急性超容性血液稀释用于老年患者围术期节约用血的观察

急性超容性血液稀释技术(AHHD)能有效扩容,节约手术用血,但其研究对象大多为青壮年,对于老年人是否可行尚需进一步探讨。琥珀酰明胶是临床上常用的一种人工胶体,价格适中,具有血液扩容作用,对凝血系统影响较小,但将琥珀酰明胶用于老年人行AHHD的安全性如何,目前仍有争议。本研究对围术期老年患者采用琥珀酰明胶行AHHD时的血液动力学、电解质、凝血功能、动脉血气的变化进行观察,旨在探讨老年患者围术期施行AHHD的安全性和可行性。     

术前急性超容性血液稀释的研究进展

术前急性超容性血液稀释具有与术前急性等容性血液稀释同样的扩容效应,且具有操作简便、节约时间及费用等优点。     

术前急性超容性血液稀释的研究进展

术前急性超容性血液稀释具有与术前急性等容性血液稀释同样的扩容效应,且具有操作简便、节约时间及费用等优点。     

急性高容性血液稀释复合控制性降压应用于围术期脊柱手术

急性高容性血液稀释(AHH)是手术前短时间内快速输入一定量的胶体类血浆代用品,使血管内容量高于正常容量的方法。它可以减少手术中红细胞和其他血液成分,如凝血因子的损失,减少围手术期输异体库血,从而减少因输血带来的不良反应,降低医疗费用和减少血源传播性疾病。控制性降压是采用药物     

急性超容性血液稀释结合去氨加压素用于肝叶切除围术期节约用血的临床观察

本研究旨在探讨急性超容量血液稀释(acute hypervolemic hemodilution，AHH)结合去氨加压素(desmopressin，DDAVP)用于肝叶切除术，观察术中出血及围术期Hct、Hb和凝血功能的变化。     

6%羟乙基淀粉急性超容性血液稀释对开胸手术患者围术期肾功能的影响

目的 观察术中输入6％中分子量羟乙基淀粉(HES)急性超容性血液稀释(AHHD)对开胸手术病人围术期肾功能的影响。方法 肾功能正常的择期开胸手术病人30例,随机分为两组:HES组(A组)和对照组(B组),每组15例。A组在25 min内快速输注6％HES 15 ml/kg,使血容量增加约20％,术中丢失的血液以等量的HES代替,用等量乳酸林格氏液补充其余液体需要量。B组输注乳酸林格氏液,但不行AHHD。测定麻醉前(T1)、术毕(T2)、术后72 h(T3)血及尿肌酐(BCr,UCr)、血尿素氮(BUN)、尿α1-微球蛋白(α1-MG)、尿白蛋白(ALB)、尿免疫球蛋白G(IgG),计算肌酐清除率(CCr)和钠排泄分数(FENa)。结果 两组各时点血BUN、尿ALB、尿IgG、CCr和FENa均在正常范围内;两组尿α1-MG在T2及T3均高于T1(P<0.01或0.05)。各指标组间比较差异均无显著性。结论 用6％中分子量HES行AHHD对肾功能正常患者的肾功能无明显影响。     

急性高容性血液稀释用于大手术的临床观察

本院自２００１年以来，对大手术者采用术前急性高容性血液稀释法（acutehypervolemichemodilution，AHH），在一定程度上节约了用血，并为术中血流动力学平稳提供了保证。资料和方法１．一般资料：选择ASAⅠ～Ⅱ级，无心、肺、肝、肾疾患，血红蛋白（Hb）＞１１g／L，红细胞压积（HCT）＞３５％，估计术中出血＞８００ml以上者，采用AHH法，此作为实验组。以２０００年相应病例未采用AHH法者作为对照组。２．实验方法：实验组患者入室后选择上肢大静脉和／或颈内静脉穿刺置管，开放１～２路静脉，按１５～２０ml／kg·h速率，以１∶…     

围术期急性高容量血液稀释结合硝酸甘油控制性降压的观察

血液稀释结合控制性低血压是血液保护的新措施,可以有效地减少手术出血和输血量,对于节约用血、减少或避免血源性传染病有重要价值。本研究采用围术期急性高容量血液稀释(AHH)联合硝酸甘油控制性低血压,用于食管癌、贲门癌手术病人,探讨AHH联合控制性降压临床应用的可行性。     

