急性高容量血液稀释对LPD老年患者血流动力学和凝血功能的影响

发布时间：2018-06-14 11:19

本文选题：急性高容量血液稀释 + 血液保护　；参考：《河北医科大学》2017年硕士论文

【摘要】：近年来,异体输血引发的问题越来越多,我国又面临着血源短缺的严峻形势,因此节约用血,减少异体血输入成为当下医学研究的一项重要课题。临床应用逐渐增多的一种有效的血液保护方法是急性高容量血液稀释(AHH),随着我国进入人口老龄化阶段,需要外科手术的老年人越来越多。然而急性高容量血液稀释应用于老年人的安全性和有效性仍需要进一步探讨。本研究将评价不同液体对老年患者凝血的影响,旨在为临床提供参考。目的:探讨不同胶体用于急性高容量血液稀释对腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy,LPD)老年患者血流动力学和凝血功能的影响。方法:选取择期行LPD的45例ASA分级为Ⅱ或Ⅲ级的老年患者为研究对象,随机分为三组,乳酸钠林格注射液组(对照组,R组,n=15),6%羟乙基淀粉130/0.4氯化钠注射液组(H组,n=15),4%琥珀酰明胶注射液组(G组,n=15)。患者入室后开放外周静脉通路,1%利多卡因局麻下行桡动脉穿刺置管术,监测有创动脉血压。三组患者均输入10ml/kg乳酸钠林格氏液以补充禁食水所失液体量,然后H组和G组以25ml/min的速度分别输注6%羟乙基淀粉130/0.4氯化钠注射液和4%琥珀酰明胶注射液总预计量(15ml/kg)的1/3,以防全麻诱导时循环抑制引起的低血压。全麻诱导均静脉注射咪达唑仑0.05mg/kg,舒芬太尼0.3μg/kg,丙泊酚1.5mg/kg,顺式阿曲库铵0.15mg/kg,阿托品0.5mg,瑞芬太尼1~2μg/kg。麻醉维持静脉泵注瑞芬太尼注射液0.1~0.3μg·kg-1·min-1,丙泊酚2~6mg·kg-1·h-1,术中间断追加顺式阿曲库铵来维持肌松。气管插管改机械通气后行右侧颈内静脉穿刺置管术,补液并监测中心静脉压(CVP)。全麻诱导后至手术切皮前再输入总预计量的2/3,以达到超容血液稀释状态。R组按15ml·kg-1·h-1的速度常规输入乳酸钠林格注射液而不行AHH。若术中Hb80g/l,Hct25%时输入同型异体血,CVP15cm H2O给予利尿剂。分别在AHH前(T0),AHH后30min(T1),AHH后1h(T2),手术结束时(T3)采取静脉血测快速血栓弹力图各个参数:凝血反应时间(R)、血凝块形成时间(K)、Angle值、最大振幅(MA)、30min血凝块幅度减少速度(LY30)。动脉血气值(Hb,Hct),连续监测并记录Sp O2、Pet CO2、HR、MAP、CVP、T、BIS。记录术中尿量、输血量、出血量。结果:(1)三组患者的性别构成、年龄、体重、手术时间、出血量等差异均无统计学意义(P0.05)。(2)R组的异体输血量和液体总输入量明显高于H组和G组(P0.05),而H组和G组患者的尿量明显多于R组(P0.05)。(3)在AHH前各组HR、MAP、CVP、Sp O2、Pet CO2差异无统计学意义(P0.05)。与T0相比,R组的MAP在T1明显下降,且与H组和G组组间差异有统计学意义(P0.05或P0.01),三组患者MAP其余各点基本稳定,组间比较差异无统计学意义(P0.05)。与T0相比,H组和G组的HR在T1明显下降(P0.05),G组与R组比较差异有统计学意义(P0.05)。三组的Sp O2、Pet CO2各时点比较差异无统计学意义(P0.05)。与T0相比,R组的CVP在T1明显降低,H组和G组的CVP在T1、T2、T3均明显升高,且在T1与R组比较差异有统计学意义(P0.05)。三组患者的T、BIS差异无统计学意义(P0.05)。(4)与T0相比,R组的Hb、Hct在T1-T3无明显变化;H组和G组的Hb、Hct在AHH后均显著降低(P0.05),但两组组间比较差异无统计学意义(P0.05)(5)血栓弹力图指标:稀释前,3组患者的TEG指标无差异(P0.05);ACT值组内比较H组和G组在T1、T2、T3与T0比较时间明显延长(P0.05),AHH后H组和G组与R组比较差异有统计学意义(P0.05);R值组内比较H组和G组T1、T2、T3与T0比较升高,差异有统计学意义(P0.05),AHH后组间比较R值H组、G组与R组比较差异均有统计学意义(P0.05);K值与Angle角组内比较H组和G组的T3与T0比较差异有统计学意义(P0.05)R组组内比较差异无统计学意义(P0.05),组间比较H组和G组与R组比较差异有统计学意义(P0.05);MA值组内比较H组、G组的T3与T0比较明显减小(P0.05)组间比较H组、G组与R组比较差异均有统计学意义(P0.05);H组与G组比较差异也有统计学意义(P0.05);EPL、LY30组内组间比较均无差异(P0.05)。结论:(1)6%羟乙基淀粉130/0.4氯化钠注射液与4%琥珀酰明胶注射液均可以安全有效地用于LPD老年患者的容量替代治疗。(2)AHH用于LPD老年患者能有助于维持患者血流动力学稳定,减少术中的出血量和异体输血量。(3)4%琥珀酰明胶注射液和6%羟乙基淀粉130/0.4氯化钠注射液均能有效的改善老年患者的高凝状态,且羟乙基淀粉使术后血液呈轻度低凝状态,更有利于老年患者预防术后静脉血栓的形成。(4)血栓弹力图(TEG)动态监测凝血功能,为临床围手术期凝血功能监测提供重要的数据依据。
[Abstract]:In recent years, there are more and more problems caused by allogeneic blood transfusion, and China is facing a severe situation of blood supply shortage. Therefore, it is an important issue to save blood and reduce the input of blood allograft. An effective method of increasing the clinical application of blood is acute high volume hemodilution (AHH). In the aging stage of the mouth, more and more elderly people need surgical surgery. However, the safety and effectiveness of acute hypervolemic hemodilution used in the elderly still need further discussion. This study will evaluate the effect of different liquids on blood coagulation in elderly patients. The purpose of this study is to provide reference for clinical purposes. Objective: To explore the use of different colloids for acute high volume. The effect of hemodilution on the hemodynamic and coagulation function of the elderly patients with laparoscopic pancreaticoduodenectomy (LPD). Methods: 45 elderly patients with ASA grade of LPD were selected as the subjects of grade II or grade III, and were randomly divided into three groups, Sodium Lactate Ringer's Injection group (control group, R group, n=15), 6 % Hydroxyethyl Starch 130/0.4 and Sodium Chloride Injection group (group H, n=15), 4% Succinylated Gelatin Injection group (group G, n=15). Patients were open peripheral venous access after admission, 1% lidocaine local anesthesia under radial artery catheterization and monitoring of invasive arterial blood pressure. The three groups were fed with 10ml/kg lactate Ringer's solution to supplement the amount of lost fluid in the fasting water. In the post H and G groups, the 1/3 of 6% Hydroxyethyl Starch 130/0.4 and Sodium Chloride Injection and 4% Succinylated Gelatin Injection total prediction (15ml/kg) was injected at the speed of 25ml/min to prevent the hypotension