急性超容性血液稀释对电解质及酸碱平衡的影响
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摘要
目的：以急性超容性血液稀释(AHHD)为基础，观察AHHD对电解质及酸碱平衡的影响。方法：临床选择14例择期行耳鼻喉科或颌面外科手术患者，ASA Ⅰ～Ⅱ级，静吸复合麻醉诱导及气管插管后，在30min内用林格式液10ml·kg~(-1)补充生理需要量，以6％羟乙基淀粉溶液按双变量稀释法：扩容量(v)mL=估计血容量×(初始Hct-稀释后Hct)／稀释后Hct进行AHHD。在AHHD过程中每10min采动脉血1ml，用血气分析仪测定电解质、pH值、HCT、Hb判断血液稀释的程度直至血液稀释完成。动态监测心率(HR)、平均动脉压(MAP)和中心静脉压(CVP)。结果：AHHD后患者Na~+、Cl~-升高(p≤0.05)；Lac~-、Hct、Hb、Hco_3~-、BE降低(p≤0.05)：CVP升高(p≤0.05)，升幅为0.730±0.779；其他检测指标差异无统计学意义。结论：1)以双变量稀释法行AHHD是安全有效的，稀释后Hct可达到预定目标值；2)AHHD可使电解质发生轻度变化但不会导致酸碱平衡紊乱。合理实施血液稀释并选择与机体血液成分更相近的稀释液是保障AHHD过程中电解质及酸碱平衡稳定的前提。
Objective: To investigate the effect of acute hypervolemic hemodilution (AHHD) on plasma electrolytes and acid-base equilibrium.
Methods:Fourteen ASA Ⅰ ~ Ⅱ patients(6 male,8 female) undergoing elective orthopedic surgery were entered in this study. After induction of anesthesia the patients received 10ml·kg~(-1) Ringer's solution and 6% HES [predicted volume of infusion= predicted blood volume × (Hct_(before AHHD)-Hct_(after AHHD))/ Hct_(after AHHD)] within 20-30min . Arterial blood samples were taken every 10 minute for determination of the plasma electrolytes, acid-base equilibrium and the degree of hemodilution. And during the hemodilution the heart rate (HR),mean arterial blood presure (MAP) and central vein pressure (CVP) were continuoused to monitor.Results:After AHHD the plasma sodium concentration, chloride concentration and CVP increased (p≤0.05 ),but the lactate concentration bicarbonate concentration,Hct, Hb and BE decreased (p<0.05) .The pH value drcreased slightly but without statistical meaning.The other values did not change during the hemodilution. Conclusion: 1) After AHHD ,the Hct value can decreased to the predicted value(Hct=0.26). AHHD with the formula[ predicted volume of infusion= predicted blood volume X (Hct_(before AHHD)- Hct_(after AHHD))/ Hct_(after AHHD)] was effective and safe .2)AHHD can chang the plasma electrolytes slightly but can not induce the acid-base unequal.The colloid with more "physiologic" composition could be the key of keeping the balance of acid-based during the AHHD.
Objective: To investigate the effect of acute hypervolemic hemodilution (AHHD) on plasma electrolytes and acid-base equilibrium.
Methods:Fourteen ASA Ⅰ ~ Ⅱ patients(6 male,8 female) undergoing elective orthopedic surgery were entered in this study. After induction of anesthesia the patients received 10ml·kg~(-1) Ringer's solution and 6% HES [predicted volume of infusion= predicted blood volume × (Hct_(before AHHD)-Hct_(after AHHD))/ Hct_(after AHHD)] within 20-30min . Arterial blood samples were taken every 10 minute for determination of the plasma electrolytes, acid-base equilibrium and the degree of hemodilution. And during the hemodilution the heart rate (HR),mean arterial blood presure (MAP) and central vein pressure (CVP) were continuoused to monitor.Results:After AHHD the plasma sodium concentration, chloride concentration and CVP increased (p≤0.05 ),but the lactate concentration bicarbonate concentration,Hct, Hb and BE decreased (p<0.05) .The pH value drcreased slightly but without statistical meaning.The other values did not change during the hemodilution. Conclusion: 1) After AHHD ,the Hct value can decreased to the predicted value(Hct=0.26). AHHD with the formula[ predicted volume of infusion= predicted blood volume X (Hct_(before AHHD)- Hct_(after AHHD))/ Hct_(after AHHD)] was effective and safe .2)AHHD can chang the plasma electrolytes slightly but can not induce the acid-base unequal.The colloid with more "physiologic" composition could be the key of keeping the balance of acid-based during the AHHD.
