等渗透剂量20%甘露醇与3%高渗盐水对大脑半球胶质瘤切除术患者血浆渗透浓度和电解质影响的比较

目的 比较择期大脑半球胶质瘤切除术中应用等渗透剂量的3%高渗盐水(hypertonie saline,HTS)和20%甘露醇(mannitol,M)降颅内压(intracranial pressure,ICP)的同时,患者血浆渗透浓度和电解质的变化及其临床意义. 方法 择期行大脑半球胶质瘤切除术患者40例,根据计算机随机分组表分为高渗盐水组(HTS组)和甘露醇组(M组)(n=20).两组均行静吸复合麻醉,异氟醚呼气末浓度达1 MAC后,在15 min内输注等渗透剂量3%HTS(5.33 ml/kg)或20%M(1 g/kg).记录输注前即刻(T0)、输注后即刻、输注后5、15、30、60、90、120 min(T1～T7)平均动脉压(MAP)、心率(HR),同时采取5 ml动脉血测定血球压积、血浆Na+、K+、Cl浓度、血pH、血浆渗透浓度,同时监测颅内压.结果 两组血浆渗透浓度在输注高渗溶液后均明显升高,在T1达高峰[HTS组:(305.1+4.3)mOsm/L;M组:(304.6±3.5)mOsm/kg](P<0.05),HTS组血浆Na+和cl浓度明显升高,于T1达高峰(152.3+5.2)mEq/kg(P<0.05),M组血浆Na+度降低,在T1达低谷(131.2±3.3)mEq/kg(P<0.05);血浆Cl-浓度在HTS组升高(P<0.05),M组降低(P<0.05).HTS组ICP在T2～T5降低(P<0.05),尤以T1～T2时段降低幅度更为明显,M组ICP在T3～T5降低(P<0.05).结论 在实施择期神经外科手术的患者,单剂静脉输注5.49 mOsm/kg的3%HTS和20%M引起同等程度的血浆渗透浓度上升,并在输注末达到高峰.     

Influence of rate and volume of infusion on the kinetics of 0.9% saline and 7.5% saline/6.0% dextran 70 in sheep

We examined whether volume kinetic variables obtained during infusion of a short bolus of 0.9% saline (NS) or 7.5% saline/6.0% dextran 70 (HSD) predict the dilution-time curve resulting from a 20-min infusion of the same fluid. Each of six conscious, splenectomized sheep (mean body weight, 36 +/- 3 kg), on 4 different days, in a random order, received each of 4 IV boluses: NS at a rate of 1.2 mL. kg(-1). min(-1) over 5 min or 20 min or 4.0 mL/kg of HSD over 2 min or 20 min. One, 2, and 3-volume kinetic models were fitted to the dilution of the arterial hemoglobin concentration and the urinary excretion as sampled during 180 min. The maximum dilution of arterial plasma at the end of the 5-min and 20-min infusions of NS was approximately 10% and 22%, respectively, and after the 2-min and 20-min infusions of HSD, maximum dilution was 24% and 21%, respectively. The median absolute performance error was virtually identical when the mean variable estimates from the 5-min infusion of NS were used to predict the individual dilution-time curves of the 5-min (mean, 0.027 dilution units) and 20-min (mean, 0.027) infusions and when the 2-min infusion of HSD was used to predict the dilution during the individual 2-min (mean, 0.050) and 20-min infusions (mean, 0.047). Computer simulations indicated that the difference at the end of infusion between the volume effects of NS and HSD is larger after longer infusions. We concluded that the volume kinetic variables obtained during a short infusion can be used to predict the outcome of a longer one, even if the longer infusion also delivers a larger volume. IMPLICATIONS: Kinetic analysis of a short infusion of 7.5% saline/6% dextran or 0.9% saline accurately predicts the effects of a longer infusion of the same volume (7.5% saline/6% dextran) or of a larger volume (0.9% saline).     

