周文全 梁建平 劉英英
[摘 要] 目的:研究不同劑量羥乙基淀粉(130/0.4)對(duì)骨科全麻患者血流動(dòng)力學(xué)及凝血功能的影響。方法:選取2014年5月-2015年5月擬在我院行髖關(guān)節(jié)置換手術(shù)的全麻患者200例,根據(jù)給予羥乙基淀粉劑量的不同隨機(jī)分為A、B兩組,各100例。A組患者給予羥乙基淀粉10mL/kg; B組患者給予羥乙基淀粉20mL/kg。記錄擴(kuò)容前(T1)、輸液后15min(T2)、輸液30min(T3)、輸液60min(T4)血流動(dòng)力學(xué)指標(biāo):心率(HR)、平均動(dòng)脈壓(MAP)、中心靜脈壓(CVP)、尿量變化情況。T1和T4時(shí)間點(diǎn)抽取患者外周靜脈血5mL監(jiān)測(cè)患者的凝血功能指標(biāo):凝血酶原時(shí)間(PT)、激活部分凝血活酶時(shí)間(APTT)、纖維蛋白原濃度(FIB)、血小板聚集功能(PAG)以及血小板計(jì)數(shù)(PLT)、血紅蛋白(Hb)、血紅細(xì)胞壓積(HCT)含量的變化。結(jié)果:兩組患者一般情況及手術(shù)情況相比差異無(wú)統(tǒng)計(jì)學(xué)意義,具有可比性。兩組患者T1時(shí)刻HR、MAP、CVP及尿量相比,差異無(wú)統(tǒng)計(jì)學(xué)意義;T2~T4時(shí)刻,兩組患者HR、MAP與T1時(shí)間點(diǎn)相比差異無(wú)統(tǒng)計(jì)學(xué)意義且組間比較也無(wú)差異;兩組患者T2~T4時(shí)間點(diǎn)CVP、尿量明顯高于T1時(shí)間點(diǎn),差異有統(tǒng)計(jì)學(xué)意義,B組稍高于A組但差異無(wú)統(tǒng)計(jì)學(xué)意義。兩組患者術(shù)前PT、APTT、FIB、PAG、PLT、Hb、HCT相比差異無(wú)統(tǒng)計(jì)學(xué)意義,T4時(shí)間點(diǎn)兩組患者APTT明顯高于T1時(shí)間點(diǎn),差異有統(tǒng)計(jì)學(xué)意義,兩組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義;兩組患者T4時(shí)間點(diǎn)PLT、Hb、HCT明顯低于T1時(shí)間點(diǎn)且B組患者明顯低于A組患者,差異有統(tǒng)計(jì)學(xué)意義。結(jié)論:全麻患者給予10mL/kg、20mL/kg劑量的羥乙基淀粉對(duì)患者凝血功能的影響小,均能保證患者圍術(shù)期血流動(dòng)力學(xué)的穩(wěn)定。
[關(guān)鍵詞] 羥乙基淀粉;血流動(dòng)力學(xué);凝血功能;全身麻醉
中圖分類號(hào):R614.2 文獻(xiàn)標(biāo)識(shí)碼:B 文章編號(hào):2095-5200(2016)05-059-04
[Abstract] Objective: To study the effects of different doses of hydroxyethyl starch (130/0.4) on hemodynamics and coagulation function in orthopedics patients undergoing general anesthesia. Methods: 200 general anesthesia patients undergoing hip replacement surgery in our hospital from May 2014 to May 2015 were randomly divided into groups A and B according to different doses of hydroxyethyl starch, 100 cases in each goup. Group A was treated with hydroxyethyl starch injection in a dose of 10mL/kg; group B was treated with hydroxyethyl starch injection in a dose of 20mL/kg. Hemodynamic indexes were recorded before the expansion (T1), 15 min after infusion (T2), infusion of 30 min (T3), and infusion of 60 min (T4): heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), urine volume changes. At T1 and