月至2023年6月于金华市中心医院行髋关节置换术的老年患者102例进行回顾性研究,患者均采用AHH、自体血回输与控制性降压,根据AHH程度将其分成A组(n=55)与B组(n=47)。A组设定目标稀释值为红细胞压积(hematocrit,HCT) 30%,B组设定为HCT 25%。比较两组患者的一般资料、尿量、输液总量、出血量及麻醉诱导后(T_(0))、血液稀释后(T_(1))、术毕(T_(2))的心率、体温、凝血酶原时间(prothrombin time,PT)、纤维蛋白原(fibrinogen,FIB)、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)、血小板(platelet,PLT)及胃黏膜二氧化碳分压(gastric intramucosal carbon dioxide tension,PgCO_(2))、胃黏膜pH值(gastric intramucosal pH,pHi)。结果 B组患者的扩容液体总量、输液总量显著多于A组(P<0.05)。两组患者T_(1)的心率、体温显著低于T_(0)与T_(2),B组患者T_(1)的心率显著低于A组(P<0.05)。两组患者T_(1)、T_(2)的PT显著长于T_(0),FIB、PLT显著低于T_(0) (P<0.05);B组患者T_(1)、T_(2)的PLT显著低于A组(P<0.05)。两组患者T_(1)、T_(2)的PgCO_(2)显著高于T_(0),pHi显著低于T_(0) (P<0.05),且B组患者T_(1)、T_(2)的pHi显著低于A组(P<0.05)。结论 AHH目标值设定为HCT 25%~30%的总体安全性高,其中目标值为HCT25%时PLT水平更低,但亦在正常范围内,而PgCO_(2)增高,pHi有所降低。

急性等容血液稀释性血液回输对体外循环下患者术后谵妄的影响

目的探讨急性等容血液稀释(ANH)性血液回输对体外循环下行心脏瓣膜手术患者术后谵妄(POD)的影响。方法选择2021年9月至2022年12月期间,体外循环下行瓣膜手术患者60名,按照随机数字法分为ANH组和对照组。ANH组患者在全麻下通过右侧颈内静脉三腔中心静脉导管连接含有枸橼酸钠抗凝剂的储血袋,依靠重力作用采集患者全血,并于手术结束前回输,对照组按常规手术处理。在术前(T1)、体外循环结束时(T2)、术毕(T3)取患者全血5 ml,检测并记录血清中白介素(IL)-1β、IL-6、IL-10、游离血红蛋白(FHb)浓度和脑电双频指数(BIS)值。记录两组患者术中低脑氧饱和度、POD、术后ICU停留时间、气管插管带管时间、24 h心包纵膈引流量、围术期血制品输注量及术后血管活性药物使用量等情况。结果ANH组POD发生率、IL-1β、IL-6、T2和T3时FHb的浓度、T3时的BIS值、术后24 h白细胞、C反应蛋白、乳酸值、引流量、血制品输注量以及带管时间和ICU停留时间等均低于对照组(P<0.05),血管活性药使用量亦显著减少(P<0.05);两组术中发生低脑氧饱和度及其他临床结果无明显差异(P>0.05)。结论ANH性血液回输可以降低体外循环下患者POD的发生率,其原因可能与降低患者术中炎性因子及FHb的浓度、减少血制品的输入量和术后血管活性药物的使用有关。

急性等容血液稀释对靶控输注依托咪酯血药浓度和肾上腺皮质功能的影响

目的观察急性等容血液稀释(ANH)对靶控输注(TCI)依托咪酯血药浓度和肾上腺皮质功能的影响。方法选择多节段脊柱手术患者60例,男35例,女25例,年龄30~60岁,BMI 20~25 kg/m^(2),ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组:ANH组和对照组,每组30例。TCI依托咪酯麻醉诱导和麻醉维持。ANH组麻醉诱导平稳后行ANH,理想Hct 28%~30%,术后1 h内回输完毕;对照组常规处理。记录依托咪酯用量。采用液相色谱-串联质谱(LC-MS/MS)法检测两组术毕即刻、术后10、20、30 min的依托咪酯血药浓度和ANH组自体血采集入储血袋即刻、在储血袋保存1 h、回输即刻的依托咪酯血药浓度。采用化学发光免疫分析(CLIA)法检测麻醉诱导前、术毕即刻、术后1、2 d的血浆皮质醇(Cor)、促肾上腺皮质激素(ACTH)和醛固酮(ALD)浓度。结果两组依托咪酯用量差异无统计学意义。与术毕即刻比较,术后10、20和30 min两组依托咪酯血药浓度明显降低(P<0.05)。与对照组比较,术后10 min ANH组依托咪酯血药浓度明显升高(P<0.05)。ANH组自体血采集入储血袋即刻、在储血袋保存1 h和回输即刻依托咪酯血药浓度分别为(547.8±119.4)、(536.7±107.8)、(522.8±91.7)ng/ml。与麻醉诱导前比较,术毕即刻两组Cor、ALD浓度明显降低(P<0.05),ACTH浓度明显升高(P<0.05),麻醉诱导前和术后1、2 d两组Cor、ALD和ACTH浓度差异无统计学意义。结论ANH用于TCI依托咪酯的骨科手术中,采集的自体血回输后仅短暂(10 min左右)增加依托咪酯的血药浓度,肾上腺皮质功能在术后24 h内恢复到麻醉诱导前水平。

静脉-动脉体外膜肺氧合启动后即刻血液稀释对心脏疾病患者器官功能和治疗策略的影响

目的 探讨心脏疾病患者在静脉-动脉体外膜肺氧合(VA-ECMO)辅助启动后血液快速稀释对器官功能改变及临床治疗策略选择的影响。方法 回顾性分析2019年1月至2023年1月于中国人民解放军总医院第一医学中心心血管内科重症监护室接受VA-ECMO辅助的50例患者的临床资料。根据VA-ECMO启动后红细胞压积(Hct)下降的程度,将患者分为Hct下降≥30%组(Hct^(Δ30%+)组,n=17)和Hct下降<30%组(Hct^(Δ30%-)组,n=33)。比较两组患者器官功能相关生物标志物、接受输血、主动脉内球囊反搏(IABP)及持续肾替代治疗(CRRT)情况。采用SPSS 25.0统计软件进行数据分析。根据数据类型,分别采用t检验、Mann-Whitney U检验、χ^(2)检验或Fisher精确检验进行组间比较。结果 Hct^(Δ30%+)组65岁及以上患者占比52.9%(9/17),Hct^(Δ30%-)组65岁及以上患者占比36.4%(12/33)。Hct^(Δ30%+)组与Hct^(Δ30%-)组患者一般临床特征及VA-ECMO辅助前临床指标比较,差异均无统计学意义(P>0.05)。在VA-ECMO启动后,肌酸激酶同工酶、天冬氨酸氨基转移酶及丙氨酸氨基转移酶的峰值在Hct^(Δ30%+)组中更高,差异均有统计学意义(P<0.05)。Hct^(Δ30%+)组与Hct^(Δ30%-)组相比,接受IABP(70.6%和36.4%)和CRRT(64.7%和18.2%)治疗的患者比例更高;Hct^(Δ30%+)组患者输注悬浮红细胞和血浆的单位数更多,差异均有统计学意义(P<0.05)。结论 VA-ECMO启动后Hct降低≥30%的患者输血量更大、器官损伤更重,采用IABP或CRRT联合辅助比例更高。VA-ECMO启动后Hct降低≥30%作为一个新的临床指标,为治疗策略的选择及改善预后提供重要参考依据。