吳曉云,李沅敏,金相蘭,劉銀梅,臧旺福
(上海市第十人民醫(yī)院心臟外科 200072)
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·論 著·
成人心臟圍術(shù)期膠體滲透壓變化及其臨床意義
吳曉云,李沅敏,金相蘭,劉銀梅,臧旺福△
(上海市第十人民醫(yī)院心臟外科 200072)
目的 探討成人心臟外科手術(shù)圍術(shù)期血漿膠體滲透壓(COP)的變化規(guī)律。方法 選擇21例行成人心臟外科手術(shù)的患者,根據(jù)手術(shù)不同分為體外循環(huán)瓣膜置換組(CPB組)、微創(chuàng)不停跳冠脈搭橋組(OP組)。記錄麻醉后5 min(T0)、體外循環(huán)開始后5 min/搭橋血管遠(yuǎn)端時(shí)(T1)、體外循環(huán)結(jié)束后5 min/搭橋血管近端時(shí)(T2)、手術(shù)結(jié)束返回ICU(T3)、術(shù)后2 h(T4)、4 h(T5)、8 h(T6)、24 h(T7)的COP,以及術(shù)后3 d檢驗(yàn)指標(biāo)的變化、機(jī)械通氣時(shí)間、ICU時(shí)間等數(shù)據(jù)。比較各時(shí)間點(diǎn)的數(shù)據(jù)差異。結(jié)果 所有患者術(shù)前基本情況相同。2組患者圍術(shù)期COP均有下降,但組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。CPB組在術(shù)中COP變化值最明顯,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。2組的并發(fā)癥發(fā)生率及術(shù)后ICU時(shí)間、機(jī)械通氣時(shí)間比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 心臟體外循環(huán)手術(shù)可使COP下降,但通過(guò)糾正COP均能恢復(fù)正常,對(duì)臨床預(yù)后無(wú)明顯影響。
圍術(shù)期; 體外循環(huán); 膠體滲透壓
血漿膠體滲透壓(COP)是對(duì)抗血漿中水分從血管內(nèi)移到血管外的一種牽制力,對(duì)穩(wěn)定血容量、預(yù)防組織水腫起重要的作用[1-2]。心臟手術(shù)需要在體外循環(huán)(CPB)下進(jìn)行,由于體外循環(huán)過(guò)程中的血液稀釋、炎性反應(yīng)激活、缺血-再灌注損傷等導(dǎo)致患者COP下降,使術(shù)后并發(fā)癥增加,對(duì)患者康復(fù)造成影響[3]。現(xiàn)對(duì)同期在該院進(jìn)行成人心臟手術(shù)患者圍術(shù)期不同時(shí)間點(diǎn)的COP進(jìn)行檢測(cè),觀察術(shù)后并發(fā)癥、機(jī)械通氣及ICU住院時(shí)間的變化,探討體外循環(huán)術(shù)對(duì)圍術(shù)期COP的影響,以及對(duì)臨床預(yù)后的關(guān)系。
1.1 一般資料 2016年1~3月于該院行心臟外科手術(shù)的成年患者21 例,根據(jù)手術(shù)不同分為2組:體外循環(huán)瓣膜置換組(CPB組),微創(chuàng)不停跳搭橋組(OP組)。排除標(biāo)準(zhǔn):術(shù)前肝腎功能明顯受損;心功能不全;年齡大于75歲;合并其他影響恢復(fù)的臟器疾病(如慢性阻塞性肺病、肥胖、重度肺動(dòng)脈高壓等)。納入研究的CPB組11例,OP組10例。2組患者的性別、年齡、體質(zhì)量指數(shù)(BMI)、左室射血分?jǐn)?shù)(LVEF),以及術(shù)前血紅蛋白(Hb)、清蛋白(ALB)、肌酐(Scr)比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。見表1。
1.2 麻醉方法 入室后建立頸內(nèi)靜脈輸液通路,局麻下行橈動(dòng)脈穿刺,持續(xù)監(jiān)測(cè)血壓。給予維庫(kù)溴銨0.15 mg/kg、舒芬太尼0.6 μg/kg、右美托咪啶1 μg/kg麻醉誘導(dǎo)。麻醉維持采用右美托咪啶、舒芬太尼、維庫(kù)溴銨和七氟醚,體外循環(huán)期間停用七氟醚。呼吸機(jī)均使用定容模式,潮氣量8~10 mL/kg,呼吸頻率12次/分。
1.3 體外循環(huán)預(yù)充方式 患者麻醉成功后,由橈動(dòng)脈取血,應(yīng)用i-stat檢測(cè)HCT,預(yù)充總量以目標(biāo)HCT為20%估算。若患者HCT>0.45,根據(jù)情況由橈動(dòng)脈放血300~500 mL(手術(shù)結(jié)束或體外循環(huán)結(jié)束后回輸給患者),同時(shí)補(bǔ)充等量4%琥珀酰明膠。預(yù)充液包括:5%碳酸氫鈉1.5 mL/kg,20%甘露醇5 mL/kg,硫酸鎂0.25 mmol/kg,氯化鉀0.5 mmol/kg,甲強(qiáng)龍,20%人血清蛋白100 mL,其余由乳酸鈉林格注射液補(bǔ)充。