T4 time points, 5 mL venous blood were taken from patients for monitoring coagulation indexes: prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), platelet aggregation (PAG) and platelet count (PLT), hemoglobin (Hb), red blood cell hematocrit (HCT) content changes. Results: There was no significant difference between the two groups in general condition and operation condition. MAP, CVP and HR and urine volume were compared between two groups of patients at T1 time point, the differences were not statistically significant; at T2 and T4 time points, HR and MAP of two groups of patients were compared with those at T1 time point, there were no significant intra-group and inter-group differences; CVP and urine volume at T2 and T4 time points were significantly higher than those of T1 time point in the two groups, the intra-group difference was statistical significant, CVP and urine volume of group B was higher than those of group A, but the differences were not statistically significant. There were no significant differences in PT, APTT, FIB, PAG, PLT, Hb and HCT between the two groups of patients before treatment, APTT at T4 time points in two groups of patients were significantly higher than those at the T1 time point, there were statistically significant intra-group differences, but no significant difference between the two groups; PLT, Hb, HCT at T4 time point were significantly lower than those at T1 time points in both two groups, but PLT, Hb, HCT of group B were significantly lower than those of group A, the differences were statistically significant. Conclusions: The effects of a dose of 10mL/kg and 20mL/kg hydroxyethyl starch on coagulation function in patients undergoing general anesthesia were both small, and both can guarantee the stable hemodynamics in patients during the perioperative period.
[Key words] hydroxyethyl starch; hemodynamics; blood coagulation; general anesthesia
羥乙基淀粉(130/0.4)是一種新型的膠體型血漿代用品,能夠有效地增加患者血容量,改善患者心輸出量以及機(jī)體的氧供氧需,改善創(chuàng)傷、休克、血容量不足患者各器官功能,保證患者血流動(dòng)力學(xué)平穩(wěn)。髖關(guān)節(jié)置換患者多為老年患者,常伴有心肺功能疾病,施行全身麻醉期間可能發(fā)生血流動(dòng)力學(xué)波動(dòng),因此圍術(shù)期的容量管理則顯得至關(guān)重要。相關(guān)研究表明不同的容量管理對(duì)患者圍術(shù)期血流動(dòng)力學(xué)以及凝血功能的影響不同[1-3],因此本研究將探討不同劑量羥乙基淀粉(130/0.4)對(duì)骨科全麻患者血流動(dòng)力學(xué)及凝血功能的影響,為臨床全麻患者合理使用羥乙基淀粉提供指導(dǎo)。
