脊柱侧弯围手术期输血方式对预后效果的影响

背景自体输血已广泛应用于骨科手术中,但对其预后效果引起了医务工作者的关注.目的研究自体血回输与异体输血对脊柱侧弯患者围手术期的细胞免疫方面的影响,以及对早期功能康复的意义.设计随机对照的研究.单位解放军第二军医大学长海医院输血科.对象2000-02/2003-02第二军医大学长海医院收治成人脊柱侧弯患者98例,纳入标准ASA(美国麻醉医师协会)分级Ⅰ～Ⅱ级,术前血细胞比容＞35%,围术期接受输血;排除标准有内分泌及免疫性疾病史,有激素治疗史,应用影响免疫功能的药物.符合条件的患者48例,男14例,女34例,平均16.7岁,体质量平均42.2 kg.干预根据术中输血的方式分为2组异体输血组(12例)术中全部输异体成分血;自体血回输组(36例)术中采用血液回收机将自体血回输给患者,而使患者术后血细胞比容≥30%,血红蛋白≥10 g/L.主要观察指标测定T细胞亚群和自然杀伤细胞的数量,并观察输血时过敏反应的发生率.结果采用血液回收组可以明显减少异体库血的需要量,而且可避免输异体血时发生的过敏反应.术后1 d,异体输血组患者的CD3+,CD4+,CD4+/CD8+与术前相比明显降低,分别为67.1±9.8,32.6±7.9,1.3±0.2(t=2.85,1.96,1.85,P＜0.05),而自体血回输组只有CD4+有显著性降低,为38.2±0.6(t=1.92,P＜0.05),其他指标差异无显著性意义.术后第5天异体输血组CD3+,CD4+,CD4+/CD8+,自然杀伤细胞仍较术前显著减少,分别为62.4±11.5,31.3 ±0.4,1.1±0.2,13.5±7.0(t=2.91,2.01,1.94,P＜0.05),自体输血组基本恢复正常;与异体输血组比较,自体输血组CD3+,CD4+,自然杀伤细胞均有显著性升高,分别为74.8±3.8,40.4±9.9,18.4±3.8(t=1.87,1.96,2.84,P＜0.05).结论血液回收输血在脊柱侧弯矫形术中具有很高的应用价值,围术期异体输血患者免疫功能的抑制较自体血回输者严重,自体输血对免疫抑制轻,术后免疫功能恢复快,术后康复效果得到明显改善.

Effects of blood transfusion modes during perioperative period on prognosis of patients with scoliosis

BACKGROUND: Autologous transfusion has been widely used in orthopaedic operation and its effects on prognosis have attracted medical workers' attention.OBJECTIVE: To explore the effects of autologous transfusion and homologous transfusion on cellular immunity during perioperative period in patients with scoliosis, as well as on early functional rehabilitation.DESIGN: A randomized controlled study.SETTLNG: Department of Transfusion Medicine, Changhai Hospital, Second Military Medical University of Chinese PLA.PARTICIPANTS: Totally 98 adult patients with scoliosis hospitalized in Changhai Hospital, Second Military Medical University during February 2000and February 2003 were selected for this study. Inclusion criteria: American Society of Anesthesiologists(ASA) classification: levels Ⅰ - Ⅱ; preoperative hematocrit ＞ 35% ; taking blood transfusion during perioperative period. Exclusion criteria: with medical history of endocrine or immunological diseases; with hormonotherapy history; medication with drugs affecting immunity. Totally, there were 48 patients according with the criteria including 14 males and 34 females with mean age of 16.7 years old and a mean body mass of 42. 2 kg.INTERVENTIONS: The 48 patients were divided into two groups according to transfusion modes. Twelve patients in homologous transfusion group(groupⅠ)were taken homologous blood, and 36 patients in autologous transfusion group (group Ⅱ) were taken autologous blood by using blood recovery machine to maintain the hematocrit ≥ 30 % and ferrohemoglobin ≥ 10 g/L.MAIN OUTCOME MEASURES: The quantity of T cell subsets and natural killer(NK) cells were assayed, and the incidence of allergic reaction during transfusion was observed.RESULTS: The requirement of homologous blood was greatly decreased and the allergic reaction of homologous transfusion can be avoided in group Ⅱ. On the 1st postoperative day, the CD3 +, CD4 + and CD4 +/CD8 +were 67.1 + 9.8,32.6 + 7.9, 1.3 ± 0.2 respectively in group Ⅰ, significantly decreased as compared with those of preoperation ( t = 2. 85, 1.96,1.85, P＜0.05) . However, in group Ⅱ, only CD4 + decreased significantly(38.2 +0.6, t = 1.92, P＜0.05) and no significant difference was found in other indexes. On the 5th postoperative day, the values of CD3 +, CD4 +, CD4 +/CD8 +, NK cells in group Ⅰ were 62.4 ± 11.5,31.3 ±0.4, 1.1 +0.2, 13.5 +7.0 respectively, less than those before operation(t= 2.91, 2.01, 1.94, P＜0.05) while those almost returned to normal in group Ⅱ. Compared with group Ⅰ, the CD3 +, CD4 + and NK cells were significantly increased in group Ⅱ, and were 74.8 +3.8,40.4 ±9.9, 18.4 ±3.8 respectively(t = 1.87, 1.96, 2. 84, P＜0.05).CONCLUSION: The intraoperative autologous transfusion has great value in orthomorphia of scoliosis. The inhibitive effect of homologous transfusion on immunologic functions is more severe than that of autologous transfusion. It has proved that autologous transfusion slightly affects immunosupression so that the immunologic functions recover much quickly and the rehabilitative effects are greatly improved.