本文選題：急性高容量血液稀釋 + 血液保護　； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：近年來,異體輸血引發(fā)的問題越來越多,我國又面臨著血源短缺的嚴峻形勢,因此節(jié)約用血,減少異體血輸入成為當下醫(yī)學(xué)研究的一項重要課題。臨床應(yīng)用逐漸增多的一種有效的血液保護方法是急性高容量血液稀釋(AHH),隨著我國進入人口老齡化階段,需要外科手術(shù)的老年人越來越多。然而急性高容量血液稀釋應(yīng)用于老年人的安全性和有效性仍需要進一步探討。本研究將評價不同液體對老年患者凝血的影響,旨在為臨床提供參考。目的:探討不同膠體用于急性高容量血液稀釋對腹腔鏡胰十二指腸切除術(shù)(laparoscopic pancreaticoduodenectomy,LPD)老年患者血流動力學(xué)和凝血功能的影響。方法:選取擇期行LPD的45例ASA分級為Ⅱ或Ⅲ級的老年患者為研究對象,隨機分為三組,乳酸鈉林格注射液組(對照組,R組,n=15),6%羥乙基淀粉130/0.4氯化鈉注射液組(H組,n=15),4%琥珀酰明膠注射液組(G組,n=15)。患者入室后開放外周靜脈通路,1%利多卡因局麻下行橈動脈穿刺置管術(shù),監(jiān)測有創(chuàng)動脈血壓。三組患者均輸入10ml/kg乳酸鈉林格氏液以補充禁食水所失液體量,然后H組和G組以25ml/min的速度分別輸注6%羥乙基淀粉130/0.4氯化鈉注射液和4%琥珀酰明膠注射液總預(yù)計量(15ml/kg)的1/3,以防全麻誘導(dǎo)時循環(huán)抑制引起的低血壓。全麻誘導(dǎo)均靜脈注射咪達唑侖0.05mg/kg,舒芬太尼0.3μg/kg,丙泊酚1.5mg/kg,順式阿曲庫銨0.15mg/kg,阿托品0.5mg,瑞芬太尼1~2μg/kg。麻醉維持靜脈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,術(shù)中間斷追加順式阿曲庫銨來維持肌松。氣管插管改機械通氣后行右側(cè)頸內(nèi)靜脈穿刺置管術(shù),補液并監(jiān)測中心靜脈壓(CVP)。全麻誘導(dǎo)后至手術(shù)切皮前再輸入總預(yù)計量的2/3,以達到超容血液稀釋狀態(tài)。R組按15ml·kg-1·h-1的速度常規(guī)輸入乳酸鈉林格注射液而不行AHH。若術(shù)中Hb80g/l,Hct25%時輸入同型異體血,CVP15cm H2O給予利尿劑。分別在AHH前(T0),AHH后30min(T1),AHH后1h(T2),手術(shù)結(jié)束時(T3)采取靜脈血測快速血栓彈力圖各個參數(shù):凝血反應(yīng)時間(R)、血凝塊形成時間(K)、Angle值、最大振幅(MA)、30min血凝塊幅度減少速度(LY30)。動脈血氣值(Hb,Hct),連續(xù)監(jiān)測并記錄Sp O2、Pet CO2、HR、MAP、CVP、T、BIS。記錄術(shù)中尿量、輸血量、出血量。結(jié)果:(1)三組患者的性別構(gòu)成、年齡、體重、手術(shù)時間、出血量等差異均無統(tǒng)計學(xué)意義(P0.05)。(2)R組的異體輸血量和液體總輸入量明顯高于H組和G組(P0.05),而H組和G組患者的尿量明顯多于R組(P0.05)。(3)在AHH前各組HR、MAP、CVP、Sp O2、Pet CO2差異無統(tǒng)計學(xué)意義(P0.05)。與T0相比,R組的MAP在T1明顯下降,且與H組和G組組間差異有統(tǒng)計學(xué)意義(P0.05或P0.01),三組患者MAP其余各點基本穩(wěn)定,組間比較差異無統(tǒng)計學(xué)意義(P0.05)。與T0相比,H組和G組的HR在T1明顯下降(P0.05),G組與R組比較差異有統(tǒng)計學(xué)意義(P0.05)。三組的Sp O2、Pet CO2各時點比較差異無統(tǒng)計學(xué)意義(P0.05)。與T0相比,R組的CVP在T1明顯降低,H組和G組的CVP在T1、T2、T3均明顯升高,且在T1與R組比較差異有統(tǒng)計學(xué)意義(P0.05)。三組患者的T、BIS差異無統(tǒng)計學(xué)意義(P0.05)。(4)與T0相比,R組的Hb、Hct在T1-T3無明顯變化;H組和G組的Hb、Hct在AHH后均顯著降低(P0.05),但兩組組間比較差異無統(tǒng)計學(xué)意義(P0.05)(5)血栓彈力圖指標:稀釋前,3組患者的TEG指標無差異(P0.05);ACT值組內(nèi)比較H組和G組在T1、T2、T3與T0比較時間明顯延長(P0.05),AHH后H組和G組與R組比較差異有統(tǒng)計學(xué)意義(P0.05);R值組內(nèi)比較H組和G組T1、T2、T3與T0比較升高,差異有統(tǒng)計學(xué)意義(P0.05),AHH后組間比較R值H組、G組與R組比較差異均有統(tǒng)計學(xué)意義(P0.05);K值與Angle角組內(nèi)比較H組和G組的T3與T0比較差異有統(tǒng)計學(xué)意義(P0.05)R組組內(nèi)比較差異無統(tǒng)計學(xué)意義(P0.05),組間比較H組和G組與R組比較差異有統(tǒng)計學(xué)意義(P0.05);MA值組內(nèi)比較H組、G組的T3與T0比較明顯減小(P0.05)組間比較H組、G組與R組比較差異均有統(tǒng)計學(xué)意義(P0.05);H組與G組比較差異也有統(tǒng)計學(xué)意義(P0.05);EPL、LY30組內(nèi)組間比較均無差異(P0.05)。結(jié)論:(1)6%羥乙基淀粉130/0.4氯化鈉注射液與4%琥珀酰明膠注射液均可以安全有效地用于LPD老年患者的容量替代治療。(2)AHH用于LPD老年患者能有助于維持患者血流動力學(xué)穩(wěn)定,減少術(shù)中的出血量和異體輸血量。(3)4%琥珀酰明膠注射液和6%羥乙基淀粉130/0.4氯化鈉注射液均能有效的改善老年患者的高凝狀態(tài),且羥乙基淀粉使術(shù)后血液呈輕度低凝狀態(tài),更有利于老年患者預(yù)防術(shù)后靜脈血栓的形成。(4)血栓彈力圖(TEG)動態(tài)監(jiān)測凝血功能,為臨床圍手術(shù)期凝血功能監(jiān)測提供重要的數(shù)據(jù)依據(jù)。
[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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R614

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本文編號：2017198