引文
[1] 邓硕曾，纪宏文．麻醉医师应站在血液保护的第一线[J]．临床麻醉学杂志，1999，15(1)：18-21
[2] Lars Letal, Mike LL, Entholzner E et al. Preoperative acute normovelemic hemodilution with hypdroxyethyl starch: an alternative to acute normovelemic hemodilution[J] inesth Analg, 1997; 84: 26
[3] Entholzner E, Mielke H, pcotz W, et al. Hypervolemic hemodilution as a means of preventing homologous blood transfusion, A simple alternative to acute normovelemic hemodilution [J]. Fortschr Med, 1994 20; 112(29)): 410
[4] 刘克玄，闵振兴，林世清，等．术前急性超容性血液稀释的研究进展．[J]麻醉与复苏分册，2000，21(6)：328-330
[5] 吴新文，曹云飞，颜志伟．急性高容量血液稀释及麻醉相关问题[J]．第一军医大学分校学报，2004，27(2)：186-190
[6] Kikuchi K Konishi A, Terashima M, et al . Hemodynamics during hypervolemic hemodilution (HH) technique[J]. Masui, 1994; 43(11): 1701
[7] 于布为，顾敏杰，薛庆生，等．急性高容血液稀释对氧供、氧耗、循环血容量和血管外肺水的影响[J]．临床麻醉学杂志，2003，19：23-26
[8] 秦翔，吴新民，张春丽．急性血液稀释中不同血浆代用品的容量扩充效应[J]．中华麻醉学杂志，2002，22(11)：691-672
[9] van Daele ME, Trouwborst A, van Woerkens LC, et al. TransersopHageal echocardiograHic monitoring of preperative acute hypervolemic hemodilution [J]. Anesthesiology, 1994, 81(3): 602-609
[10] 王清秀，靳凤玲，金清尘，等．手术病人对急性等容血液稀释的耐??受程度[J]．中华麻醉学杂志，1997，17：652-655
[11] 郭晓丽，葛衡江．急性高容量血液稀释对凝血功能的影响[J]．重庆医学，2004，33(2)：248-251
[12] 单闯，吴国荣，张顺，等．急性高容量血液稀释对全髋关节置换术患者血小板膜糖蛋白表达的影响[J]．中华麻醉学杂志，2003，23(9)：648-651
[13] Trotwborst Aet al Br J Anaesth, 1990; 64: 646
[14] Gostishchev VK et al. Khirurgiia-Mosk, 1991; (7); 54
[15] Singbartl K et al. J Surg Res, 1999: 86 (2): 206-212
[16] 赵砚丽，杨宾侠，王丽华，等．不同晶体液扩容对子宫全切术患者电解质、酸碱平衡的影响[J]．中华麻醉学杂志，2005，25：71-73
[17] 金惠铭，主编．病理生理学[M]．第一版．北京人民卫生出版社．2000．66-71
[18] Wilkes NJ, Woolf R, Mutch M, et al. The effect of balanced versus saline-baesd hetastarch and crystalloid solutions on acid-base and electrolyte status and mucosal perfusion in elderly surgical patients. Anesth Analg, 2001, 93: 811-816
[19] Markus Rehm, M. D, VictoriaOrth,M.D, StefanScheingraber, M D, et al. Acid-base changes caused by 5% albumin versus 6％ hydroxyethyl starch solution in patients undergoing acute normovolemic hemodilution. Anwsthesology, 2000, 93: 1174-83
[20] 余微萍，徐旭仲，寿红艳，等．术前急性高容血液稀释对围术期控制性降压内环境的影响[J]．实用医学杂志，2004，20 (7)：773-774
[21] 魏蔚，郑祥德，龚全，等．不同血浆代用品术前急性超容血液稀释可行性的比较[J]．中华麻醉学杂志，2004，24(7)：493-496[1] 申屠建中，吴丽花，章霞，等．高效液相色谱-荧光检测法测定异丙酚的血药浓度．药物分析杂志，2002，22(1)：65-67
[2] Guitton J, Desage M, Lepape A, et al. Quantitation of propofol in whole blood by gas chromatography-mass spectrometry. J Chromatogr B, 1995, 669: 358-365
[3] 刘文英．药物分析．第4版，北京：人民卫生出版社，1999
[4] 曾经泽．生物药物分析．第2版，北京：北京医科大学、中国协和医科大学联合出版社，1998．1
[5] 张燕婉，刘进，赵延．高效液相色谱法测定血浆中丙泊酚浓度．中国药学杂志，1999，34(12)：831-833
[6] 李正翔，王舒，张素品，等．高效液相色谱法测定人血清中异丙酚浓度．中国医院药学杂志，1997，17(7)：293
[7] 易杰，苏薇，罗爱伦．改良高效液相色谱荧光法测定脑脊液中异丙酚浓度的可行性．中华麻醉学杂志，2003，23(2)：151
[8] Fan SZ, Yu HY, Chen YL, et al. Propofol concentration monitoring in plasma or whole blood by gas chromatography and high-performance liquid chromatography. Anesth Analg, 1995, 81: 175-8
[9] Vree TB, Bars AM, Grood Pmrm. High performance liquid chromatography determination and preliminary. pharmacokinetics of propofol and its metabolites in human liasma and urine. J chromatogr, 1987, 417: 458-464
[10] 郑宏，曹新华，王江，等．气相色谱-质谱法测定异丙酚血药浓度．中华麻醉学杂志，2004，24(1)：71-72