1.4 COP測(cè)定方法 使用德國(guó)產(chǎn)ONKOMETER BMT932血漿膠體滲透壓測(cè)定儀,儀器平衡歸零后,吸干并加入血樣。橈動(dòng)脈取血0.5 mL,滴入加樣孔,平衡約15 s,吸干后再加樣,顯示數(shù)據(jù)為COP值。
1.5 各時(shí)點(diǎn)檢測(cè) 檢測(cè)麻醉后5 min(T0)、體外循環(huán)開始后5 min/冠脈搭橋患者為搭橋血管遠(yuǎn)端時(shí)(T1)、體外循環(huán)結(jié)束后5 min/冠脈搭橋患者為搭橋血管近端時(shí)(T2)、手術(shù)結(jié)束返回ICU(T3)、術(shù)后2 h(T4)、4 h(T5)、8 h(T6)、24 h(T7)的COP。
2.1 2組患者一般資料結(jié)果比較 2組患者一般資料比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。見表1。
2.2 2組患者圍術(shù)期COP結(jié)果比較 CPB組患者各時(shí)間點(diǎn)COP值雖然略高于OP 組,但差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。而手術(shù)開始后COP減少的絕對(duì)值(△T1)比較,差異有統(tǒng)計(jì)學(xué)意義[(-5.48±2.40 )vs. (-1.91±0.97),P<0.05]。見表2、3。
表1 2組患者一般資料結(jié)果比較±s)
注:-表示該項(xiàng)無(wú)數(shù)據(jù)。
表2 2組患者圍術(shù)期COP結(jié)果比較
表3 2組患者圍術(shù)期COP絕對(duì)值結(jié)果比較±s)
圖1 2組患者圍術(shù)期Hb、ALB、Scr、氧合指數(shù)結(jié)果比較
組別機(jī)械通氣時(shí)間(min)ICU時(shí)間(min)急性肺損傷(n)急性腎損傷(n)低心排綜合征(n)CPB組12.50±5.7258.67±11.94000OP組27.20±22.3661.10±25.86000t-1.70390.1628P0.08840.8707
2.3 2組患者各指標(biāo)檢測(cè)結(jié)果比較 2組患者在手術(shù)結(jié)束、術(shù)后第1天的RBC、ALB、Scr、氧合指數(shù)比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。2組患者術(shù)后機(jī)械通氣時(shí)間、ICU時(shí)間比較,差異無(wú)統(tǒng)計(jì)學(xué)意義[機(jī)械通氣時(shí)間(12.50±5.72)vs. (27.20±22.36),P>0.05);ICU時(shí)間(58.67±11.94)vs. (61.10±25.86),P>0.05]。2組患者均無(wú)急性肺損傷、急性腎損傷、低心排綜合征發(fā)生率。見圖1和表4。
人體血漿COP 70%由清蛋白形成,其余由纖維蛋白原、球蛋白等大分子非離子物質(zhì)形成[4-5]。正常的COP是對(duì)抗水分由血管向組織轉(zhuǎn)移的最重要力量,對(duì)穩(wěn)定血容量、預(yù)防組織水腫有重要作用[6]。正常成年人的COP為25 mm Hg,COP低于16 mm Hg時(shí)血管保水能力減弱,大量液體移至組織間隙,引起液體在肺、心肌、腸壁及外周組織聚集,進(jìn)而影響術(shù)后呼吸功能、心功能、腸道運(yùn)動(dòng)和傷口愈合[7-8]。體外循環(huán)過(guò)程中,由于低溫、炎性反應(yīng)、血液稀釋、蛋白變性、蛋白滲出血管外等因素導(dǎo)致血漿ALB減少,從而引起COP降低[3,9-11]。本研究結(jié)果與國(guó)內(nèi)外相關(guān)研究結(jié)果相同,表明體外循環(huán)開始后COP顯著降低,持續(xù)至手術(shù)結(jié)束,與OP組比較,術(shù)中COP雖有下降但差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。
有關(guān)臨床及動(dòng)物試驗(yàn)提示,提升體外循環(huán)術(shù)中的COP,可預(yù)防液體聚集和體質(zhì)量增加,達(dá)到保護(hù)呼吸功能、心臟功能的作用[12-14]。Golab等[15]研究發(fā)現(xiàn),術(shù)中維持較高的COP可降低術(shù)后血乳酸水平及縮短機(jī)械通氣時(shí)間,帶來(lái)較好的臨床效果。本研究CPB組通過(guò)使用ALB預(yù)充、術(shù)后超濾等手段,提高體外循環(huán)術(shù)后的COP,致使2組患者在手術(shù)結(jié)束返回ICU時(shí)COP差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。2組患者手術(shù)后低心排綜合征、急性肺損傷的發(fā)生率均為0,且急性腎損傷的發(fā)生率比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),2組患者的機(jī)械通氣時(shí)間、ICU 時(shí)間差異也無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。