1 材料與方法
1.1 一般資料
選擇2014年5月至2015年5月擬在我院行髖關(guān)節(jié)置換手術(shù)的全麻患者200例,55~75歲,ASA I~Ⅲ級(jí),排除術(shù)前患有嚴(yán)重心臟病;呼吸系統(tǒng)疾病;肝腎功能異常;Hb<110g/L;近期使用過(guò)影響血小板功能、凝血系統(tǒng)、纖溶以及抗凝系統(tǒng)的藥物者;高血壓、糖尿病患者。排除圍術(shù)期失血量超過(guò)總血容量20%以及輸血的患者。根據(jù)給予羥乙基淀粉劑量的不同隨機(jī)分為A、B兩組,各100例。本研究經(jīng)醫(yī)院倫理委員會(huì)批準(zhǔn)且所有患者均簽署了知情同意書(shū)。
1.2 麻醉方法
所有患者術(shù)前完善血尿常規(guī)、肝腎功能電解質(zhì)、凝血功能、心電圖、胸片等檢查,術(shù)前一天常規(guī)禁食禁飲。清醒進(jìn)入手術(shù)室后常規(guī)吸氧2L/min,開(kāi)放外周靜脈給予乳酸林格式液10mL/kg,常規(guī)監(jiān)測(cè)心電圖、脈搏氧飽和度,局麻下行橈動(dòng)脈穿刺持續(xù)監(jiān)測(cè)有創(chuàng)動(dòng)脈血壓并在局麻下行鎖骨下靜脈穿刺持續(xù)監(jiān)測(cè)中心靜脈壓力。A組患者給予羥乙基淀粉10mL/kg,B組患者給予羥乙基淀粉20mL/kg,0.5~1h內(nèi)輸完后給予乳酸林格式液維持。麻醉誘導(dǎo)給予咪達(dá)唑侖0.04mg/kg、依托咪酯2mg/kg、順式阿曲庫(kù)銨0.2mg/kg、瑞芬太尼2μg/kg,3min后在可視喉鏡下進(jìn)行氣管插管,接麻醉機(jī)進(jìn)行機(jī)械通氣,調(diào)整呼吸參數(shù)潮氣量VT 6~8mL/kg、呼吸頻率RR12次/分、吸呼比I:E為1:2,維持呼吸末二氧化碳分壓PETCO2為30~35mmHg。兩組患者均采用靜吸復(fù)合麻醉維持麻醉,丙泊酚(4~12 mg·kg-1·h-1)、瑞芬太尼(0.2mg·kg-1·min-1)、七氟烷1%~2%,調(diào)整丙泊酚和七氟烷的用量使腦電雙頻指數(shù)BIS值維持在40~50。圍術(shù)期合理使用血管活性藥物使血壓波動(dòng)低于基礎(chǔ)值的20%,并根據(jù)手術(shù)情況合理追加順式阿曲庫(kù)銨。兩組患者均在手術(shù)結(jié)束前30min給予注射用帕瑞昔布鈉超強(qiáng)鎮(zhèn)痛,待患者睜眼意識(shí)清醒、自主呼吸恢復(fù)、肌張力恢復(fù)后拔出氣管導(dǎo)管。
1.3 觀察指標(biāo)
統(tǒng)計(jì)兩組患者麻醉手術(shù)時(shí)間以及圍術(shù)期的出血量;擴(kuò)容前(T1)、輸液后15min(T2)、輸液30min(T3)、輸液60min(T4)血流動(dòng)力學(xué)指標(biāo):心率(HR)、平均動(dòng)脈壓(MAP)、中心靜脈壓(CVP)、尿量變化情況。并于T1和T4時(shí)間點(diǎn)抽取患者外周靜脈血5mL監(jiān)測(cè)患者的凝血功能指標(biāo):凝血酶原時(shí)間(PT)、激活部分凝血活酶時(shí)間(APTT)、纖維蛋白原濃度(FIB)、血小板聚集功能(PAG)以及血小板計(jì)數(shù)(PLT)、血紅蛋白(Hb)、血紅細(xì)胞壓積(HCT)含量的變化。
1.4 統(tǒng)計(jì)學(xué)方法
應(yīng)用SPSS19.0統(tǒng)計(jì)學(xué)軟件進(jìn)行統(tǒng)計(jì)學(xué)分析,計(jì)量資料采用t檢驗(yàn),計(jì)數(shù)資料采用χ2檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組患者一般情況及手術(shù)情況
兩組患者一般情況(年齡、性別比、體重指數(shù)、手術(shù)時(shí)間、術(shù)中失血量)相比差異無(wú)統(tǒng)計(jì)學(xué)意義,見(jiàn)表1。
2.2 圍術(shù)期兩組患者血流動(dòng)力學(xué)比較
