临床麻醉学杂志：术中应用羟乙基淀粉维持血容量血浆胶体渗透压的变化.doc

术中应用羟乙基淀粉维持血容量血浆胶体渗透压的变化摘要 目的 观察非体外循环冠状动脉旁路移植术（OPCAB）中输注6%羟乙基淀粉130/0.4（万汶）血浆胶体渗透压（COP）的变化。方法 选择34例行OPCAB手术的患者(NYHA)，麻醉诱导时开始输注万汶至血管吻合完毕，总量控制为2530 mlkg-1。分别于万汶输注前(T0)、离断乳内动脉后(T1)、桥血管吻合完毕时(T2)监测血浆COP，观察血流动力学，记录输液量，失血量，血红蛋白（Hb），红细胞比积（Hct）和心脏指数（CI）。结果 手术过程血流动力学稳定，T0、T1、T2三个时段的COP均在正常值范围。T1失血量为12030 ml，输注万汶998110 ml，血浆COP由T0的21.71.4 mmHg升至22.31.3 mmHg (p0.05)；T2时段失血量为778179 ml，输注万汶2190135 ml，血浆COP降至21.51.4 mmHg，与T0相比不具有显著性差异(p0.05)。T2时段的Hb和Hct比T0下降明显(p0.05)，但仍保持在安全范围。T2时段的CI比T0有显著提高(p0.05)。结论 失血量低于10.9 1.2% 血容量时，输注万汶27.92.5 mlkg-1，血浆COP相对恒定。关键词 6%羟乙基淀粉130/0.4；血浆胶体渗透压COP；非体外循环冠状动脉旁路移植术OPCAB刘扬 首都医科大学北京朝阳医院麻醉科， 邮编100020 Changes of plasma colloid osmotic pressure after hydroxyethyl starch infusion during operationLIU Yang ZHANG Yong-qian WU Di YUE YunAbstrct Objective The effects of 6% hydroxythyl starch 130/0.4 (voluven) infusion on plasma colloid osmotic pressure (COP) were studied in patients during off-pump coronary artery bypass (OPCAB) surgery. Methods Thirty four patients (NYHA) underwent OPCAB were infused with voluven at a dose of 2530 mlkg-1 from induction of anaesthesia until the end of bypass. We determined COP at beginning of infusion (T0), after the transsection of artery (T1) and at the end of bypass (T2). Hemodynamics, requirement for voluven, blood loss, Hb，Hct and cardiac index (CI) were record consequently. Results Circulatory conditions were generally stable during operation. In three measurement points, the COP were always within the normal range. At T1, patients received 998110 ml of Voluven, the loss of blood was 12030 ml, the COP increased significantly compared to T0 (p0.05). Hb and Hct were always within normal range, but decreased significantly at T2 compared to T0 (p0.05). CI were higher at T2 than T0 (p120 gL-1，血浆白蛋白25 gL-1，血浆渗透压为 280310 mmolL-1，无肝肾功能不全及凝血功能异常。若术前合并室壁瘤、瓣膜病、对羟乙基淀粉过敏或术中出血量 25%血容量、血管吻合过程需要输血及血浆者排除本实验。麻醉方法 所有患者于入手术室前30 min肌注安定10 mg、吗啡10 mg、东莨菪碱0.3 mg。入室后面罩吸氧，在ECG、SpO2监测下建立外周静脉通路，局麻下桡动脉穿刺置管测MAP。麻醉诱导采用静注咪达唑仑0.030.05 mgkg-1、依托咪酯0.2 mgkg-1、舒芬太尼12 gkg-1、阿端0. 10.15 mgkg-1，气管插管后机械通气，依血气结果调整呼吸参数，维持PaCO2在3540 mmHg。经右锁骨下静脉置入三腔中心静脉管，经右颈内静脉置入Swan-Ganz漂浮导管(7 F, Baxter, Irvine, CA,美国)，用Baxter Edwards心输出量和Viridia 24 c血液动力学监测仪（Hewlett-packard公司，美国）、连续监测心排血指数（CI）、肺毛细血管楔压（PCWP）和中心静脉压（CVP）。