綜上所述,心臟體外循環(huán)手術(shù)發(fā)展至今,技術(shù)已趨于成熟,預(yù)充液成分的調(diào)整,超濾技術(shù)的改良使得體外循環(huán)造成的不良反應(yīng)減少,從而降低術(shù)后并發(fā)癥,減少機(jī)械通氣時(shí)間和ICU時(shí)間,臨床預(yù)后相較于非體外心臟手術(shù),差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),是比較安全的手術(shù)。由于本研究樣本量有限,有待進(jìn)一步收集更多數(shù)據(jù)以進(jìn)行論證。
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The tendency of plasma colloid osmotic pressure in perioperative period and its clinical significance in adult patients who undergoing cardiac surgery
WUXiaoyun,LIYuanming,JINXianglan,LIUYinmei,ZANGWangfu△
(DepartmentofCardiacSurgery,theTenthPeople′sHospitalofShanghai,Shanghai200072,China)
Objective To observe the tendency of colloid osmotic pressure (COP) in perioperative period and the influence of COP change on the clinical prognosis.Methods Totally 21 adult patients undergoing cardiac surgery were divided into 2 groups:cardiopulmonary bypass in valve replacement group (CPB,n=11),off-pump coronary artery bypass grafting group (OP,n=10).COP of blood samples in 8 points(5 min after anesthesia (T0),5 min after the beginning of cardiopulmonary bypass(CPB)/5 min after suturing the distal of the graft vessel (T1),5 min after the ending of CPB/5 min after suturing the proximal of the graft vessel (T2),returned to ICU (T3),2 h (T4),4 h(T5),8 h (T6),24 h (T7) after operation from patients were tested.We also collected the datas of laboratory tests in 48 h,mechanical ventilation time,ICU time.Looking for the tendency of COP changing and effects on clinical prognosis.Results All patients were in the same basic situation.The COP were decreased during the cardiac surgery,but there was no significant difference between the 2 groups (P>0.05).However,the value of COP changes in the CPB group(△T1) was the most significant (P<0.05).There was no difference in the postoperative complications,ICU time,and the time of mechanical ventilation between the groups (P>0.05).Conclusion Cardiopulmonary bypass surgery can make the colloid osmotic pressure decreasing,but by correcting,the CPB can return to normal in the end of surgery.There is no significant impact on clinical prognosis.
perioperative period; cardiopulmonary bypass; colloid osmotic pressure
吳曉云,女,主治醫(yī)師,主要從事心臟外科術(shù)后監(jiān)護(hù)研究?!?/p>
10.3969/j.issn.1673-4130.2016.20.005
A
1673-4130(2016)20-2815-03
2016-05-13
2016-07-21)