Boldt J, Zickmann B, Thiel A, Herold C, Dapper F, Hempelmann G
Abteilung Anaesthesiologie und Operative Intensivmedizin, Justus-Liebig-Universität Giessen.
Anaesthesist. 1990 Aug;39(8):412-9.
The ideal solution for use in volume therapy is still a matter of debate. Hypertonic sodium (HS) solutions have been advocated for resuscitation from hemorrhagic shock (small volume resuscitation). As hypertonic fluids may also be of interest in cardiac surgery, the effects of a new HS solution were studied. METHODS. In 90 patients undergoing aorto-coronary bypass grafting studies were performed at three different periods: I (n = 30) after induction of anesthesia (before onset of the operation); II (n = 30) during cardiopulmonary bypass (CPB); III (n = 30) after termination of bypass. During these periods the patients were randomly allocated to one of three groups with 10 patients in each group: group 1 received a new hypertonic solution prepared in hydroxyethyl starch (HES) solution (72 g/l NaCl, 60 g/l HES, 2400 mosmol/l; HS-HES patients), group 2 received a 6% HES solution (200/0.5; HES patients), and group 3 received no volume infusion and served as controls. RESULTS. After the induction of anesthesia, significantly less HS-HES solution (4.5 +/- 0.5 ml/kg) than 6% HES solution (10.1 +/- 1.4 ml/kg) was necessary to double the baseline PCWP. The fluid balance during CPB was negative in the patients who had received HS-HES preoperatively (-0.03 +/- 0.01 ml/kg.min CPB), whereas 6% HES (+0.06 +/- 0.02 ml/kg.min CPB) and control patients (+0.13 +/- 0.03 ml/kg.min CPB) had a positive fluid balance. Both after the induction of anesthesia and after termination of bypass, CI increased more in the HS-HES group than in the HES patients, and it even decreased in the control group. SVR decreased in the HS-HES patients, whereas it increased in the control group. Rapid infusion of HS-HES during CPB was followed by a significant, but short-lasting decrease in MAP (-40 mmHg) and an increase in the oxygenator volume. Pulmonary gas exchange (= paO2) was least compromised in the HS-HES patients; the sodium concentration increased only in the HS-HES patients, but never exceeded 150 mmol/l. DISCUSSION. Cardiac surgery procedures offer a special situation for volume therapy as there is a possibility of deterioration in the macro- and microcirculation before, after, and during the period of CPB. Hemodynamic effects of the new HS-HES solution included an increase in CI and a decrease in SVR, which were not merely transient as has been reported which hypertonic saline solution used alone. It was also observed that HS-HES patients required significantly smaller volumes of fluids, both during CPB and during the early postoperative period. This effect seems to be due to a redistribution of interstitial fluid to the intravascular space, possibly decreasing tissue edema. CONCLUSION. The hypertonic saline HES solution adds a new dimension to volume therapy for cardiac surgery patients. The improvement in hemodynamics was effective and not only transient. Fluid requirements were significantly reduced during as well as after CPB, and pulmonary gas exchange was least compromised in these patients.
用于容量治疗的理想溶液仍是一个有争议的问题。高渗钠（HS）溶液已被提倡用于失血性休克的复苏（小容量复苏）。由于高渗液在心脏手术中也可能有用，因此研究了一种新的HS溶液的效果。方法：在90例行主动脉冠状动脉搭桥术的患者中，在三个不同时期进行研究：I期（n = 30）在麻醉诱导后（手术开始前）；II期（n = 30）在体外循环（CPB）期间；III期（n = 30）在体外循环结束后。在这些时期，患者被随机分为三组，每组10例：第1组接受用羟乙基淀粉（HES）溶液配制的新的高渗溶液（72 g/l氯化钠，60 g/l HES，2400 mosmol/l；HS-HES患者），第2组接受6% HES溶液（200/0.5；HES患者），第3组不进行容量输注，作为对照组。结果：麻醉诱导后，使基线肺毛细血管楔压（PCWP）加倍所需的HS-HES溶液（4.5±0.5 ml/kg）明显少于6% HES溶液（10.1±1.4 ml/kg）。术前接受HS-HES的患者在CPB期间的液体平衡为负（-0.03±0.01 ml/kg.min CPB），而6% HES组（+0.06±0.02 ml/kg.min CPB）和对照组患者（+0.13±0.03 ml/kg.min CPB）的液体平衡为正。在麻醉诱导后和体外循环结束后，HS-HES组的心指数（CI）升高幅度均大于HES患者组，而对照组的心指数甚至下降。HS-HES患者的全身血管阻力（SVR）降低，而对照组的SVR升高。在CPB期间快速输注HS-HES后，平均动脉压（MAP）显著但短暂下降（-40 mmHg），氧合器容积增加。HS-HES患者的肺气体交换（=动脉血氧分压）受损最小；仅HS-HES患者的钠浓度升高，但从未超过150 mmol/l。讨论：心脏手术过程为容量治疗提供了一种特殊情况，因为在CPB之前、之后和期间，大循环和微循环都有可能恶化。新的HS-HES溶液的血流动力学效应包括CI升高和SVR降低，这并不像单独使用高渗盐溶液时所报道的那样只是短暂的。还观察到，HS-HES患者在CPB期间和术后早期所需的液体量明显较少。这种效应似乎是由于间质液向血管内空间的重新分布，可能减少了组织水肿。结论：高渗盐水HES溶液为心脏手术患者的容量治疗增添了新的内容。血流动力学的改善是有效的，而且不仅仅是短暂的。在CPB期间和之后，液体需求量显著减少，这些患者的肺气体交换受损最小。
