| Summary: | 碩士 === 國立臺灣大學 === 臨床醫學研究所 === 97 === Abstract
Background: In major abdominal surgery, patients are easily suffered from absolute or relative intravascular volume deficits because of preoperative fasting, gastrointestinal preparation, perioperative bleeding, exposure evaporation, third-space losses, and vasodilation after anesthesia. Hypovolemia during surgery has been associated with intraoperative hemodynamic instability and tissue hypoperfusion. Therefore, adequate restoration of intravascular volume is important to fulfill the nutritive role of the circulation. The choice of the ideal fluid management still poses a clinical dilemma. Colloid fluids, such as hydroxyethyl starch (HES) preparations, are commonly used during surgery because of improved volume expansion effect to avoid of tissue edema and enhance tissue perfusion. However, the known adverse effect of hemostatic impairment associated with HES is concerned. The aim of the investigation was to assess the influence of a newly HES preparation (Voluven®, 6% HES, 130/0.4) on tissue perfusion and coagulation in patients undergoing major abdominal surgery, and to compare it with lactated Ringer’s solution (LR).
Methods: Forty adults patients undergoing elective major abdominal surgery was randomized to received either Voluven® or lactated Ringer’s solution to keep arterial blood pressure between 65 – 90 mmHg or central venous pressure between 8 -12 mmHg. Tissue perfusion parameters using heart rate, arterial blood pressure, central venous pressure, cardiac index, stroke volume index and central venous oxygen saturation were measured at T0 (baseline), T1 (start of surgery ), T2 (1 hour after start of surgery) and T3 (end of surgery). Coagulation parameters using thrombelastography were measured at T0 (baseline), T4 (after 15 mL/kg fluid transfused) and T5 (24 hours after baseline). Analysis of variance (ANOVA) was applied to detect the significance between groups and repeated measures ANOVA for significance within group. Significance level is p < 0.05.
Results: Baseline data were compatible in both groups, including sex, age, height, weight, type and time of procedures, and concentration of preoperative hemoglobin. A total intraoperative fluid administration were 1498.1 ± 209.4 mL and 2596.2 ± 328.1 mL in HES group and LR group, respectively (p < 0.001); including 1269.2 ± 394.5 mL of Voluven® (HES group) and 1787.9 ± 686.0 mL of LR (LR group). The parameters of tissue perfusion, such as hemodynamics and central venous oxygen saturation, did not differ significantly between the two groups. Intraoperative amount of blood loss and urine output were not significant but more red blood transfusion was needed to complete surgery in LR group than HES group (10 units vs. 0 units, p = 0.047). The kinetics of clot formation (clot formation time, R time) significantly increased after 15 mL/kg Voluven® transfused (8.8 ± 2.5 vs. 7.5 ± 1.8, p = 0.045) and lasted until 24 hours (8.8 ± 2.5 vs. 7.4 ± 1.5, p = 0.031). The MA amplitude decreased significantly after 15 mL/kg Voluven® (61.5 ± 8.5 vs. 55.9 ± 7.6, p = 0.034) and recovered to baseline after 24 hours.
Conclusion: Intraoperative intravascular volume replacement with the new HES preparation Voluven® was comparable with LR on tissue perfusion; however, Voluven® showed an improved volume expansion effect than LR. Although strength of clot was impaired after Voluven® replacement as detected by TEG, it did not result in clinically significant bleeding during surgery and hence in needs of blood transfusion. Voluven® may be considered as a safe and effective choice of colloid fluid in major abdominal surgery.
|
|---|