急性超容性血液稀释对靶控输注异丙酚药代动力学的影响

目的 探讨急性超容性血液稀释(AHHD)对靶控输注(TCI)异丙酚药代动力学的影响。方法36例ASAⅠ-Ⅱ级并符合纳入标准的择期手术病人,随机分为2组,每组18例。稀释组按10ml·kg-1输入复方乳酸林格氏液补充生理需要量后,行异丙酚TCI,TCI 10 min时开始AHHD(在30 min内输入6％羟乙基淀粉20 ml·kg-1)。TCI以恒定靶血浆药物浓度(3μg·ml-1)变速输注60 min。对照组仅输入复方乳酸林格氏液10 ml·kg-1并以相同方式行TCI,但不实施AHHD。分时点间断采动脉血90min,应用气相色谱-质谱(GC-MS)法测定异丙酚血药浓度。间断测定血浆总蛋白(TPP)、白蛋白(AIb)、血红蛋白(Hb)及红细胞压积(Hct)判断AHHD程度。采用非线性混合效应模型(NONMEM)软件分析与计算药代动力学参数。结果 AHHD对TCI异丙酚药代动力学的影响可用二室指数开放型药代动力学模型描述。与对照组比较,稀释组病人的中央室分布容积(V1)和周边室分布容积增大,隔室间的转运速率和清除率加快。AHHD后Hb与Hct较AHHD前分别降低31.0％、31.3％;TPP与AIb分别较AHHD前降低30.1％、25.7％。结论 AHHD后异丙酚TCI所需的靶血浆药物浓度可能相对增加,药物作用时间可能相对缩短。     

急性超容性血液稀释对心肌钙蛋白的影响

临床研究报道了急性超容性血液稀释（acute hypervolemic hernodilution,AHHD）不仅与等容血液稀释具有同样的血液保护作用,而且有省时、省费、病人感染机会少、痛苦少等优点,但可能引起心脏负荷过重。因此,我们对无心肺疾患在全麻下行非心脏手术的成年患者,采用AHHD,通过观察心肌钙蛋白（cTnI）的变化,评价AHHD对心肌的影响,为围术期适度、合理地进行血液稀释,提供更为可靠的临床依据。     

6%羟乙基淀粉130/0.4和6%羟乙基淀粉200/0.5急性高容量血液稀释对全麻患者凝血功能的影响

目的 评价6%羟乙基淀粉130/0.4(6% HES130/0.4)和6%羟乙基淀粉20010.5(6% HES200/0.5)急性高容量血液稀释(AHHD)对全麻患者凝血功能的影响.方法 择期全麻手术患者60例,ASA Ⅰ或Ⅱ级,年龄18～64岁,随机分为3组(n=20):对照组(C组)、6%HES200/0.5组(H组)及6%HES130/0.4组(V组).H组和V组于麻醉诱导前90 min分别静脉输注6% HES200/0.5或6% HES130/0.4,速率20 ml·kg-1·h-1,扩容量20ml/kg;C组仅静脉输注乳酸钠林格氏液6～8 ml·kg-1·h-1.于AHHD前、AHHD后即刻及AHHD后1 h采血,进行下述指标的测定:血小板计数、凝血酶原时间(PT)、血小板最大聚集率和Sonoclot玻璃珠激活全血凝固时间(gbACT)、凝结速率(CR)、血小板功能(PF)和曲线达峰时间.H组和V组同时还测定活化部分凝血活酶时间(APTT)、凝血因子Ⅷ活性(FⅧ:C)、von Willebrand因子(vWF)水平.结果 与AHHD前比较,H组和V组AHHD后PT和APTY均延长,FⅧ:C下降(P＜0.05),但2组AHHD后1 h FⅧ:C高于AHHD后即刻(P＞0.05);H组和V组AHHD后血小板最大聚集率降低,但AHHD后1 h高于AHHD后即刻(P＜0.05).与H组比较,V组AHHD后CR降低(P＜0.05),其他凝血功能指标比较差异无统计学意义(P＞0.05).结论 6%HES130/0.4和6% HES200/0.5(20 ml/kg)AHHD对全麻患者凝血功能的抑制作用较轻;两者对凝血功能的影响无明显差异.     