兩組患者T1時(shí)刻HR、MAP、CVP及尿量相比,差異無(wú)統(tǒng)計(jì)學(xué)意義;T2~T4時(shí)刻,兩組患者HR、MAP與T1時(shí)間點(diǎn)相比差異無(wú)統(tǒng)計(jì)學(xué)意義且組間相比也無(wú)差異;兩組患者T2~T4時(shí)間點(diǎn)CVP、尿量明顯高于T1時(shí)間點(diǎn),差異有統(tǒng)計(jì)學(xué)意義,B組稍高于A組但差異無(wú)統(tǒng)計(jì)學(xué)意義,見(jiàn)表2。
2.3 兩組患者擴(kuò)容前和輸液60min后凝血功能、PLT、Hb、HCT含量的比較
兩組患者術(shù)前PT、APTT、FIB、PAG、PLT、Hb、HCT相比差異無(wú)統(tǒng)計(jì)學(xué)意義,T4時(shí)間點(diǎn)兩組患者APTT明顯高于T1時(shí)間點(diǎn),差異有統(tǒng)計(jì)學(xué)意義,兩組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義;兩組患者T4時(shí)間點(diǎn)PLT、Hb、HCT明顯低于T1時(shí)間點(diǎn)且B組患者明顯低于A組患者,差異有統(tǒng)計(jì)學(xué)意義,見(jiàn)表3。
3 討論
目前臨床上尚不能做到精確判斷患者血容量以及補(bǔ)充液體的情況,圍術(shù)期液體治療常出現(xiàn)過(guò)量和不足情況[4-5]。單位時(shí)間內(nèi)液體輸入過(guò)多或者輸入液體過(guò)快常會(huì)引起肺水腫嚴(yán)重情況甚至引起患者肺功能受損而死亡[6-7]。但是圍術(shù)期液體量不足也常會(huì)引起患者血流動(dòng)力學(xué)的不穩(wěn)定,患者可能出現(xiàn)休克癥狀,心率增快、血壓降低、尿量減少,嚴(yán)重影響患者圍術(shù)期生命體征的穩(wěn)定以及預(yù)后情況[8-9]。尤其是對(duì)于老年患者,心臟血管功能下降,術(shù)前長(zhǎng)時(shí)間禁飲禁食引起其血容量減少,在全身麻醉誘導(dǎo)和維持期間常出現(xiàn)血流動(dòng)力學(xué)的波動(dòng),因此完善圍術(shù)期液體的管理對(duì)于其安全度過(guò)圍術(shù)期具有重要意義。
羥乙基淀粉(130/0.4)是目前臨床上普遍認(rèn)為的一種較為理想安全的人工膠體溶液,能夠快速有效地增加患者血容量,提高血漿滲透壓,維持時(shí)間長(zhǎng)達(dá)4h,擴(kuò)容效果明顯且對(duì)患者的血糖、肝腎功能、凝血功能較小,同時(shí)還具有防止毛細(xì)血管滲漏的優(yōu)點(diǎn)[10-12]。羥乙基淀粉的維持時(shí)間長(zhǎng)短、擴(kuò)容強(qiáng)度大小以及不良反應(yīng)的強(qiáng)度主要是由其平均分子量大小、濃度以及取代級(jí)和取代方式來(lái)決定的。分子量越大,取代級(jí)越高的羥乙基淀粉代謝時(shí)間越長(zhǎng),擴(kuò)容能力越強(qiáng)同時(shí)對(duì)患者腎臟功能的影響也就越大[13-14]。
有研究結(jié)果表明,圍術(shù)期患者輸入羥乙基淀粉劑量小于50mL/kg時(shí),患者的凝血功能影響輕微,不會(huì)增加圍術(shù)期出血的情況[15-16]。在本研究中擴(kuò)容后60min兩組患者PT與擴(kuò)容前相比差異無(wú)統(tǒng)計(jì)學(xué)意義,而APTT明顯高于擴(kuò)容前,表明羥乙基淀粉對(duì)外源性的凝血途徑?jīng)]有影響而對(duì)內(nèi)源性的凝血途徑具有抑制作用,但都在正常范圍內(nèi),且兩組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義。由于血液稀釋的原因兩組患者擴(kuò)容后PLT、Hb、HCT明顯低于擴(kuò)容前且B組患者明顯低于A組患者,兩組患者纖維蛋白原濃度雖然低于擴(kuò)容前但仍在正常范圍水平,且兩組患者的血小板功能也沒(méi)有受到影響,表明圍術(shù)期輸入不同劑量的羥乙基淀粉不會(huì)影響患者的凝血功能。兩組患者不同時(shí)間點(diǎn)HR、MAP相比無(wú)差異,表明羥乙基淀粉能夠保證患者圍術(shù)期的血流動(dòng)力學(xué)穩(wěn)定,由于B組患者輸入羥乙基淀粉劑量更多因此CVP及尿量也比A組患者高。
綜上所述,全麻患者給予10mL/kg、20mL/kg劑量的羥乙基淀粉對(duì)患者凝血功能的影響小,均能保證患者圍術(shù)期血流動(dòng)力學(xué)的穩(wěn)定,可以安全的用于臨床全麻患者。
參 考 文 獻(xiàn)
[1] RAHBARI NN, ZIMMERMANN JB, SCHMIDT T, et al. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery[J]. Br J Surg, 2009,96(4):331-341.
