急性超容量血液稀释联合硝酸甘油控制性降压对脑氧代谢...

急性超容量血液稀释联合硝酸甘油控制性降压对脑氧代谢... 急性超容量血液稀释联合硝酸甘油控制性降压对脑氧代谢的影响 史晓勇 王亚平 常业恬 邹定全 李李 徐军美 410011 长沙市 中南大学湘雅二医院麻醉科 摘 要 目的:观察急性超容量血液稀释(AHH)联合硝酸甘油控制性降压(CH)对脑氧代谢的影响，探讨AHH&CH是否改变脑氧代谢的平衡。 方法:择期行椎体内固定手术的全麻患者30例，随机分成三组，每组10例。?组为对照组;?组在全麻诱导后手术前行AHH，以 -1-115ml?kg的总量50 ml?min的速率输入万汶(6,HES，130/0.4);?组行AHH&CH，AHH同?组，于切皮前泵入硝酸甘油维持MAP在基础血压的65%,75%至手术结束前45分钟;当Hct<25%或者出血量大于20%时输异体血，各组患者术中出血量和异体血需求量，连续监测HR、MAP、CVP、PetCO、BIS、TEMP，分别于诱导2 后AHH(AHH&CH)前(T)、AHH(AHH&CH)后15分钟(T)、01AHH(AHH&CH)后60分钟( T)、手术结束前60分钟 (T) 、手术23结束时(T)五个时间点抽取动脉、颈内静脉球部的血作血气分析并计4 算CaO、CjvO、CEO、VADL。术中每30min监测一次Hb、Hct。 222 结果:?组和?组患者的出血量明显高于?组(P<0.05);?组输血量显著少于?组(P<0.05),非常显著少于?组(P<0.01)。?组、?组患者Hct在T T T T明显低于T(P<0.05)，?组与?组患者12340 之间的Hct无统计学差异，T时三组Hct无显著性差异，但均低于术4 1 前且大于25%。三组患者术中HR变化无显著性差异;?组CVP在 AHH后T T T明显升高(P<0.05)，但都在正常范围;?组MAP123 在CH后T T T显著降低(P<0.05);CVP、MAP在T时无显著差1234 异。?组SjvO在T T T升高，有统计学差异(P<0.05), 其中两人2123 SjvO在不同时间点大于75%,其余均在正常范围，T时SjvO恢复到242 术前水平;?组和?组之间SjvO的变化没有统计学差异;?组和?2 组患者T T T T四点CEO降低，有统计学差异(P<0.05)，Da-jvO123422 降低，差异有显著性(P<0.05);?组患者CEO与Da-jvO在T T2234 降低，有统计学差异(P<0.05);三组患者术中VADL变化无显著性 差异且均在正常范围。 结论:轻、中度AHH不会引起患者脑氧供不足，但有小部分患者 可能会发生不同程度的脑血流灌注过度的问;AHH&CH既不会发 生脑供氧不足，也不会发生脑血流灌注过度，对脑氧代谢无不利影响。 关键词:血液稀释, 控制性降压, 氧代谢, 血流动力学, 脑过度灌注 Abstract Objective: To observe the effect of acute hypervolemic hemodilution (AHH) combined with controlled hypotension (CH) with nitroglycerin on cerebral oxygen metabolism and investigate whether AHH&CH can change the balance of cerebral oxygen metabolism. Methods: Thirty ASA?,?patients scheduled for internal fixation surgery of thoracic/lumbar vertebrae under general anesthesia were 2 divided randomly into three groups: control group(group?)、AHH(group ?) and AHH&CH(group ?). In group ?, patients was infused 6% -1HES (130/0.4, Voluven) in speed of 50ml?min and with volume of 15 -1ml?kg after induction and before operation . In group ?, CH was initiated before incision and terminated at 45 minutes prior to the end of surgery, induced with nitroglycerin to maintain MAP at 65%,75% of the basic MAP. Radial artery and right internal jugular vein was cannulated for pressure monitoring and blood sampling. Blood transfusion was considered when Hct<25% or the intraoperative blood loss >20% of blood volume. HR、MAP、CVP、PetCO、BIS、TEMP were continuously 2 monitored throughout the operation. Arterial and internal jugular venous blood samples were taken for measuring CaO、CjvO、CEO、VADL at 222 five time points: T(after induction and before AHH/AHH&CH), T(15 0 1 minutes after AHH/AHH&CH), T(60 minutes after AHH/AHH&CH), 2 T(60 minutes before the end of surgery),T(at the end of surgery). Hb 34 and Hct must be monitored every 30 minutes during the operation. Result: The intraoperative blood loss was more lower in group ? than in group ? and group?(P<0.05). The intraoperative blood transfusion was more lower in group ? than in group ?(P<0.05), and more markedly lower than in group?(P<0.01). In group ? and group ?, Hct after AHH at T T T Twas more lower than T(P<0.05). There 1234 0 were no significantly differences between group ? and group ? on 3 Hct. Hct at Twas no differences among three groups and all exceeded 4 25%. There were no significantly changes among three groups on HR in the study. CVP was markedly increased at T T T in group ?(P<0.05), 123 but all in normal; MAP was markedly decreased at T T T in group ?123 (P<0.05), but all in normal. Differences on MAP and CVP weren’t to exist among three groups at T. SjvO in group ? was increased with 42 statistical significance at T T T(P<0.05), but it isn’t in group ? and 123 group?. In group ?, SjvO only for two persons exceeded 75% , and it 2 was to recover the original level at the end of opration . In group ? and group?, CEO and Da-jvO were decreased at T T T T, while all with 221234 statistical significance(P<0.05)，they were also decreased in group?, but statistical significance was to exist at T T(P<0.05). Markedly 34 differences on VADL wasn’t to exist and all in normal among three groups. Conclusions: This study suggests that during AHH the balance of cerebral oxygen metabolism can be well maintained in most patients, but cerebral hyperperfusion might occur in a few patients. It also indicates that cerebral anoxia and cerebral hyperperfusion didn’t occur during AHH&CH, AHH&CH can’t change the balance of cerebral oxygen metabolism. Key words: Hemodilution，Controlled hypotension，Oxynen metabolism，Hemodynamics，cerebral hyperperfusion 4 5