| Backgrouds and Objective: The risks associated with transfusion of homologous blood have provide the impetus for the development if technique to minimize transfusions. At present measures of saving blood in common use during operation include: Preoperative autologous blood donation, intra- and postoperative salvage of the patient's blood and its retransfusion, acute normovolemic hemodilution, acute hypervolemic hemodilution .controlled hypotension, hypothermia, and intra- and postoperative use of hemostat. However, every method has its limit, the combination of several measures of saving blood was advocated in recent years compositive measures of saving blood. AHH and CH can reduce the loss of blood and blood transfusion. Compared with ANH ,AHH can save time and cost, and reduce contamination of blood. AHH and CH can utilize other's strong points to offset one's weakness if they are combined, thus the loss of blood and blood transfusion can be more reduced. It will be more widely used in clinic gradually and it is the new measure of the blood saving. It is significant to avoid the disease induced by blood transfusion and resolve the problem f saving blood also has to be more discussed.Whether the oxygen metabolism of organization and organa is balanceable or not is the important criteria to evaluate the safety of the combination of AHH and CH. Brain has special characteristic of high metabolism ratio and the weak resistance to the lack of oxygen and blood and it is one of the most sensitive organa. The safety of the combination of AHH and CH in the cerebral neurosystem needs more basic and clinic research to evaluateand develop the new measure of blood saving. So in this study the patients undergoing scheduled elective meningioma operation selected randomly were adopted mild degree AHH with 6%HES, which were devided into two groups and combined with CH induced by SNP or ND, and compared with the group (CH not practiced on it), to observing the changes of hemodynamics, cerebral oxygen supply and consumption and cerebral energy metabolism . The purpose of this study is to investigate the influence degree of AHH or the combination of AHH and CH induced with different medicament on hemodynamics, cerebral oxygen supply and consumption and cerebral energy metabolism and to discuss the safety and effectiveness of the combination of AHH and CH induced with different medicament, And to provide clinical bases for its administration in anesthesia.Materials and methods: Thirty patients, ASA I ~ II, HCT=35%, HB> 110g.1~-1 undergoing scheduled elective meningioma operation were randomly divided into 3 groups, with 10 in each group. Group A: control group, Group B:AHH combined with CH induced by SNP, Group C:AHH combined with CH induced by ND, The anesthesia induction and drug of anesthesia maintenance are all the same. The patients were premedicated with intramuscular hyoscine 0.3mg and luminal O.lg. Anesthesia was induced with midazolam O.lmg-kg"1, fentantl Sug-kg"1 propofol 2mgkg"1and scoline l.lSmg-kg"1 and maintained with propofol O.lmg-kg^-min'1 and remifentantl O.lug-kg^-min^.Muscle relaxation was maintained with intermittent intravenous boluses of vecuronium and fentantl.The patients were mechanically ventilated after tracheal intubation and PE1CO2 was maintained at 4.66-5.32KPa. Right internal jugular ,subclavian vein and left radialis artery were cannulated. Radial artery was cannulated for intra-arterial pressure monitoring and blood sampling and subclavian vein were cannulated for CVP monitoring and jugular vein were cannulated for blood sampling. All the patients were adopted mild degree AHH with lSmLkg"1 HES was infused intravenously at a rate of 25ml.min"1 after induction.0.9%NS 6-8 ml-kg"1 was infused before induction to compensate for preoperative fluid restrition after midnightAnd during operation blood loss was replaced withequal volume of 6%HES. Blood transfusion was considered to maintain HCT> 25%. When Hb<80 g/L and HCT< 25%.GroupB with SNP was infused at rate l-4//g.kg"1.min"1 and GroupC with ND at 1-6 /ig.kg"1.min"1 after open the meninx and MAP was maintained at 70% of the baseline, and stop infusion after the major operation is over. MAP(Mean Arterial Pressure), HR(Heart Rate), CVP(Central Venous Pressure), SpO2(pulse oxygen saturation), PetCO2 were monitored continually during the whole experiment. Collect venous and arterial blood samples before AHH(To,baseline), after AHH(Ti), AHH combined with CH 30 min (T2), 60 min AHH(T3), after CH 30 min(T4) respectively for determining the following data: (l)Blood gases, record Haematocrit (HCT) and Hemoglobin(HB); SjvO2(jugular venous oxygen saturation), CaO2(arterial oxygen content), CjvChOugular oxygen content), Da-jvO2 (arterial-jugular venous difference of oxygen), CEO2(cerebral extraction of oxygen);(2) Da-jvL (jugular venous-arterial difference of lactate);(3) Ca-jvSOD (jugular venous-arterial difference of superoxide dismntase); (4) Ca-jvMDA (jugular venous-arterial difference of malondialdehyde). ANOVA, Fisher's exact test were employed to analyze the data in SPSS 10.0. P value less than 0.05 was considered statistically significant. Results:1.General dataThere were no significance difference among three groups in age, sex, weight, baseline value of HCT and operation time.2.Changes on hemodynamicsChanges on MAP:At To, there were no significant differences among three groups (P>0.05). Compare between groups: In groupB or groupC MAP were no significant alterations at Ti and T4(P>0.05) and significantly decreased at T2 ,T3 (P<0.05) compared with control group. There were no significant difference between groupB and groupC at To~T4. Compare within groups: Within group A, there were no significant alterations at all time; In groupB or groupC MAP were no significant alterations at Ti and T4 (P>0.05) and significantly decreased at T2 /I3 (P<0.05) compared with To. Changes onCVP:At To, there were no significant differences among three groups (P>0.05). Compare between groups: In groupB or groupC CVP were no significant alterations at Ti and T4 (P>0.05) compared with control group; At T2 ,T3 CVP significantly decreased (P<0.05) in groupB and group C compared with control group; CVP significantly decreased (P<0.05) at T2 ,T3 in group B compared with group C. Compare within groups: Within group A and group C, CVP were higher than To at Ti—T4 (P<0.05); CVP significantly increased at Ti ^ T4 (P<0.05) in groupB. Compared with Ti, CVP were lower at T2> T3(P<0.05) in groupB or groupC. Changes on HR: there were no significant differences among three groups (P>0.05).3.Changes on HCT and HB:There were no significant differences among three groups (P>0.05). Compare within groups: HCT and HB were significantly decreased (P<0.05) at Ti~ T4 compared with To and were comparable at Ti~ T4(P>0.05) in three groups.4.Changes on cerebral oxygen supply and consumption and energy metabolism:Changes on SjvO2: At To, there were no significant differences among three groups (P>0.05). Compare between groups: In groupB SjvCh were no significant alterations at Ti and T4 (P>0.05) and significantly decreased at T2 ,T3 (P<0.05) compared with control group. There were no significant difference between groupB and control group at To~ T4(P>0.05). SjvO2 significantly decreased (P<0.05) at T2 ,T3 and in group B compared with group C. Compare within groups: SjvO2 significantly increased (P<0.05) at Ti~ T4 in groupA or group C compared with To,Within group B SjvO2 significantly decreased at T2 ,T3 (P<0.05) and significantly increased at Ti ,T4 (P<0.05)compared with To.Changes on CaO2: There were no significant differences among three groups (P>0.05). Compare within groups: Compared with To, CaO2 significantly decreased at Ti~ T4(P<0.05),and there were no significant differences at the corresponding points(P>0.05).Changes on CjvO2: There were no significant differences among threegroups (P>0.05). Compare between groups: In groupB CJVO2 were no significant alterations at Ti and T4 (P>0.05) and significantly decreased at T2 ,T3 (P<0.05) compared with control group. There were no significant alterations in group C at To—T4(P>0.05) compared with control group. CjvO2 significantly decreased (P<0.05) at T2 ,T3 in group B compared with group C. Compare within groups: CJVO2 significantly decreased (P<0.05) in three groups compared withT0(P<0.05).Changes on Da-jvO2: There were no significant differences among three groups (P>0.05). Compare between groups: In groupB Da-jvO2 were no significant alterations at Ti and T4 (P>0.05) and significantly increased at T2 ,T3 (P<0.05) compared with control group. There were no significant alterations in group C at To~T4(P>0.05) compared with control group. Da-jvO2 significantly increased (P<0.05) at T2 ,T3 in group B compared with group C. Compare within groups: Da-jvO2 significantly decreased (P<0.05) in group A or group C at Ti—T4 compared with To (P<0.05). Da-jvO2 significantly decreased (P<0.05) at Ti -> T4 and increased at T2n T3 (P<0.05) compared with To in group B .Changes on CEO2: There were no significant differences among three groups (P>0.05). Compare between groups: In groupB CEO2were no significant alterations at Ti and T4(P>0.05) and significantly increased at T2 ,T3 (P<0.05) compared with control group. There were no significant alterations in group C at To~T4(P>0.05) compared with control group. CEO2 significantly increased (P<0.05) at T2 ,T3 in group B compared with group C. Compare within groups: Da-jvC>2 significantly decreased (P<0.05) in group A or group C at Ti~ T4 compared with To (P<0.05). CEO2 significantly decreased (P<0.05) at Ti> T4 and increased at T2> T3 (P<0.05) in group B compared with To.Changes onDa-jv!^ Da-jvSOD> Da-jvMDA: Da-jvl^ Da-jvSC^ Da-jvMDA: They were normal during the experiment and there were no significant alterations among three groups (P>0.05).5. Changes on blood transfusion and dose of intraoperative d transfusion:Intraoperative blood loss and transfusion and fluid infusion volume all significantly decreased (P<0.05) in group B or group C compared with group A,And there were no significant differences between group B and group C(p>0.05) (measured by weighting sponges and calculating intraoperative suctioned blood). No significant differences among three groups were found in dose intraoperative urine (p>0.05). Conclusions:1. Preoprative AHH with 6%HES ( 15mL/kg ) combined with intraoperative CH can utilize other's strong points to offset one's own weakness. For AHH can provide enough blood volume to avoid the lack of the perfusion of important organs induced by CH., and CH can avoid the adverse effect of circulation overload on heart. And it also can enforce hemodynamic stability, and be superior to sheer preoperative AHH.2. IN process of preoprative AHH combined with CH induced with SNP or ND, SNP is more effective in reducing preload, whereas the effect of controlled hypotension of ND is more moderate and long,and blood pressure comes back slowly after infusion, and ND is better for neurosurgery patients.3. According to the criteria and time limit of CH and the level of AHHwhich are studied. Preoprative AHH or Preoprative AHH combined with CH induced with SNP or ND, has no adverse effect on cerebral oxygen supply and consumption and has no deposit of lactate. The metabolism of cerebral free radical and energy can be well maintained. Compared with SNP, ND is safer to cerebral neurosystem.4. Preoprative AHH can effectively expand the blood volume , reinforce the body's tolerance for blood loss and effectively reduce blood transfusion; compared with sheer preoperative AHH, preoperative AHH combined with intraoperative CH can more reduce the loss of blood and be more effective in blood saving. And it is feasible in the meningioma operation. Therefore, it may be as a feasible, safe and effective method of blood saving to apply in major surgery. |
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