Журнал «Медицина неотложных состояний» 8 (55) 2013
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Features of perioperative infusion - transfusion therapy and antithrombotic prophylaxis during major liver resections in oncology
Авторы: V. Cherniy, K. Oleinikov - Maxim Gorky Donetsk National Medical Universityt; K. Kolganova, S. Bubnov, A. Mihalenko - Donetsk Regional Anticancer Center
Рубрики: Медицина неотложных состояний
Разделы: Клинические исследования
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Introduction. Anesthetic management of liver resection still remains a major problem in modern medicine, due to requirement of massive multicomponent infusion and transfusion therapy (ITT) related to expressed intraoperative bleeding. High risk of venous thromboembolism determined by tumor availability, elderly age, varicose veins of the lower limbs and long duration of operation in hepatology onkosurgery requires holding of active antithrombotic prophylaxis.
The object of work was developing and evaluation efficacy/ safety of perioperative intensive therapy scheme in patients with liver tumors, comprising preoperative autoblood reservation with subsequent autotransfusion, normovolemic hemodilution and perioperative anticoagulant thromboprophylaxis.
Materials and Methods. 121 patients were included in the clinical research, undergoing to liver resection. All patients, depending on the methods of perioperative ITT, were divided into 2 groups, matched for age, sex, anthropometric indicators, character and duration of the operative intervention.
To the patients of the first (control) group (n=42), ITT was conducted by the standard scheme. The preparations of donor blood were transfused only for special reasons.
To the patients of the second (observable) group (n=79) in the preoperative period it was provided autoblood reservation (2-3 times) with total size of 400-1200 ml. Before the induction of anesthesia in a volume of 15 - 20 ml / kg it was the normovolemic hemodilution conducted. An autoblood transfusion were implemented intraoperatively, the additional preparations were injected in donor blood only by necessity. The comparative analysis of efficacy/ safety of described schemes ITT was made for the most clinically important indicators of hemodynamic, hemogram and coagulation, a requirement in the infusion-transfusion environments, the frequency of bleeding and thrombotic events clinically significant, serum concentrations of activated anti-X factor of coagulation dynamics perioperative period.
Results and their discussion. Received laboratory results indicates that the holding of preoperative autoblood preparation in describing method is secure from the viewpoint of saving oxygen-transport function and its hemostatic potential. In the observable group it was a statistically significant decreased heart rate, increase of stroke index and elevated central venous pressure at the end of operation, compared with the control group. The perioperative values of cardiac index in both groups were not differed, but after end of operation as a result of autoblood reinfusion its value in the control group achieved by increased frequency of cardiac contractions, and in the observable one - by increase of impact index with a decrease of heart rate, which was more favorable option. In consequence of this, conditions for reduction of the load on the myocardium and reduce of its oxygen demand, facilitate cardiac output and coronary blood flow increase were formed in the second group of patients. Improved method of ITT in the observable group was characterized by high hemodynamic performance compared with conventional scheme used in the control group. After the operation levels of hemoglobin, erythrocyte and hematocrit in the observable group were significantly higher than in control group (M ± m: 92,5 ± 4,31, 2,94 ± 0,45, 28,6 ± 2,3 vs 112 93 ± 5,39, 3,28 ± 0,62, 37,2 ± 2,9, p <0.05), which reduced the need for transfusion of donor. Between groups 1 and 2 there was none revealed significant differences in total infusion volume of crystalloid and colloid solutions, however, the amount of used donor blood was significantly lower in the observable group compared to the control one- 0,175 ± 0,02 ml / kg vs 0,454 ± 0,09, p <0,01; FFP - 0,172 ± 0,04 ml / kg vs 1,069 ± 0,11, p <0.01). The use of anticoagulants clinically significant cases was registered neither thrombosis nor bleeding tissue, and massive bleeding was among 9 patients (5 from 1st group (11%) and 4 from the 2nd group (5%)) due to the specifics of surgical hemostasis. Necessary for thromboprophylaxis level of activated in anti-X Factor coagulation was achieved after the first injection and persisted throughout the postoperative period.
Conclusion. The developed scheme of intensive perioperative therapy provides high hemodynamic stability, reduces the bleeding cases, helps to reduce a requirement in transfusion of blood products and provides more effective thromboembolic prophylaxis without hemorrhagic risks increasing.
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