急性高容量血液稀释并低中心静脉压对肝叶切除患者失血和肝肾功能的影响

目的 观察急性高容量血液稀释(AHHD)联合低中心静脉压(LCVP)应用于肝叶切除术患者的血液保护效果以及对肝肾功能的影响.方法 择期行肝叶切除术的肝癌患者60例,随机分为三组(n=20);对照组(A组)、LCVP组(B组)和LCVP联合AHHD组(C组).三组均采用复合全麻.A组维持正常中心静脉压；B组控制CVP在2～5 cmH2O,切肝后快速扩容使CVP维持在6～ 12 cmH2O；C组麻醉后行(AHHD),使Hct维持在25％～30％,应用LCVP技术,在肝叶切除后10 min输注6％羟乙基淀粉50 mg/kg·h使CVP回复正常水平.测定各时段血红蛋白(Hb)、红细胞压积(Hct)、凝血功能指标(PT)、谷丙转氨酶(ALT)和肾功能尿素氮(BUN)、肌酐Cr)指标,并记录各组输液量、尿量、术中失血、输血情况及术后并发症的发生情况.结果 三组患者肾功能均在正常范围,与B组相比,C组BUN的波动更小(P＜0.05),与A组相比,B组和C组ALT术后七天恢复更好(P＜0.05);与A组(1193.00±443.05)ml比较,B组(875.00±415.01)ml、C组(769.00±405.57) ml失血量显著减少(P＜0.05)、C组少于B组(P＜ 0.05);与A组(642.00±69.10) ml比较,B组(435.50±59.43)ml、C组(491.00±64.70) ml尿量明显减少(P＜0.05),C组尿量较B组增加(P＜0.05).结论 肝叶切除术中AHHD联合LCVP能显著减少术中失血量和异体输血,并且较单纯LCVP有更好的肝肾功能保护,具有良好的安全性.

Effects of acute hypervolemic hemodilution and low central venous pressure on blood loss and liver and renal function in patients undergoing keratectomy

Objective To evaluate the blood-saving effect of low central venous pressure （CVP） combined with acute hypervolemic hemodilution （AHHD） in patients undergoing hepateetomy. Methods Sixty ASA I or U patients undergoing hepatectomy for primary malignant hepatoma under epidural combined with general anesthesia were randomly divided into 3 groups （n=20 each）; Control Group （Group A）; LCVP Group （Group B） and LCVP＋AHHD Group （Group C）. Group A received crystalloid and colloid in a ratio of 1：1 during the operation to maintain central venous pressure between 6 and 12 cmH20; in group B, CVP was maintained between 2 and 5 cmH2O, CVP and MAP returned to normallevels by hypervolemic hemodilution with intravenous infusion of crystalloid and colloid after hepatectomy was completed. In Group C, Hematocrit（ Hct） was maintained at 25% N 30% by administration of crystalloid and colloid after tracheal intubation. And CVP and MAP returned to normal levels by hypervolemic hemodilution with intravenous infusion of 6% hydroxyethyl starch 50 ml · kg^-1· h^-1 for 10 minutes after hepatic lobectomy was completed. Hemoglobin （ Hb ）, Hct, blood coagulation parameters （PT）, Alanine aminotransferase （ALT）and renal blood urea nitrogen （BUN）, creatinine （Cr） were determined before operation, immediately after hepatic lobectomy was completed, at the end of operation ,1 d and 7 days after operation. The amount of infusion, the urine volume, intraoperative blood loss and complications should be recorded. Results Renal function of patients in three groups were within normal range. BUN fluctuations in Group Cwere more smoothly than in those Group B （P〈0.05）, ALT recovery was better （P〈0.05） in Group B and Group C than that in Group A 7 days after operation. Compared with the Group A（1193.00±443.05）, the amount of blood loss in group B （875.00 ± 415.01） and in group C （769.00 ±405.57） were significantly less （P〈0.05）,and urinary output in Group B was signifieantly less than that in Group C. Compared with the group A（642.00± 69.10）, the amount of urinary output in Group B （435.50 ± 59.43） and in Group C（491.00±64.70） were significantly less （P〈O.05）, and Group C more than in Group B（P〈0.05）.Conclusion The LCVP combined with AHHD during hepatic resection can effectively decrease intraoperative blood loss. What＇ s more, the combination of the LCVP and AHHD provides better and safer protection for the functions of liver and kidney than the LCVP alone.