The comparison of hypertonic saline (7.5%) and normal saline (0.9%) for initial fluid administration before spinal anesthesia

Hypertonic saline can be used for initial fluid administration before spinal anesthesia. It is effective in small-volume fluid resuscitation. This randomized double-blinded study compared the effects of 7.5% hypertonic saline (HS) and 0.9% normal saline (NS) in doses containing 2 mmol/kg of sodium in 40 ASA physical status I-II patients undergoing arthroscopy or other lower limb surgery under spinal anesthesia. We infused 1.6 mL/kg of HS or 13 mL/kg of NS for initial fluid administration before spinal anesthesia induced with a 10-mg dose of 0.5% hyperbaric bupivacaine. Etilefrine was administered to maintain mean arterial pressure at > or =80% of its control value. Systolic and diastolic blood pressure, heart rate, and cardiac index did not differ between the groups, and the amount of etilefrine administered was similar in the treatment groups. In all our patients, the plasma sodium concentrations were within the normal range after surgery and serum osmolality was within the normal range after spinal anesthesia. The time and the volume of the first micturition were similar in both groups, despite the much smaller amount of infused free water in the HS group. We conclude that 7.5% HS was as good as NS for the initial fluid administration before spinal anesthesia when the amount of sodium was kept unchanged.     

Effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance

BACKGROUND: The purpose of the study was to compare the effect of equiosmolar solutions of mannitol and hypertonic saline (HS) on brain relaxation and electrolyte balance. METHODS: After institutional review board approval and informed consent, patients with American Society of Anesthesiologists physical status II-IV, scheduled to undergo craniotomy for various brain pathologies, were enrolled into this prospective, randomized, double-blind study. Patients received 5 ml/kg 20% mannitol (n = 20) or 3% HS (n = 20). Partial pressure of carbon dioxide in arterial blood was maintained at 35-40 mmHg, and central venous pressure was maintained at 5 mmHg or greater. Hemodynamic variables, fluid balance, blood gases, electrolytes, lactate, and osmolality (blood, cerebrospinal fluid, urine) were measured at 0, 15, 30, and 60 min and 6 h after infusion; arteriovenous difference of oxygen, glucose, and lactate were calculated. The surgeon assessed brain relaxation on a four-point scale (1 = relaxed, 2 = satisfactory, 3 = firm, 4 = bulging). Appropriate statistical tests were used for comparison; P < 0.05 was considered significant. RESULTS: There was no difference in brain relaxation (mannitol = 2, HS = 2 points; P = 0.8) or cerebral arteriovenous oxygen and lactate difference between HS and mannitol groups. Urine output with mannitol was higher than with HS (P < 0.03) and was associated with higher blood lactate over time (P < 0.001, compared with HS). Cerebrospinal fluid osmolality increased at 6 h in both groups (P < 0.05, compared with baseline). HS caused an increase in sodium in cerebrospinal fluid over time (P < 0.001, compared with mannitol). CONCLUSION: Mannitol and HS cause an increase in cerebrospinal fluid osmolality, and are associated with similar brain relaxation scores and arteriovenous oxygen and lactate difference during craniotomy.     

7.5%高渗盐水对腹部外科手术后液体平衡的影响

目的　探讨 7.5 %高渗盐水对腹部外科手术后液体平衡的影响。方法　 2 0例择期腹部大手术和 6例重症腹膜炎急诊手术患者 ,配对分为两组对比。术毕进入外科ICU后 ,研究组(n =13 )应用 7.5 %高渗盐水 (4ml/kg体重 ) ,后续平衡液 ;对照组 (n =13 )仅用平衡液。比较两组患者的输液量、尿量、液体平衡和体重变化。结果　与对照组相比 ,研究组术后尿量较多 ,术后第 1天和术后 48h的差异有显著性 (t =2 .6612 ,P =0 .0 2 0 7;t=3 .6863 ,P =0 .0 0 3 1) ;手术当日和术后 48h的液体正平衡量较少 ,差异有显著性 (t =2 .3 40 8,P =0 .0 2 79;t =2 .3 691,P =0 .0 2 62 ) ;术后体重增加幅度低于对照组 ,差异有显著性 (t =2 .2 761,P =0 .0 42 0 ) ;术后体重下降时间早于对照组 ,差异有非常显著性 (t =7.615 4,P =0 .0 0 44 )。结论　 7.5 %高渗盐水有明显的利尿作用 ,可动员、排出体内扣押的过多液体 ,减少腹部外科手术后液体正平衡 ,促进液体负平衡提前出现。     