[11] Plummer GF. Improved method for the determination of propofol in blood by high-performance liquid chromatography with fluorescence detection. J Chromatogr, 1993, 615: 77-81[12] Pavan I, Buglione E, Berardino M, et al. Monitoring Propofol serum level by rapid and sensitive reversed phase high-performance liquid chromaography during prolonged sedation in ICU parients. J Chromatogr Sci, 1992, 30(5) : 164
[13] Ying YH, Kai LJ. Quantitation of propofol in plasma by capillary gas chromatography. J Chromatogr Sci, 1993, 615: 67-68
[14] Dawidowicz AL. Determination of propofol in blood by HPLC comparision of the extraction and precipition methods. JChromatogr Sci, 1995, 31(7): 337
[15] Elbast W, Guitton J, Desage M, et al. Comparision between gas chromatography-atomic emission detection and gas chromatography-mass spectrometry for the assay of propofol. J Chromatogr B, 1996, 686: 97-102
[16] Adam HK, Doulas EJ, Plummer GF, et al. Estimation of ICI 35,868 (Diprivan R) in blood by high-performance liquid chromatography, following coupling with Gibb reagent. Chromatography 1981, 223: 232-237
[17] Sebel PS, Lowdon JD. Propofol: a new intravenous anesthetic. Anesthesiology , 1989,71:260-77
[18] Yeganeh MH, Ramzan I. Determination of propofol in rat whole blood and plasma by high performance liquid chromatography. J Chromatogr, 1997, 691:478-482
[19] Simons PJ, Cockshott EJ, Douglas EA, et al. Species differences in blood profile, metabolism and excretion of 14C-propofol-after intravenous dosing to rat, dog and rabbit. Xenobiotica, 1992,21: 1243-1256
[20] Knibe AJ, Koster VS, Deneer VH, et al. Determination of propofol in low-volum samples by high-performance liquid chromatography with fluorescene detection. J Chromatogr B, 1998, 706 (2): 305
[2] Lars Letal, Mike LL, Entholzner E et al. Preoperative acute normovelemic hemodilution with hypdroxyethyl starch: an alternative to acute normovelemic hemodilution[J] inesth Analg, 1997; 84: 26
[3] Entholzner E, Mielke H, pcotz W, et al. Hypervolemic hemodilution as a means of preventing homologous blood transfusion, A simple alternative to acute normovelemic hemodilution [J]. Fortschr Med, 1994 20; 112(29)): 410
[4] 刘克玄，闵振兴，林世清，等．术前急性超容性血液稀释的研究进展．[J]麻醉与复苏分册，2000，21(6)：328-330
[5] 吴新文，曹云飞，颜志伟．急性高容量血液稀释及麻醉相关问题[J]．第一军医大学分校学报，2004，27(2)：186-190
[6] Kikuchi K Konishi A, Terashima M, et al . Hemodynamics during hypervolemic hemodilution (HH) technique[J]. Masui, 1994; 43(11): 1701
[7] 于布为，顾敏杰，薛庆生，等．急性高容血液稀释对氧供、氧耗、循环血容量和血管外肺水的影响[J]．临床麻醉学杂志，2003，19：23-26
[8] 秦翔，吴新民，张春丽．急性血液稀释中不同血浆代用品的容量扩充效应[J]．中华麻醉学杂志，2002，22(11)：691-672
[9] van Daele ME, Trouwborst A, van Woerkens LC, et al. TransersopHageal echocardiograHic monitoring of preperative acute hypervolemic hemodilution [J]. Anesthesiology, 1994, 81(3): 602-609
[10] 王清秀，靳凤玲，金清尘，等．手术病人对急性等容血液稀释的耐??受程度[J]．中华麻醉学杂志，1997，17：652-655
[11] 郭晓丽，葛衡江．急性高容量血液稀释对凝血功能的影响[J]．重庆医学，2004，33(2)：248-251
[12] 单闯，吴国荣，张顺，等．急性高容量血液稀释对全髋关节置换术患者血小板膜糖蛋白表达的影响[J]．中华麻醉学杂志，2003，23(9)：648-651
[13] Trotwborst Aet al Br J Anaesth, 1990; 64: 646
[14] Gostishchev VK et al. Khirurgiia-Mosk, 1991; (7); 54
[15] Singbartl K et al. J Surg Res, 1999: 86 (2): 206-212
[16] 赵砚丽，杨宾侠，王丽华，等．不同晶体液扩容对子宫全切术患者电解质、酸碱平衡的影响[J]．中华麻醉学杂志，2005，25：71-73
[17] 金惠铭，主编．病理生理学[M]．第一版．北京人民卫生出版社．2000．66-71