麻醉维持采用静脉持续泵注异丙酚，按需间断追加舒芬太尼和阿端。术中维持血流动力学相对稳定，持续泵注硝酸异山梨醇(0.050.1 mgkg-1min-1 )，根据需要静脉泵注多巴胺(38 gkg-1min-1 )。手术过程 所有手术由同一组外科医生完成。胸部正中切口，纵劈胸骨，取左乳内动脉及大隐静脉备用。离断左乳内动脉前给予肝素150Ukg-1，维持全血激活凝血时间( ACT ) 350 s。用心脏固定器固定目标血管，行左乳内动脉与左前降支原位端侧吻合，然后大隐静脉与左回旋支、第一对角支和/或钝缘支、右冠等目标血管行远端吻合，最后行大隐静脉近端与升主动脉前壁吻合。所有病人均行桥血管血流定量测定，确认每根桥血流满意。冠脉血管吻合完成后静注鱼精蛋白，以1: 1的比例拮抗肝素效应。应用自体血液回收仪（Haemonetics, cell saver 5+ 2005，USA）回收术野中的出血。手术时间为45 h。输液方法 麻醉诱导前静脉预注乳酸林格液( RL ) 58 mlkg-1，诱导即刻开始输注万汶(北京费森尤斯卡比有限公司），并根据MAP、HR、CVP调整补液速度。术中万汶输注总量控制为2530 mlkg-1，其余容量需要用RL补充，维持CVP 712 mm Hg，PCWP 612 mm Hg，尿量12 mlkg-1 h -1。术中维持Hb 90 gL-1(有明显心肌缺血时则Hb 100 gL-1 ) 、Hct 28%，监测血浆COP前不输血（包括自体血）和血浆。血样采集及监测指标 分别于万汶输注前(T0)、离断乳内动脉后(T1)、桥血管吻合完毕时(T2)应用抗凝注射器抽取静脉血1 ml于BMT- 923胶体渗透压测定仪（德国，Osmomat 050, Gonotex, Berlin, molecular cut-off at 20 kDa)测定血浆COP，同时经血气分析仪 （GEM Premier 3000）检测Hb 、Hct。记录术中输液量，失血量（血液回收仪储血量和敷料含血量）及尿量。统计分析 采用SPSS13.0统计软件进行统计分析，数据以均数标准差（）表示。组间采用随机区组方差检验 (two-way ANOVA)进行处理，并用SNK法进行两两比较。P 25%血容量（ 20 mlkg-1），需在测定血浆COP前输血而被排除本实验。术中麻醉平稳，MAP、HR控制在正常范围，CVP、PCWP保持稳定(表2 )，且在T0、T1、T2三个时段差异无显著性 (P 0.05 )，T2时段的CI比T0显著提高 (表2，P 0.05)。T0、T1、T2的血浆COP均在正常值范围 (表3)。T0血浆COP为21.71.4 mmHg，T1血浆COP升至22.31.3 mmHg，与T0相比，差异具有统计学意义 ( P 0.05)。T1 和T2的万汶输注剂量分别为998110 ml和2190135 ml，输注最大剂量为33 ml kg-1，截至T2时段RL输注总量为825 110ml。T1出血量为 120233 ml，Hb和Hct分别由T0的138.33.7 gL-1和45.60.9%下降至124.110.6 gL-1和41.13.9%，两个时段差异不具有显著性(P 0.05)；T2出血量为 778179 ml (13.81.2%血容量)，Hb和Hct分别下降至95.77.5 gL-1和28.53.4%，与T0相比差异具有显著性 (P 25%血容量而被排除实验外，其余患者血管吻合过程血流动力学保持稳定，CVP平稳，CI较术前显著提高，Hb和Hct均在安全范围而无需输血。研究结果提示在OPCAB术中，失血量13.81.2% 血容量情况下，输注大剂量6%羟乙基淀粉130/0.4能够使患者血浆COP处于正常范围，是手术容量治疗的理想选择。表1患者一般情况（）n=32 (男22 女10)年龄(yr)62.6 6.9体重(kg)73.6 2.1 体表面积(BSA)2.10.2LVEF(%)62.0 5.5Hb(g.L-1)138.33.7Hct(%)45.60.9表2. 患者术中血流动力学变化（n=32, ）T0T1T2MAP(mmHg)77.312.869.79.372.28.1HR(bpm)61.68.475.96.583.29.7CVP(mmHg)7.62.77.92.67.72.1PCWP(mmHg)10.54.19.82.29.73.2CI(ml.min.m2) 2.20.52.40.42.90.6*注：T2与T0相比，*P 0.05 表3. 患者术中血浆COP、Hb/Hct和出入量的变化（n=32, ）T0T1T2COP (mmHg) 21.71.422.31.3*21.51.4Hb(gL-1)138.313.7124.110.6*95.77.5*Hct(%)45.91.941.13.9*28.53.4*出血量(ml)-120 30778 179尿量(ml)- 260 50750 108万汶剂量(ml)-9981102190 135RL(ml)2355023550825110注：T1、T2与T0相比，*P 0.05，*P 0.01参考文献： 1. 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