目标导向性液体治疗对围术期高凝患者凝血功能的影响

目的 探讨目标导向性液体治疗(GDFT)与传统输液治疗对围术期血液高凝患者凝血功能的影响.方法 选择ASAI～Ⅲ级需行胃肠道肿瘤手术且入手术室后(输液前)第1次血栓弹力图结果为高凝(CI＞3)的中老年患者60例,随机分为2组(n=30),I组采用中心静脉压(CVP)指导围术期输液即为CVP组,Ⅱ组采用每搏变异度(SVV)指导围术期输液即SVV组.CVP组根据CVP指导输液,维持CVP在9～15 mmHg(1.2～2 kPa);Ⅱ组采用SVV指导围术期输液,维持SVV＜10％;记录2组患者输液前(T0)、麻醉开始后3 h(T2)、手术后24 h(T3)血栓弹力图的凝血情况,包括反应时间(R)、凝固时间(K)、angle、血栓形成的最大幅度(MA)、综合凝血指数(CI),低凝发生率;记录2组患者输液前(T0)、麻醉诱导后即刻(T1)、麻醉诱导后3 h(T2)的平均动脉压(MAP)、心率(HR)、手术时间、麻醉时间、麻醉诱导后3h的总输液量、总出血量、尿量、血管活性药使用情况、手术后至手术后24 h的总出血量、术后大出血的发生率、术后7d内血栓性事件的发生率. 结果 与I组比较,Ⅱ组患者To血栓弹力图结果无明显差别(P＞0.05);2组患者T2,T3时的凝血因子功能和纤维蛋白原功能明显减弱(P＜0.05),而血小板功能和综合凝血功能无差别(P＞0.05).与I组比较,Ⅱ组T2时的凝血因子功能较强(P＜0.05);综合凝血功能较强(P＜0.05);低凝的发生率明显减少,差别有统计学意义(P＜0.05);T3的R,K,angle及MA差别无统计学意义(P＞0.05);To,T1及T2的MAP,HR,麻醉诱导后3h内的总出血量及血管活性药使用量差别无统计学意义(P＞0.05);麻醉诱导后3h内的总输液量、尿量明显减少,差别有统计学意义(P＜0.05);手术结束后24 h的总出血量差别无统计学意义(P＞0.05).2组患者术后7d内均无血栓事件发生. 结论 GDFT与传统输液治疗比较,可较好的纠正围术期血液高凝患者的凝血状态.

Effect of Goal-Directed Fluid Therapy on Coagulation Function ofHypercoagulable Patients in Perioperative Period

Objective To investigate the effect of goal-directed fluid therapy (GDFT) on coagulation function of patients with hypercoagulable state in perioperative period.Methods 60 elderly patients with ASA Ⅰ ～ Ⅲ who received gastrointestinal tumor surgery and with CI＞3 by pre-operative TEG were divided into two groups randomly (n=30).Group Ⅰ used CVP(1.2～2 kPa) to guide the perioperative infusion (CVP Group),while Group Ⅱ used SVV(＜10％),so named SVV Group.The central line was established in both groups.The patients'clinical data were analyzed.The data included the value of R,K,angle,MA,CI and low coagulation rate by TEG before transfusion (T0),time of anesthesia (T1),three hours after induction (T2),and 24 hours after operation (T3).Data recorded were MAP,HR,the time of operation and the time of anesthesia,the total amount of infusion,the total amount of bleeding,urine volume,vasoactive agent amounts on T2,and the total amount of bleeding on T3.The hemorrhage and the adverse thrombotic events were also recorded.Results There were no significant differences in the value of K,angle,MA at T2 between the two groups,but the values of R in Group Ⅱ were lower than that in Group Ⅰ,while the values of CI in Group Ⅱ were greater than that in Group Ⅰ (P＜0.05).There were no significant differences in the result of TEG between the two groups at T0.The values of R,K in Group Ⅰ and Group Ⅱ at T2 were higher than that at T0 (P＜0.05),while angle of Group Ⅰ and Group Ⅱ at T2 were lower than that at T0 (P＜0.05).The values of R,K in Group Ⅰ and Group Ⅱ at T3were higher than that at T0 (P＜0.05),while angle in Group Ⅰ and Group Ⅱ at T3 were lower than that at T0 (P＜0.05).There were no significant differences in the value of MA and CI between T0 and T3(P＞0.05).There were also no significant differences in the value of R,K,angle,MA,and CI between T2 and T3 (P＞0.05).At T2,the value of R in Group Ⅱ was lower than that in Group Ⅰ and the CI ishigher than that in Group Ⅰ(P＜0.05).The low coagulation rate in Group Ⅰ was higher than that in Group Ⅱ at T2 (P＜0.05).At T3,there were also no significant differences in the value of R,K,angle,MA,and CI between the two groups(P＞0.05).There were no significant differences in MAP,HR,the total amount of bleeding,and the amount of vasoactive drugs among the three time points in the two groups during the time from To to T2 (P＞0.05).The total amount of infusion and urine volume in 3 h after anesthesia induction significantly decreased(P＜0.05).However,there were no differences in total amount of bleeding at 24 hours after operation.There were no adverse thrombotic events 7 days after operation.Conclusion Compared with the traditional infusion therapy,GDFT can improve the coagulation function of perioperative patients with hypercoagulable condition.