7.5%高渗盐水对择期腹部大手术后液体平衡的影响

目的　探讨 7 5 %高渗盐水对择期腹部大手术后液体平衡的影响。方法　 2 2例择期腹部大手术患者 ,配对分为两组。术毕进入外科ICU后 ,研究组 11例应用 7 5 %高渗盐水 4ml kg ,后续平衡液 ;对照组 11例仅用平衡液。比较两组患者的输液量、尿量、液体平衡和体重变化。结果　与对照组相比 ,研究组手术日和术后第 1天尿量较多 [(2 6 5 0± 5 31)mlvs (2 0 4 6± 5 72 )ml,t=2 5 5 17,P <0 0 5 ;(2 716± 6 4 0 )mlvs (2 2 32± 4 89)ml,t=2 2 878,P <0 0 5 ];术日和术后 4 8h的液体正平衡量较少[(40 5 8± 115 9)mlvs (5 92 2± 14 93)ml,t=2 870 1,P <0 0 5 ];(492 6± 2 6 98)mlvs (76 5 6± 2 5 4 3)ml,t=2 2 2 94 ,P <0 0 5 ];术后体重增加幅度低于对照组 [(5 0± 1 9)kgvs (7 2± 1 3)kg ;t=2 80 98,P <0 0 5 ];术后体重下降时间早于对照组 [(2 4 4± 3 4 )hvs (31± 5 )h ;t =3 382 6 ,P <0 0 1]。结论　7 5 %高渗盐水有明显的利尿作用 ,可动员、排出体内扣押的过多液体 ,减少择期腹部大手术后液体正平衡 ,促进液体负平衡提前出现。     

Effects of hypertonic saline (7.5%) on extracellular fluid volumes in healthy volunteers

This study evaluated the effects of 7.5% saline on plasma and other extracellular fluid volumes. After baseline measurements, eight healthy postmenopausal female volunteers received 4 ml.kg-1 of hypertonic saline over 30 min. After the fluid infusion, the volunteers were studied for 60 min. Plasma volume was measured using a dilution of 125-iodine-labelled human albumin. Extracellular water and cardiac output were measured by whole body impedence cardiography. The infused volume was 4 ml.kg-1 (average 260 ml). Plasma volume increased rapidly during the infusion (mean +/- standard deviation, 442 +/- 167 ml). At the end of the 1-h follow-up period, plasma volume had increased by on average 465 ml (SD 83). The increase of extracellular water at the end of infusion and at the end of study was 650 ml (SD 93) and 637 ml (SD 192), respectively. The highest serum sodium recorded in the volunteers was 158 mmol.l-1. The effect of 7.5% saline on plasma volume was rapid and lasted for at least 1 h. Plasma volume remained elevated by more than the infused volume at the end of the study. The increase in plasma and extracellular fluid volumes was partly achieved by mobilizing intracellular water to extracellular compartment.     

7.5%高渗盐水对择期腹部大手术后全身性炎症反应的影响

目的　探讨 7.5 %高渗盐水对择期腹部大手术后全身性炎症反应的影响。方法　连续 5 2例择期腹部大手术病人 ,配对分为两组对比。术毕进入SICU后 ,研究组 ( n=2 6)应用 7.5 %高渗盐水 ( 4ml/kg) ,后续平衡液 ;对照组 ( n =2 6)仅用平衡液。比较两组病人的液体平衡量、体重变化、PaO2 /FiO2 比值 ,以及并发症发生率和死亡率。结果　与对照组相比 ,研究组手术日和术后48h的液体正平衡量减少 (P <0 .0 0 1) ;术后体重增加幅度降低 (P <0 .0 0 1) ,体重下降时间提前 (P <0 .0 0 1) ;术后PaO2 /FiO2 比值较高 (P =0 .0 0 0 111) ;术后总体并发症发生率和肺部感染发生率较低 (P =0 .0 175 ,P =0 .0 3 74)。结论　 7.5 %高渗盐水可减少择期腹部大手术后的液体正平衡量 ,促进液体负平衡提前出现 ,有明显的抗炎作用     

The effect of acetate ringer solution, 6% hydroxyethyl starch saline and 20% mannitol solution on the serum concentration of propofol continuously infused