Organ blood supply and oxygenation during limited isovolemic hemodilution with 6% HES 200/0.62 and 6% Dextran 70]

Oxygen delivery (systemic oxygen transport) is directly dependent upon cardiac output and oxygen content of the blood. The rheology of blood, however, represents a co-determinant of oxygen delivery. It has recently been argued that the increase in plasma viscosity occurring under hemodilution with dextran could be detrimental to blood flow and, hence, tissue oxygenation. METHODS. Twelve splenectomized beagles (12.5 +/- 1.7 kg) were anesthetized and randomly assigned to hemodilution to 20 vol% hematocrit (hct) with 6% hydroxyethyl starch (HES 200/0.62) or 6% dextran-70 (DX-70). The effects of hemodilution (HD) upon macrohemodynamics, plasma and blood volumes (131I dog albumin distribution), organ blood flow (radioactive-labelled microspheres, phi 15 microns), and local tissue oxygenation (pO2 multiwire surface electrode) were evaluated with special reference to any actual plasma viscosity. RESULTS. Moderate HD with either solution resulted in equivalent changes in macrohemodynamics and plasma and blood volumes. Tissue oxygen extraction increased (p less than 0.05) due to a small rise (maximally 28%) in cardiac output. HD with either solution resulted in an increase in plasma viscosity that was more pronounced in the DX-70 group (1.45 +/- 0.07 mPa.s) as compared to HES-diluted animals (1.16 +/- 0.04 mPa.s). Blood flow increased (p less than 0.01) in all organs after HD independently of the diluent. Both higher pO2 values on the surface of liver and skeletal muscle (p less than 0.01) as well as a shift of the pO2 histograms to the right indicated a more homogeneous tissue perfusion during HD. CONCLUSIONS. In normotensive animals without peripheral arterial occlusive disease undergoing moderate hemodilution, organ blood flow was independent of plasma viscosity. Systemic oxygen transport was not affected by plasma viscosity changes, but is primarily determined by systemic hct. Local surface tissue oxygenation on skeletal muscle and liver was not impaired, but rather improved during hemodilution despite raised plasma viscosity. Of the rheological factors influencing oxygen delivery, hct thus plays the predominant role while plasma viscosity is of minor importance.     

6%羟乙基淀粉急性高容性血液稀释在儿科病人的应用

目的研究6%羟乙基淀粉用于婴幼儿和儿童对于血液流变学、血小板功能和凝血功能等的影响.方法20例手术病人按年龄分为婴幼儿组（Ⅰ组,〈3岁,n=9）和儿童组（C组,3～12岁,n=11）,术前用6%羟乙基淀粉10 ml/kg行高容性血液稀释,输液前后分别抽取颈静脉血测定血液流变学、血小板功能和凝血功能,比较各组输液前后以及两组之间的变化.结果两组病人输液后全血低切、中切和高切粘度均显著下降（P〈0.01）,但血浆粘度无显著改变;两组病人血细胞比容、纤维蛋白原在输液后均显著下降（P〈0.01）;红细胞聚集指数、刚性指数、变形指数在输液前后无显著变化;与输液前比较,输液后红细胞电泳指数显著增加（P〈0.05）;两组病人血沉、血小板计数和血小板聚集率、部分凝血活酶时间在输液后无显著变化;C组病人输液后凝血酶原时间显著延长.两组间各项指标相同时点比较虽有一定变化,但无显著性差异（P＞0.05）.结论6%羟乙基淀粉用于1～12岁儿科病人进行术前急性高容性血液稀释,能改善血液流变性,稳定血液动力学,但对凝血功能无影响,不增加出血倾向.     

A prospective randomized study comparing two techniques of perioperative blood conservation: isovolemic hemodilution and hypervolemic hemodilution

We compared hypervolemic hemodilution (HVH) and isovolemic hemodilution (IVH) as means of perioperative blood conservation under standardized conditions. Thirty ASA status I/II adults slated for orthopedic, ear-nose-throat, or general surgery with expected blood loss of >500 mL underwent either IVH (n = 15) or HVH (n = 15). They were hemodiluted to a hematocrit (Hct) of 25% by blood withdrawal and simultaneous polygeline (Hemaccel((R))) infusion (IVH) or by infusing polygeline without blood withdrawal, thus creating hypervolemia (HVH). Further blood loss to a Hct of 20% was allowed before autologous/allogeneic blood transfusion to aim for a 24-h postoperative Hct of > or =25%. Systolic blood pressure (P = 0.0107) and central venous pressure (P = 0.0281) were significantly higher during HVH. The mean difference (MD) between the target postdilution Hct of 25% and the Hct achieved was not statistically significant in either group (MD [95% confidence interval; CI], 0% [-0.7% to 0.7%] for IVH and 0.6% [-0.1% to 1.3%] for HVH). The actual amount of allogeneic blood used was similar in the two groups, with an MD (95% CI) of -7 (-326 to 312), and was significantly less than the corresponding projected amount (MD [95% CI], -581 mL [-753 to -409 mL] in IVH; -376 mL [-531 to -221] in HVH). The two techniques were similar in time taken (MD [95% CI] = 7 min [-0.5 to 14.5 min]), cost incurred (MD [95% CI] = $1.7 (-$4.10 to $7.50]), and volumes of polygeline used (MD [95% CI] = -6 mL/kg body weight [-16 to 4 mL/kg body weight]). This study found IVH and HVH comparable in significantly reducing perioperative allogeneic blood requirements, time needed, and cost incurred. The formula used for achieving the desired HVH appears promising. IMPLICATIONS: Both hypervolemic hemodilution (HVH) and isovolemic hemodilution (IVH) claim to reduce red blood cell loss during surgery by diluting the patient's blood. This study found both comparable in significantly reducing the exposure to bank blood in the perioperative period, the time needed, and the cost incurred. HVH, being simpler, because it does not involve blood withdrawal, appeared superior to IVH in the healthy adults studied. Larger studies are needed to substantiate the results.     

