CAJ | 학술논문

目的评价氨甲环酸预防性用药对肝移植术患者的血液保护效应.方法选择同种异体原位肝移植术患者60例,年龄18～60岁,体重45 ～ 80 kg,ASA分级Ⅰ-Ⅲ级,性别不限,采用随机数字表法将患者分为2组(n=30):预防性用药组(P组)和治疗性用药组(T组).分别于麻醉诱导后即刻(T1)、无肝期30 min(T2)、新肝期30 min(T3)、新肝期2 h(T4)时取中心静脉血样,测定Fib和血小板计数;取动脉血样检测血栓弹力图(TEG)指标.T组根据TEG检测结果,若最大振幅后30 min血凝块幅度减少速率＞7.5％,凝血综合指数≤1.0,提示发生原发性纤溶亢进,则静脉注射氨甲环酸15～20 mg/kg.P组于切皮即刻、门静脉阻断即刻和门静脉开放即刻,静脉注射氨甲环酸1g,若发生原发性纤溶亢进则静脉注射氨甲环酸15 ～ 20 mg/kg.记录术中出血量、液体出入量、成分输血量.记录ICU停留时间、ICU期间腹腔引流量、术后72 h内输血量,记录术后1周门静脉及肝动脉血栓的发生情况.结果与T组比较,P组术中出血量、琥珀酰明胶注射液用量、血小板及冷沉淀用量减少,T2时Angle升高,T2.3时最大振幅后30 min血凝块幅度减少速率和T3时最大振幅升高(P＜0.05),ICU停留时间、术后引流量和输血量差异无统计学意义(P＞0.05).P组无一例发生原发性纤溶功能亢进.2组患者术后1周均未出现肝动脉和门静脉血栓.结论氨甲环酸预防性用药可有效预防纤溶功能亢进,减少其导致的术中出血,且不增加血栓发生风险,血液保护效应优于TEG指导下的治疗性用药.
목적 평개안갑배산예방성용약대간이식술환자적혈액보호효응.방법 선택동충이체원위간이식술환자60례,년령18～60세,체중45 ～ 80 kg,ASA분급Ⅰ-Ⅲ급,성별불한,채용수궤수자표법장환자분위2조(n=30):예방성용약조(P조)화치료성용약조(T조).분별우마취유도후즉각(T1)、무간기30 min(T2)、신간기30 min(T3)、신간기2 h(T4)시취중심정맥혈양,측정Fib화혈소판계수;취동맥혈양검측혈전탄력도(TEG)지표.T조근거TEG검측결과,약최대진폭후30 min혈응괴폭도감소속솔＞7.5％,응혈종합지수≤1.0,제시발생원발성섬용항진,칙정맥주사안갑배산15～20 mg/kg.P조우절피즉각、문정맥조단즉각화문정맥개방즉각,정맥주사안갑배산1g,약발생원발성섬용항진칙정맥주사안갑배산15 ～ 20 mg/kg.기록술중출혈량、액체출입량、성분수혈량.기록ICU정류시간、ICU기간복강인류량、술후72 h내수혈량,기록술후1주문정맥급간동맥혈전적발생정황.결과 여T조비교,P조술중출혈량、호박선명효주사액용량、혈소판급랭침정용량감소,T2시Angle승고,T2.3시최대진폭후30 min혈응괴폭도감소속솔화T3시최대진폭승고(P＜0.05),ICU정류시간、술후인류량화수혈량차이무통계학의의(P＞0.05).P조무일례발생원발성섬용공능항진.2조환자술후1주균미출현간동맥화문정맥혈전.결론 안갑배산예방성용약가유효예방섬용공능항진,감소기도치적술중출혈,차불증가혈전발생풍험,혈액보호효응우우TEG지도하적치료성용약.
Objective To evaluate the blood-saving effect of prophylactic use of tranexamic acid in patients undergoing orthotopic liver transplantation.Methods Sixty ASA physical status Ⅰ-Ⅲ patients of both sexes,aged 18-60 yr,weighing 45-80 kg,scheduled for elective orthotopic liver transplantation,were randomly assigned to one of 2 groups (n =30 each) using a random number table:prophylactic use group (group P) and therapeutic use group (group T).Immediately after induction of anesthesia (T1),at 30 min of anhepatic phase (T2),and at 30 min and 2 h of neohepatic phase (T3,4),central venous blood samples were collected to determine plasma fibrinogen concentration (Fib) and platelet count,and the arterial blood samples were obtained to detect thromboelastography (TEG) parameters.In group T,when lysis after 30 min＞7.5％ and Clot Index ≤ 1.0 according to the results of TEG,which indicating that primary hyperfibrinolysis occurred,tranexamic acid 15-20 mng/kg was injected intravenously.In group P,immediately after beginning of skin incision,immediately after occlusion of portal vein,and immediately after portal vein unclamping,tranexamic acid 1 g was injected intravenously,and a single injection of tranexamic acid 15-20 mg/kg was given when primary hyperfibrinolysis occurred.The intraoperative blood loss,fluid input and output and transfusion of blood components were recorded.The duration of stay in ICU,amount of abdominal drainage during stay in ICU,volume of blood transfused within 72 h after operation,and hepatic artery and portal vein thrombosis within 1 week after operation were recorded.Results Compared with group T,the intraoperative blood loss,volume of succinylated gelatin injection transfused,and requirement for platelet and cryoprecipitate were significantly reduced,Angle at T2 and lysis after 30 min at T2,3 and maximum amplitude at T3 were increased,and no significant change was found in the duration of stay in ICU,postoperative amount of abdominal drainage and volume of blood transfused in group P.No patients developed primary hyperfibrinolysis in group P.No hepatic artery and portal vein thrombosis was detected within 1 week after operation in the two groups.Conclusion Prophylactic use of tranexamic acid can effectively prevent hyperfibrinolysis and reduce intraoperative blood loss without increasing the risk of development of thrombosis,and it provides better blood-saving effect than therapeutic use guided by TEG in patients undergoing orthotopic liver transplantation.