[18] Wilkes NJ, Woolf R, Mutch M, et al. The effect of balanced versus saline-baesd hetastarch and crystalloid solutions on acid-base and electrolyte status and mucosal perfusion in elderly surgical patients. Anesth Analg, 2001, 93: 811-816
[19] Markus Rehm, M. D, VictoriaOrth,M.D, StefanScheingraber, M D, et al. Acid-base changes caused by 5% albumin versus 6％ hydroxyethyl starch solution in patients undergoing acute normovolemic hemodilution. Anwsthesology, 2000, 93: 1174-83
[20] 余微萍，徐旭仲，寿红艳，等．术前急性高容血液稀释对围术期控制性降压内环境的影响[J]．实用医学杂志，2004，20 (7)：773-774
[21] 魏蔚，郑祥德，龚全，等．不同血浆代用品术前急性超容血液稀释可行性的比较[J]．中华麻醉学杂志，2004，24(7)：493-496[1] 申屠建中，吴丽花，章霞，等．高效液相色谱-荧光检测法测定异丙酚的血药浓度．药物分析杂志，2002，22(1)：65-67
[2] Guitton J, Desage M, Lepape A, et al. Quantitation of propofol in whole blood by gas chromatography-mass spectrometry. J Chromatogr B, 1995, 669: 358-365
[3] 刘文英．药物分析．第4版，北京：人民卫生出版社，1999
[4] 曾经泽．生物药物分析．第2版，北京：北京医科大学、中国协和医科大学联合出版社，1998．1
[5] 张燕婉，刘进，赵延．高效液相色谱法测定血浆中丙泊酚浓度．中国药学杂志，1999，34(12)：831-833
[6] 李正翔，王舒，张素品，等．高效液相色谱法测定人血清中异丙酚浓度．中国医院药学杂志，1997，17(7)：293
[7] 易杰，苏薇，罗爱伦．改良高效液相色谱荧光法测定脑脊液中异丙酚浓度的可行性．中华麻醉学杂志，2003，23(2)：151
[8] Fan SZ, Yu HY, Chen YL, et al. Propofol concentration monitoring in plasma or whole blood by gas chromatography and high-performance liquid chromatography. Anesth Analg, 1995, 81: 175-8
[9] Vree TB, Bars AM, Grood Pmrm. High performance liquid chromatography determination and preliminary. pharmacokinetics of propofol and its metabolites in human liasma and urine. J chromatogr, 1987, 417: 458-464
[10] 郑宏，曹新华，王江，等．气相色谱-质谱法测定异丙酚血药浓度．中华麻醉学杂志，2004，24(1)：71-72
[11] Plummer GF. Improved method for the determination of propofol in blood by high-performance liquid chromatography with fluorescence detection. J Chromatogr, 1993, 615: 77-81[12] Pavan I, Buglione E, Berardino M, et al. Monitoring Propofol serum level by rapid and sensitive reversed phase high-performance liquid chromaography during prolonged sedation in ICU parients. J Chromatogr Sci, 1992, 30(5) : 164
[13] Ying YH, Kai LJ. Quantitation of propofol in plasma by capillary gas chromatography. J Chromatogr Sci, 1993, 615: 67-68
[14] Dawidowicz AL. Determination of propofol in blood by HPLC comparision of the extraction and precipition methods. JChromatogr Sci, 1995, 31(7): 337
[15] Elbast W, Guitton J, Desage M, et al. Comparision between gas chromatography-atomic emission detection and gas chromatography-mass spectrometry for the assay of propofol. J Chromatogr B, 1996, 686: 97-102
[16] Adam HK, Doulas EJ, Plummer GF, et al. Estimation of ICI 35,868 (Diprivan R) in blood by high-performance liquid chromatography, following coupling with Gibb reagent. Chromatography 1981, 223: 232-237
[17] Sebel PS, Lowdon JD. Propofol: a new intravenous anesthetic. Anesthesiology , 1989,71:260-77
[18] Yeganeh MH, Ramzan I. Determination of propofol in rat whole blood and plasma by high performance liquid chromatography. J Chromatogr, 1997, 691:478-482
[19] Simons PJ, Cockshott EJ, Douglas EA, et al. Species differences in blood profile, metabolism and excretion of 14C-propofol-after intravenous dosing to rat, dog and rabbit. Xenobiotica, 1992,21: 1243-1256
[20] Knibe AJ, Koster VS, Deneer VH, et al. Determination of propofol in low-volum samples by high-performance liquid chromatography with fluorescene detection. J Chromatogr B, 1998, 706 (2): 305