Peri-operative tolerance to large-dose 6% HES 200/0.5 in major urological procedures compared with 5% human albumin

We studied the long-term efficacy and safety of medium-molecular-weight hydroxyethyl starch (HES) administered in doses above 20 ml.kg-1 during major blood replacement therapy. Blood replacement for 50 patients used 6% HES 200/0.5 (HES group) or 5% albumin (ALB group) and additional blood components according to a defined protocol. We compared safety, efficacy and costs in 4 peri-operative days. Colloid administration on the day of surgery was 38.4 ml.kg-1 (HES group) and 35.1 ml.kg-1 (ALB group). Haemodynamic, coagulation and renal function parameters were similar. Although total serum protein was still different on the third postoperative day (53.45 gl-1 (HES group) and 60.6 gl-1 (ALB group) (p < 0.01)) the colloid osmotic pressure always remained above 19.5 (2.5) mmHg (HES group). Blood loss (3810 (1632) ml (HES group) and 3455 (1733) ml (ALB group)) and the requirement for blood components was comparable. Costs were reduced by 35% (p < 0.05) in the HES group. We conclude that using 6% HES 200/0.5 as the only colloid for treatment even of large blood loss is a safe and economic alternative to albumin.     

羟乙基淀粉200/0.5和羟乙基淀粉130/0.4术前急性高容量血液稀释对结肠癌根治术患者血液流变学的影响

目的 评价6%羟乙基淀粉(HES)200/0.5和6%HES 130/0.4术前急性高容量血液稀释(AHH)对结肠癌根治术患者血液流变学的影响.方法 择期在全麻下行结肠癌根治术患者40例,ASA Ⅰ或Ⅱ级,随机分为2组(n=20),麻醉诱导期间于30 min内静脉输注15 ml/kg HES 200/0.5(Ⅰ组)或HES 130/0.4(Ⅱ组),AHH结束后开始手术.分别于麻醉诱导前(基础状态,T0)、AHH后即刻(T1)、AHH结束后1 h(T2)和术后1 h(T3)时抽取静脉血样,检测全血粘度、血浆粘度、红细胞聚集指数、血小板聚集指数和红细胞压积(Hct).结果 与T0时比较,Ⅰ组T1时全血低切粘度和红细胞聚集指数降低,T1-3时全血中切粘度、全血高切粘度、血浆粘度、血小板聚集指数和Hct降低,Ⅱ组T1-3时全血低切粘度、全血中切粘度、全血高切粘度、血浆粘度、红细胞聚集指数和Hct降低(P<0.05);与Ⅰ组比较,Ⅱ组T2,3时全血低切粘度和红细胞聚集指数降低,T1-3时血小板聚集指数升高(P<0.05).结论 6%HES 200/0.5与6%HES 130/0.4(15 ml/kg)术前AHH均能改善结肠癌根治术患者围术期血液流变学,其中6% HES 130/0.4的效果较好.     