[2] Thomas A, Doelbery M, Jungheinrich C, et al. Repetitive large dose infusion of the novel hydroxyethyl starch 130/0.4 in patients with severe head injury[J]. Anesth Analg, 2013,116(4):258.
[3] Kind SL, Spahn NG, Emmert MY, et al. Is dilutional coagulapathy induced by different colloids reversible by replacement of fibrinogen and factor XⅢ concentrates[J]. Anesth Analy, 2013,117(5):1149-1161.
[4] Gattas DJ, Dam A, Mybergh J. Fluid resuscitation with 6% hydroxyethyl starch(130/0.4) in acutely ill patients an updated systematic review and meta analysis[J]. Anesth Analg, 2012,114(5):159-169.
[5] Bion J, Bellomo R, Myburgh J, et al. Hydroxyethyl starch: putting patient safety first[J]. Intensive Care Med, 2014,40(2):256-266.
[6] Jordan S, Mitchell JA, Quinlan GJ, et al. The pathogenesis of lung injury following pulmonary resection[J]. Eur Respir J, 2010,15(4):790-799.
[7] Haisch G, Boldt J, Krebs C, et al. The influence of intravascular volume therapy with a new hydroxyethyl starch preparation(6% HES 130/0.4) on coagulation in patients undergoing major abdominal surgery[J]. Anesth Analg, 2010,92(2):565-571.
[8] Guidet B, Martinet O, Boulain T, et al. Assessment of hemodynamic efficacy and safety of 6% hydroxyethyl starch 130/0.4 vs 0.9% NaCl fluid replacement in patients with severe sepsis: the crystmas study[J]. Crit Care, 2012,16(3):94-108
[9] Akkucuk FG, Kanbak M, Ayhan B, et al. The effect of HES(130/0.4) usage as the priming solution on renal function in children undergoing cardiac surgery[J]. Ren Fail, 2013,35(2):210-231.
[10] 賈倩倩.兩種輸液方案對(duì)老年病人腹部外科手術(shù)術(shù)后恢復(fù)的影響[D].南寧:廣西醫(yī)科大學(xué),2010.
[11] Martin C, Jacob M, Vicaut E, et al. Effect of waxy maize derived hydroxyethyl starch 130/0.4 on renal function in surgical patients[J]. Anesthesiology, 2013,118(2):387-401.
[12] Mutler TC, Ruth CA, Dart AB. Hydroxyethyl starch(HES) versus other fluid therapies: effects on kidney function[J]. Cochrane Datebase syst Rev, 2013, 7:7594-7611.
[13] Bechir M, Puhan MA, Fasshaurer M, et al. Early fluid resuscitation with hydroxyethyl starch 130/0/4(6%) in severe burn jnjury: a randomized, controlled, double-blind clinical trial[J]. Crit Care, 2013,17(6):299-315.
[14] Yamakage M, Bepperling G, Wargenau M, et al. Pharmacokinetics and safety of 6% hydroxyethyl starch 130/0.4 in healthy male volunteers of Japanese ethnicity after single infusion of 500 ml solution[J]. J Anesth, 2012,26(6):851-871.
[15] 王鈺. 不同劑量羥乙基淀粉130/0.4對(duì)嚴(yán)重膿毒癥大鼠凝血功能的影響[D]. 寧波:寧波大學(xué), 2014.
[16] Hsynes GR. Risks of hydroxyethyl starch 130/0.4 in cardiac surgey[J]. J Pharm Pract, 2014,27(1):17-30.