<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /> 林成新a ,郭雅b ,刘敬臣a ,黎乐群b ,何文政a ,王喜军a ,李英英a ,彭民浩b 广西医科大学第一附属医院 a麻醉科, b肝胆外科,广西南宁530021 The effect of low cen tra l venous pressure on blood loss and rena l function dur ing liver resection. Lin Chengxin；Guo Ya, L iu J ingchen, et al.Departm ent of Anesthesia, First Aff iliated Hospital of Guangx iM edical University, Nan ning 530021, China Abstract Objective To investigate the effect of low central venous p ressure on blood loss and renal function during liver resection. Methods Seventy2four patients (ASA Ⅰ～Ⅱ) , undergoing selective liver resection under general anesthesia in our hosp ital from August 2003 to November 2004,were randomly divided into two group s: low central venous p ressure group (LCVP group, n = 37) and control group (C group, n = 37). Central venous p ressure (CVP) wasmaintainedat 0 to 5 cmH2O (1cmH2O = 01098kPa) during liver parenchyma dissection in LCVP group, and itwasmaintained at 6 to 12 cmH2O in C group. Total blood loss and blood transfusion during operation were collected in two group s. The volume of blood losswas compared in different segments of liver resection in two group s. The volume of blood loss during liver resection with and without portal trial occlusion was compared in two group s. The renal function before and after operation was compared in two group s. Results The blood loss during operation was significantly less in the LCVP group than that in the C group [ (427 ±317)mL v. s (800 ±709)mL, P < 0.05 ]. The volumes of blood loss in different segments of liver resection in the LCVP group were less than those in the corresponding C group. The mean blood losswith portal trial occlusion in the LCVP group was significantly less than that in the C group [ (413 ±297)mL, n = 29 v. s (774 ±522)mL,n = 24, P < 0.05 ]. The renal function before and after operation was no significant difference between the two group s.Conclusion Low central venous p ressure can reduce the blood loss during liver resection and has not influence on renalfunction. Keywords Low central venous pressure; Liver resection; Blood loss; Transfusion; Renal function |