Changes in serum concentrations of propofol after administration of three different fluids were investigated in 42 scheduled surgical patients. Anesthesia was induced with propofol 2 mg.kg-1 and maintained with constant rate infusion of propofol 6 mg.kg-1.hr-1. After achieving a stable depth of anesthesia, 5 ml.kg-1 of acetate Ringer's solution, 6% hydroxyethyl starch saline solution or 20% mannitol solution was infused in 15 minutes. Blood samples each 2 ml were taken before and 0, 5, 15, 30 and 60 minutes after fluid treatment. We measured hemoglobin and hematocrit of the samples for calculating the dilution rate of the plasma with infusion treatment, and determined the serum concentration of propofol by HPLC-spectrofluorometry. After administration of each fluid, the serum concentrations of propofol decreased significantly to 17 +/- 15, 25 +/- 10 and 35 +/- 8%, respectively (mean +/- SEM). The dilution rate of the plasma from the fractional change in blood hemoglobin increased to 0.08 +/- 0.02, 0.24 +/- 0.03, and 0.36 +/- 0.03, respectively. Administration of mannitol might markedly increase distribution volume of propofol, and this can be attributed to osmotic action of mannitol and resultant expansion of extracellular fluid volume. The results of the present investigation suggest that this pharmacokinetic change decreased the concentration of propofol more significantly in mannitol treatment patients than in Ringer's solution or 6% hydroxyethyl starch saline treatment patients.     

7.5%高渗盐水对急性弥漫性腹膜炎术后液体平衡的影响

目的 观察7.5%高渗盐水对急性弥漫性腹膜炎急诊手术后液体平衡的影响.方法 42例急性弥漫性腹膜炎急诊手术患者,术毕进入外科ICU后,实验组(n=21)输注7.5%高渗盐水(4 ml/kg体重)后续平衡液;对照组(n=21)仪输半衡液.比较两组患者的输液量、尿量、液体平衡、体莺变化以及并发症发生率和病死率.结果 与对照组比较,实验组手术日的输液量减少(P<0.05);手术日和术后第1天的尿量较多(P<0.05,P<0.05),液体正平衡量减少(P<0.01,P<0.01);术后体重增加幅度降低(P<0.01),体重下降时间提前(P<0.01);总体并发症发生率较低(P<0.05).结论 7.5%高渗盐水有明显的利尿作用,可减少急性弥漫性腹膜炎急诊手术后的输液量和液体正平衡量,促进液体负平衡提前出现,并使总体并发症发生率降低.     

Comparison of effects of equiosmolar doses of mannitol and hypertonic saline on cerebral blood flow and metabolism in traumatic brain injury

The potential superiority of hypertonic saline (HTS) over mannitol (MTL) for control of intracranial pressure (ICP) following traumatic brain injury (TBI) is still debated. Forty-seven severe TBI patients with increased ICP were prospectively recruited in two university hospitals and randomly treated with equiosmolar infusions of either MTL 20% (4?mL/kg; n=25 patients) or HTS 7.5% (2?mL/kg; n=22 patients). Serum sodium, hematocrit, ICP, arterial blood pressure, cerebral perfusion pressure (CPP), shear rate, global indices of cerebral blood flow (CBF) and metabolism were measured before, and 30 and 120?min following each infusion during the course of illness. Outcome was assessed at 6 months. Both HTS and MTL effectively and equally reduced ICP levels with subsequent elevation of CPP and CBF, although this effect was significantly stronger and of longer duration after HTS and correlated with improved rheological blood properties induced by HTS. Further, effect of HTS on ICP appeared to be more robust in patients with diffuse brain injury. In contrast, oxygen and glucose metabolic rates were left equally unaffected by both solutions. Accordingly, there was no significant difference in neurological outcome between the two groups. In conclusion, MTL was as effective as HTS in decreasing ICP in TBI patients although both solutions failed to improved cerebral metabolism. HTS showed an additional and stronger effect on cerebral perfusion of potential benefit in the presence of cerebral ischemia. Treatment selection should therefore be individually based on sodium level and cerebral hemodynamics.     

Comparison of equiosmolar hypertonic saline and mannitol for brain relaxation during craniotomies: A meta-analysis of randomized controlled trials