caused by cyclic inhibition in the induction of general anesthesia. All the anesthesia induction was induced by intravenous injection of midazolam 0.05mg/kg, sufentanil 0.3 mu g/kg, propofol 1.5mg/kg, CIS alqu. 0.15mg/kg, atropine 0.5mg, remifentanil 1~2 mu g/kg. anesthesia maintenance intravenous infusion of remifentanil injection 0.1~0.3 u g. Kg-1. Min-1, propofol 2~6mg kg-1. H-1, operation in the middle of CIS atracurium to maintain muscle relaxation. After endotracheal intubation to mechanical ventilation, the right internal jugular vein puncture tube, rehydration and monitoring central venous pressure (C) VP). After the induction of general anesthesia, the total estimated amount of 2/3 was entered before surgical resection to achieve hypervolemic hemodilution in group.R, which was routinely entered at the speed of 15ml. Kg-1. H-1, without AHH. if Hb80g/l, Hct25% was imported at Hct25%, and CVP15cm H2O was given the diuretic. T2), at the end of the operation (T3), the venous blood was used to measure the parameters of the rapid thrombus map: coagulation reaction time (R), blood clot formation time (K), Angle value, maximum amplitude (MA), 30min clot amplitude reduction speed (LY30). Arterial blood gas value (Hb, Hct). Results: (1) there was no significant difference in sex composition, age, weight, operation time and volume of bleeding in the three groups (P0.05). (2) the amount of allogeneic blood transfusion and total liquid input in group R were significantly higher than that of group H and G group (P0.05), while the urine volume in group H and G group was more than that of group R (P0.05). (3) HR, MAP, and MAP Statistical significance (P0.05). Compared with T0, MAP in group R was significantly decreased in T1, and there was significant difference between group H and G group (P0.05 or P0.01). The remaining points of the three groups were basically stable and there was no statistical difference between the groups (P0.05). Significance (P0.05). There was no significant difference between the three groups of Sp O2 and Pet CO2 at all time points. Compared with T0, CVP in R group was significantly reduced in T1, and there was a significant increase in H and G groups. The difference between the three groups was statistically significant. (4) There was no significant change in T1-T3, while Hb and Hct in group H and G decreased significantly after AHH (P0.05), but there was no significant difference between the two groups (P0.05) (P0.05) (5) the index of thrombus and elasticity of the 3 groups (P0.05) before the dilution (P0.05). Compared with the R group, there were significant differences (P0.05), while in the R group, the T1, T2, T3 and T0 were higher in the group H and the G group, and the difference was statistically significant (P0.05). There was no significant difference in the comparison between the groups (P0.05), and there was a significant difference between the group H and the group G and the R group (P0.05), and the H group in the MA group, and the T3 and T0 in the G group was significantly reduced (P0.05) in the H group. There is no difference in group comparison in Y30 group (P0.05). Conclusion: (1) 6% Hydroxyethyl Starch 130/0.4 and Sodium Chloride Injection and 4% Succinylated Gelatin Injection can be used safely and effectively for the capacity replacement therapy for elderly patients with LPD. (2) AHH for the elderly patients with LPD can help maintain hemodynamic stability, reduce the amount of bleeding and allogeneic infusion in the operation. Blood volume. (3) 4% Succinylated Gelatin Injection and 6% Hydroxyethyl Starch 130/0.4 and Sodium Chloride Injection can effectively improve the hypercoagulable state of the elderly patients, and hydroxyethyl starch makes the postoperative blood show mild hypocoagulable state, and is more conducive to the prevention of postoperative venous thrombosis in the elderly patients. (4) thrombus elastograph (TEG) dynamic monitoring of coagulation function, for the clinical Perioperative monitoring of coagulation function provides important data basis.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R614

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