择期非心血管手术术中失血对凝血功能的影响  

Effects of blood loss during operation on coagulation function in selective non-cardiovascular surgery patients

作　　者：王卓强[1] 徐震[1] 刘秀珍[1] 张斌[1] 王恒林[1] 范里莉[1] 

机构地区：[1]解放军309医院麻醉科,北京100091

出　　处：《解放军医学杂志》2010年第7期877-880,883,共5页Medical Journal of Chinese People's Liberation Army

摘　　要：目的观察择期非心血管外科手术患者术中不同程度失血对凝血功能的影响。方法随机选择拟行非心血管外科手术的患者20例,年龄23～57岁,ASAⅠ-Ⅱ级,术前凝血功能无异常。麻醉后在充分镇静、镇痛的基础上,给予37℃预温的林格液和羟乙基淀粉(晶胶比1:2),维持心率、血压和中心静脉压的稳定。术中监测体温和动脉血气指标以排除低体温和酸中毒可能造成的干扰。监测失血量约占全血容量的10%、15%、20%、25%时患者的血常规、常规凝血功能指标以及Sonoclot分析仪测定的凝血和血小板功能参数。结果手术前血细胞比容(Hct)为0.381±0.038,失血量10%、15%、20%、25%时下降为0.334±0.030、0.315±0.029、0.301±0.045和0.279±0.031。失血量达到或超过15%时血小板(PLT)计数较术前显著下降(P<0.01),但未超出正常值范围。失血量20%、25%时血浆凝血酶原时间(PT)、活化的部分凝血酶原时间(APTT)明显延长,与术前比较差异有统计学意义(P<0.05)。纤维蛋白原定量(Fib)浓度也都明显降低,与术前比较差异有统计学意义(P<0.01)。Sonoclot分析提示,失血20%时激活的凝血时间(ACT)、曲线达峰值时间(TP)均延长(P<0.05),失血25%时显著延长(P<0.01);失血15%时血小板功能(PF)下降(P<0.05),失血20%、25%时PF和血块凝结速率(CR)都显著下降(P<0.01)。结论在避免过度应激,最大程度地减少低体温、酸中毒对凝血功能影响的情况下,非心血管外科手术患者术中失血达20%以上者,凝血指标与术前比较均有统计学差异(P<0.05),出血量不足20%可忽略其对凝血功能的影响。Sonoclot分析技术灵敏、可靠,对于早期发现失血造成的凝血功能障碍,从而进行及时、有针对性地干预提供了有力的支持。Objective To investigate the change in coagulation function in relation to different amounts of blood loss in selective non-cardiovascular surgery patients.Methods Twenty American Anesthesia Association （ASA） class I or Ⅱ patients,aged 23-57 yr,undergoing non-cardiovascular surgery with normal preoperative coagulation were chosen randomly.After general anesthesia,on the basis of adequate sedation and analgesia,patients were given Ringer＇s solution and Voluven （pre-warmed to 37℃,volume ratio of crystalloid/colloid was 1：2） to maintain the stability of heart rate,blood pressure and central venous pressure.Temperature and blood gas analysis were monitored to prevent potential interference induced by hypothermia and acidosis.When the ratio of blood loss/blood volume reached 10%,15%,20% and 25%,all the routine blood components analysis and coagubility parameters,and Sonoclot coagulation and platelet function parameters were observed.Results Preoperative average value of Hct was 38.1%,and when ratio of blood loss/blood volume were 10%,15%,20 % and 25%,Hct was decreased to 33.4%,31.5%,30.1% and 27.9% respectively.When the ratio reached 15% or larger,platelet count decreased significantly compared with preoperative value （P〈0.01）,but it still maintain in the range of normal value.When ratio of blood loss/blood volume was 20% and 25%,PT and APTT prolonged significantly compared with preoperative value （P〈0.05）,but they were still in the range of normal value.Concentration of fibrinogen decreased significantly compared with preoperative value （P〈0.01）.When ratio of blood loss/blood volume reached 20%,prolongation of ACT and TP was observed by Sonoclot （P〈0.05）,and at 25% the prolongation was more significant （P〈0.01）.A decrease PF （P〈0.05） was observed when the ratio reached 15%,and when it reached 20% and 25%,both PF and CR decreased significantly （P〈0.01）.Conclusions When excessive stress was avoided,effects of hypothermia and acidosis on coagulation function were

关 键 词：失血 手术 血液凝固障碍 SONOCLOT分析仪 

分 类 号：R826.26[医药卫生—临床医学]