There is a controversy about the effects of hypertonic saline (HS) used for brain relaxation in patients requiring craniotomies. We conducted a meta-analysis to compare the efficacy of equiosmolar hypertonic saline with mannitol on intraoperative brain relaxation in patients undergoing craniotomies. We searched PubMed, EMBASE, Cochrane Library databases, and Web of Science for randomized controlled trials (RCTs). The outcome indicators included brain relaxation, hemodynamic status, fluid volume, and blood chemistry. A total of nine RCTs involving 665 patients were identified and included. There was a greater increase in the odds of good intraoperative brain relaxation in the HS group (odds ratio (OR) 2.05, 95% confidence interval (CI) 1.40~3.01; P = 0.0002) compared with mannitol. In comparison with HS, mannitol slightly reduced the central venous pressure (CVP) (mean difference (MD) 1.03, 95% CI 0.03~2.03; P = 0.04) as well as significantly increasing the diuretic effect regardless of the dosage of HS (standardized mean difference (SMD) ?0.86, 95% CI ?1.35~?0.37; P = 0.0006). HS increased the plasma sodium level significantly (MD 7.86, 95% CI 2.78 ~ 12.95, P = 0.002) but reduced the intraoperative fluid intake (SMD ?0.56, 95% CI ?0.98~?0.15, P = 0.008). However, there were no significant differences in plasma osmolality and mean arterial pressure (MAP). Our results suggest that there appears to be better brain relaxation without a significant increase in urine volume in the HS group compared with mannitol in patients requiring craniotomies. High-quality RCTs with larger sample sizes will be required in the future to confirm the conclusions.     

The effect of PVC packaging on the acidity of 0.9% saline

Intravenous fluids in polyvinyl chloride (PVC) packaging are known to be acidic. We proposed to determine the effect of PVC packaging on the pH of 0.9% saline solutions by comparing the predicted and measured pH of 0.9% saline equilibrated with atmospheric carbon dioxide and the measured pH of commercial solutions of 0.9% saline in PVC and polypropylene packaging. Calculation of pH was made from available physical chemistry constants and data. Measurement was made of the pH of 12 samples of prepared 0.9% saline equilibrated with atmospheric carbon dioxide. Comparison with the pH of seven commercial samples of saline in PVC packaging for intravenous use was undertaken. Further comparison was made between commercial samples of 0.9% saline in PVC or polypropylene packaging. The calculated pH of 0.9% saline was 5.61 at 20 degrees C. The median pH of the prepared samples was statistically significantly less acidic than the median pH of the PVC packaged samples for intravenous use: 5.47 vs 4.60, P < 0.05. The median pH of the PVC packaged saline was also statistically significantly more acidic than the pH of the polypropylene packaged saline: 4.62 vs 5.71, P < 0.05. The acidity of the intravenous solutions of 0.9% saline packaged in PVC was much greater than expected and is only partially explained by dissolved carbon dioxide. This acidity could be a result of packaging in PVC.     

不同液体输注对小儿围术期电解质和血糖的影响

目的 观察麻醉期间输注不同张力不同葡萄糖浓度的液体对小儿血电解质和血糖的影响.方法 80例行择期骨科手术患儿,ASA Ⅰ或Ⅱ级,年龄1～6岁,随机均分为四组:等张液组(A组),4/5张液组(B)组,1/2张液组(C组)和1/4张液组(D组).所有患儿在输液前(T0)、输液1h后(T1)、输液2h后(T2)、麻醉结束时(T3)抽取静脉血行血气分析检测血钠、血钾和血糖浓度及血pH值.结果 与T0时相比,B、C、D组T1～T3时血钠浓度均降低(P＜0.05),A组未见明显变化;四组T3时血pH值均降低而血钾浓度则升高(P＜0.05);A组在T2、T3时血糖浓度较高,而B、C、D组在T1～T3时较高(P＜0.05).结论 1～6岁小儿围术期输注等张液更有利于血电解质的稳定,不补或补少量葡萄糖可维持血糖正常.     

甘露醇对肝叶切除术患者红细胞醛糖还原酶、血浆一氧化氮和丙二醛水平的影响

目的 探讨甘露醇对肝叶切除术患者红细胞醛糖还原酶(AR)活性、血浆一氧化氮(NO)和丙二醛(MDA)浓度的影响.方法 择期行肝叶切除术患者40例,性别不限,年龄24～60岁,体重50～ 68 kg,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将其随机分为2组(n=20):生理盐水对照组(C组)和甘露醇组(M组).2组均采用硬膜外复合全麻.术中阻断肝门即刻开始静脉输注20％甘露醇1.5 ml/kg,经30 min输完,C组给予等容量生理盐水.分别于麻醉前(基础状态)、肝门开放前即刻、术毕、术后1d、术后3 d(T0-4)时采集静脉血样,测定红细胞AR活性、血浆NO和MDA浓度.结果 与C组比较,M组T1.2时AR活性及血浆MDA浓度降低,血浆NO浓度升高(P＜0.05).结论 甘露醇可降低肝叶切除术患者肝缺血再灌注损伤,其机制与清除氧自由基,抑制脂质过氧化反应有关.