| Objective: To observe the hemodynamic and effect of different blood conservation measures on clinic blood saving in elderly patients undergoing spinal surgery. To detect the intraoperative cerebral oxygen metabolism and postoperative cognitive function, evaluate the safety and efficacy of different blood conservation measures, provide a theoretical basis for their application to the elderly patients.Methods: To elective 60 cases elderly patients undergoing spinal surgery, ASAⅠ-Ⅱlevel, operative time>2h, age were 65~75 year, bleeding volume was expected >600ml, hemoglobin(Hb) ≥110g/L, hematocrit(Hct) ≥35%, platelets(Plt) count ≥100×109/L. Preoperative rountine blood count, clotting, heart、lung、kidney、brain showed no abnormal, preoperative MMSE scores>23. They were divided into four groups randomly(n=15): group of control(group A), regular input crystalloid fluids﹑colloidal liquid and allogeneic blood to add volume. ANH group(group B), exsanguinated blood through radial artery after the anesthesia patient’s condition was stable, autologous blood reinfusion was done intraoperative or before the end of surgery. CH group(group C), implemented CH after surgery began to enter the bone operation, after the major surgical procedure, disabled sodium nitroprussiate. ANH+CH group(group D), B、C groups combined. Monitored the changes of hemodynamic indicatorsof HR、MAP、Sp O2、CVP、CO、SVV、SVR et al in the patients. The radial artery and jugular bulb blood were collected after induction of anesthesia(T1)、immediately after ANH(T2)、30min after CH reach target blood pressure(T3) ﹑end of surgery(T4), analysised the blood gas. Venous blood 2ml were collected 1d before operative、1d after operative and 7d after operative, determinated the content of TNF-α、IL-1β、IL-6、IL-8、S-100β protein 、NSE in serum. Do MMSE 1d before operative、1d after operative and 7d after operative, observe the incidence of postoperative cognitive dysfunction.Results:(1) Four groups of urine output was no significant difference(p > 0.05). Compared with group A, the blood loss of group C and group D were significantly reduced(p<0.05); Compared with group A, the allogeneic blood transfusion of group B、group C and group D were significantly reduced(p<0.05), the allogeneic blood transfusion of group D was 0, that was significantly lower than group B and group C(p<0.05).(2) Compared with T1, the MAP、SVR and SVV of group B and group D reduced at T2, the HR、CVP and CO increased(p<0.05); Compared with T1, the CVP、CO of group B increased(p<0.05), the SVV、SVR reduced at T3(p<0.05); Compared with T1, the MAP、SVR of group C and group D reduced at T3(p<0.05), the HR increased(p<0.05), the CVP and CO of group C reduced, the CO of group D increased(p < 0.05); Compared with group A, the CO of group B and group D increased at T2(p<0.05), the SVV and SVR reduced(p<0.05), Compared with group A, the MAP and SVR of group C and group D reduced at T3(p<0.05), the HR increased, the SVV of group C increased(p<0.05).(3) The S jv O2 of group D at T3 is not only lower than that at T1(p<0.05). but also lower than that of group A(p<0.05). The CERO2 of group D at T3 is not only higher than that at T1(p<0.05), but also higher than that of group A(p<0.05).(4) Compared with 1d before surgery, the content of serum IL-1β、IL-6 、IL-8、TNF-a of four groups increased after surgery and 1d after surgery(p<0.05), the content of IL-1β、IL-6 、IL-8、TNF-a returned to preoperativelevels(p>0.05); there was no significant difference between groups at different time(p>0.05).(5) Compared with 1d before surgery, the content of serum S-100β protein、NSE of four groups increased after surgery and 1d after surgery(p<0.05); the content of serum S-100β protein、NSE 1d after surgery was lower than that after surgery(p<0.05); There was no significant difference between groups at different time(p>0.05).(6) Compared with 1d before surgery, the MMSE scores decreased 1d after surgery(p<0.05), recovered 7d after surgery(p>0.05), There was no significant difference between groups at different time(p>0.05). There was no significant difference between groups at different time(p > 0.05). Four groups of the incidence of POCD were 26.7%、26.7%、33.3% and 33.3% respectively,there was no significant difference 1d after surgery(p>0.05); the incidence of POCD decreased 7d after surgery(p<0.05), they were respectively 6.7%、0、6.7%、6.7%,There was no significant difference between groups at different time(p>0.05).Conclusion:(1) ANH combined with CH maintain hemodynamic stability, reduce blood loss and allogeneic blood transfusion, play a better role of blood conservation.(2) ANH combined with CH decrease the arterial oxygen content, have no significant effect on cerebral oxygen metabolism and maintain cerebral oxygen consumption at a stable level by increasing CERO2.(3) ANH combined with CH do not increase the incidence of early postoperative cognitive dysfunction obviously. Acute normovolemic hemodilution combined with controlled hypotension is safe、reliable and effective in elderly patients undergoing spinal surgery. |
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