3.5% urea-linked gelatin is as effective as 6% HES 200/0.5 for volume management in cardiac surgery patients

PURPOSE: To compare the efficacy of volume expansion with 3.5% gelatin and 6% hydroxyethyl starch 200/0.5 in patients undergoing cardiac surgery. The second objective was to compare the two colloids in terms of blood losses and allogeneic blood transfusion exposure rate. METHODS: In this open-label controlled study, patients were randomly allocated to receive either 3.5% urea-linked gelatin (GEL group: n = 55) or 6% hydroxyethyl starch 200/0.5/5.1 (HES group: n = 55) for per- (including priming of the bypass machine) and postoperative volume management with a maximum dosage of 30 +/- 3 mL.kg(-1).day(-1). Volume replacement was guided according to routine per- and postoperative care based on cardiac index, mixed venous oxygen saturation, and diuresis. If additional colloid was required, 4.5% albumin had to be given. The study period comprised per- and postoperative investigations up to 18 hr after surgery. RESULTS: All hemodynamic variables were comparable in both groups. Total study drug was 25.8 +/- 4.8 mL.kg(-1) in the GEL group and 24.5 +/- 6.0 mL.kg(-1) in the HES group. There was no difference in the number of patients receiving albumin solution or in the amount of albumin administered. Total blood loss was higher in the HES than in the GEL group (11.0 +/- 7.8 mL.kg(-1) vs 8.7 +/- 4.0 mL.kg(-1); P < 0.05) resulting in a higher need for allogeneic blood transfusion (HES: nine patients received 12 units, GEL two patients received 3 units; P = 0.026). CONCLUSION: In the conditions of the present study, HES was not associated with a better plasma expansion effect than GEL. HES could result in a higher need for allogeneic blood transfusion.     

6%羟乙基淀粉200/0.5氯化钠注射液对外科手术围术期凝血功能和肾功能的影响

目的 探讨围手术期应用6%羟乙基淀粉(Hetastarch,HES)200/0.5氯化钠注射液对外科手术中全麻患者凝血功能及肾功能的影响.方法 限期全麻胃肠道恶性肿瘤手术患者40例,随机分为两组,每组20例:6%HES 130/0.4(A组,万汶)和6%HES200/0.5(B组,代斯).根据晶胶结合(2∶1)的原则补液,全麻术中输实验药物1000ml,术后第1、2天输实验药物量为1000ml/d.术前和术后第3天检测以下指标:血红蛋白(Hb)、血细胞比容(Hct)、血尿素氮(BUN)、血清肌酐(SCr)、凝血酶原时间(PT)、凝血酶时间(TT)、部分凝血活酶时间(APTT)、von Willebrand(vWF)因子活性、Ⅷ因子活性、全血黏度高切变率、全血黏度低切变率、血浆黏度.结果 术后两组患者Hb、Hct均下降,但组间差异无统计学意义(P>0.05).术后两组患者SCr均明显下降,组间、组内差异均有统计学意义(P<0.05),但均在正常范围.两组患者PT、TT、APTT、全血黏度高切变率、血浆黏度、vWF因子活性、Ⅷ因子活性、BUN术前术后改变组间、组内差异无统计学意义(P>0.05).结论 6%羟乙基淀粉200/0.5氯化钠注射液进行容量替代治疗时对外科手术全麻患者凝血功能及肾功能的影响较小.     

The influence of two different hydroxyethyl starch solutions (6% HES 130/0.4 and 200/0.5) on blood viscosity

We performed the current study to investigate the influence of 2 different hydroxyethyl starch (HES) solutions, the novel medium molecular weight HES 130/0.4 (6%) and HES 200/0.5 (6%), on plasma and whole blood viscosity in vitro and ex vivo in patients with severe head injury. For the in vitro experiments, blood was incubated with increasing concentrations (0%-50% vol/vol plasma) of either 6% HES 130/0.4 or 6% HES 200/0.5 solution. Plasma viscosity and whole blood viscosity (hematocrit [Hct] 45%) at high (94.5 s(-1)) and low (0.1 s(-1)) shear rates were determined. Both HES solutions increased plasma viscosity, but HES 130/0.4 to a lesser extent than HES 200/0.5. Whole blood viscosity was significantly less with HES 130/0.4 than with HES 200/0.5 at concentrations of 37.5% and larger. In the ex vivo study on 31 patients with severe cranio-cerebral trauma treated randomly with either HES 130/0.4 or HES 200/0.5 over several days, frozen plasma samples were thawed and plasma viscosity was determined. Blood was reconstituted with normal erythrocytes (0, Rh neg, Hct 45%) for whole blood viscosity measurements. In both groups plasma and blood viscosity tended to increase over time without statistical significance. Although the prominent effects found in vitro are not in keeping with the ex vivo data, they are likely to reflect the true clinical situation during repetitive, large-dose HES administration. We therefore conclude that HES 130/0.4 may have hemorheological advantages over conventional HES 200/0.5 when used in large quantities.