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目前手术切除仍是治疗肝脏占位性病变的首选方法。由于肝脏组织脆性大、富含血窦及肝内血管分布复杂,在肝脏手术中常面临大出血的危险。我们在肝叶切除手术中应用控制性低中心静脉压(LCVP)技术,观察其对术中出血、输血及肝肾功能的影响。 1 资料与方法 1. 1 一般资料 2003年8月至2004年11月在我院外科行肝叶切除术病人74例,其中原发性肝癌65例,肝脏转移性肿瘤7例,肝脏血管瘤2例。74例中27例并发肝硬化。术前有糖尿病、高血压、凝血功能异常或心、肺、脑疾病者排除在本观察之外。根据美国麻醉医师协会麻醉分级(ASA)为Ⅰ～Ⅱ级。男59 例,女15 例。年龄21 ～75 岁,平均(43.6 ±11.6)岁。随机分为:低中心静脉压组(LCVP组)和对照组(C组) ,每组37例。 1. 2 麻醉方法 所有病人均在静脉复合全麻下行手术。行右侧颈内静脉穿刺置管,用于输液和监测CVP,麻醉诱导后病人留置导尿管,监测术中尿量。麻醉诱导:缓慢静注安定(0.1mg/kg) 、芬太尼( 0.005mg/kg) 、依托咪酯( 0.2mg/kg) 、卡肌宁(0.6～0.8mg/kg) 。气管内插管后接麻醉呼吸机控制呼吸,呼吸参数调节到呼气末CO2 分压维持在30～35mmHg ( 1mmHg = 0.133kPa ) 水平。麻醉维持: 异丙酚400mg +芬太尼0.3mg, 微量泵静注, 速度控制为15 ～30mL /h,根据血压和心率调整速度。吸入麻醉药选用异氟醚,吸入浓度为1％～2％。卡肌宁以40～50mg/h速度微量泵静注维持术中肌肉松弛。 1. 3 输液及CVP管理 LCVP组在麻醉诱导前输林格液,输液量控制在250～500mL,麻醉诱导后至肝实质完全离断前输液量控制为1 ～2mL / ( kg•h) ,肝实质横断过程中CVP控制在0～5cmH2O水平,必要时分次静推硝酸甘油,用量为0125～0150mg/次。在控制CVP过程中,如动脉收缩压( SBP)低于90mmHg,则减少静脉或吸入麻醉药用量,同时用100～200mL液体冲击治疗。术中用微量泵静注多巴胺以维持足够尿量,速度为01003mg/( kg•min) 。在完全离断肝实质后静脉快速补充液体,补充液体以胶体(代血浆、血浆等)为主;在肝创面止血完成前将CVP提高到8cmH2O以上。C组静脉输液按晶胶比2∶1常规进行,晶体为林格液,胶体为人工代血浆或血浆。术中CVP维持在6～12cmH2O之间, SBP维持> 90mmHg以上。两组病人术如尿量少于25mL /h,可每次静注速尿5～20 mg。术中如出血量超过全身总血容量的25%或血红蛋白(Hb) < 80g/L时开始输注全血或浓缩红细胞。 1. 4 监测指标 手术结束时根据吸引瓶中血量、纱垫吸血量、创面敷料吸血估计量之和计算病人术中总失血量,纱垫吸血量根据传统称重法进行估计。记录两组病人手术种类、手术时间、肝门阻断时间、术中输液量、输血浆量、术中尿量、术中输血量。术前及手术结束时抽取外周静脉血3mL,用i2STAT血液分析仪行血红蛋白、红细胞压积测定,用全自动生化分析仪(LX220)检测肾功能。 1. 5 统计学分析 计量资料采用均数±标准差(  ±s )表示,组间采用t检验;计数资料采用χ2 检验; P < 0.05为差异有显著性意义。 |
<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /> 2 结果 2. 1 两组病人的年龄、性别、体重、肝叶切除范围及手术时间基本相同 LCVP组病人中,有3例病人在使用硝酸甘油降低CVP 时SBP 明显下降, 低于90mmHg, 其CVP 低于 2cmH2O,经快速输入林格液200mL 后, CVP恢复到4 ～5cmH2O , SBP也高于90mmHg。LCVP组和C组分别有29例和24例病人在切肝实质过程中实施第一肝门血流阻断,阻断时间及例数差异无显著性。两组病人术中尿量和输血浆量差异无显著性,LCVP组术中输液少于C组。详见表1和表2。 <?xml:namespace prefix = v ns = "urn:schemas-microsoft-com:vml" />
2. 2 LCVP组和C组术中出血量 术中出血量分别为(427 ±317)mL和(800 ±709) mL, P < 0.05。两组病人不同部位肝叶切除术术中出血量比较见表3。LCVP组在不同部位肝叶切除术术中出血量均少于C组,尤其在Ⅶ、Ⅷ肝段手术时明显, P < 0.05。LCVP组和C组术中不进行第一肝门血流阻断者术中出血量分别为(475 ±402)mL ( n = 8例)和(584 ±445)mL ( n = 13) ,两者差异无明显性。进行肝门阻断者,LCVP组出血量明显少于C组,分别为(413 ±297)mL ( n = 29)和(774 ±522)mL ( n = 24) , P < 0.05。
 2. 3 术中LCVP组和C组分别有5例(5 /37)和16例(16 /37)须输注全血或浓缩红细胞,输血率比较差异有非常显著性意义( P < 0.01) 。需输血的病人中, C组平均输血(843 ±411)mL,而LCVP组仅为(400 ±244)mL, P < 0.05。 2. 4 两组病人术毕Hb和HCT均较术前降低,但C组下降更为明显, P <0.01。术前及术毕肾功能无明显变化。见表4。 |
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