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术中持续输注去甲肾上腺素联合限制延迟补液可显著减少接受开放性根治性膀胱切除术患者的输血需求:前瞻性随机试验结果。

Intraoperative continuous norepinephrine infusion combined with restrictive deferred hydration significantly reduces the need for blood transfusion in patients undergoing open radical cystectomy: results of a prospective randomised trial.

机构信息

Department of Anaesthesiology and Pain Therapy, Inselspital, University Hospital Bern, Bern, Switzerland.

Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland.

出版信息

Eur Urol. 2014 Aug;66(2):352-60. doi: 10.1016/j.eururo.2013.08.046. Epub 2013 Aug 28.

Abstract

BACKGROUND

Open radical cystectomy (ORC) is associated with substantial blood loss and a high incidence of perioperative blood transfusions. Strategies to reduce blood loss and blood transfusion are warranted.

OBJECTIVE

To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer's maleate solution can reduce blood loss and the need for blood transfusion.

DESIGN, SETTING, AND PARTICIPANTS: This was a double-blind, randomised, parallel-group, single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion (UD). Exclusion criteria were severe hepatic or renal dysfunction, congestive heart failure, and contraindications to epidural analgesia.

INTERVENTION

Patients were randomly allocated to continuous norepinephrine administration starting with 2 μg/kg per hour combined with 1 ml/kg per hour until the bladder was removed, then to 3 ml/kg per hour of Ringer's maleate solution (norepinephrine/low-volume group) or 6 ml/kg per hour of Ringer's maleate solution throughout surgery (control group).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed. Data were analysed using nonparametric statistical models.

RESULTS AND LIMITATIONS

Total median blood loss was 800 ml (range: 300-1700) in the norepinephrine/low-volume group versus 1200 ml (range: 400-2800) in the control group (p<0.0001). In the norepinephrine/low-volume group, 27 of 83 patients (33%) required an average of 1.8 U (±0.8) of packed red blood cells (PRBCs). In the control group, 50 of 83 patients (60%) required an average of 2.9 U (±2.1) of PRBCs during hospitalisation (relative risk: 0.54; 95% confidence interval [CI], 0.38-0.77; p=0.0006). The absolute reduction in transfusion rate throughout hospitalisation was 28% (95% CI, 12-45). In this study, surgery was performed by three high-volume surgeons using a standardised technique, so whether these significant results are reproducible in other centres needs to be shown.

CONCLUSIONS

Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss, the rate of blood transfusions, and the number of PRBC units required per patient undergoing ORC with UD.

摘要

背景

开放性根治性膀胱切除术(ORC)会导致大量失血,且围手术期输血的发生率较高。有必要采取策略来减少失血和输血。

目的

确定持续给予去甲肾上腺素联合马来酸罗哌卡因溶液术中限制补液是否可以减少出血量和输血需求。

设计、设置和参与者:这是一项双盲、随机、平行组、单中心试验,纳入了 166 例连续接受 ORC 联合尿流改道术(UD)的患者。排除标准为严重肝肾功能不全、充血性心力衰竭以及硬膜外镇痛禁忌证。

干预

患者随机分为持续输注去甲肾上腺素组(起始剂量为 2μg/kg·h,持续至膀胱切除,然后给予 3ml/kg·h 的马来酸罗哌卡因溶液)或持续输注马来酸罗哌卡因溶液组(6ml/kg·h,直至手术结束)。

主要结局测量和统计分析

评估术中失血量和围手术期需要输血的患者比例。使用非参数统计模型进行数据分析。

结果和局限性

去甲肾上腺素/低容量组的总中位出血量为 800ml(范围:300-1700ml),而对照组为 1200ml(范围:400-2800ml)(p<0.0001)。去甲肾上腺素/低容量组 83 例患者中有 27 例(33%)需要平均输注 1.8U(±0.8)的浓缩红细胞(PRBC)。对照组 83 例患者中有 50 例(60%)在住院期间需要平均输注 2.9U(±2.1)的 PRBC(相对风险:0.54;95%置信区间[CI],0.38-0.77;p=0.0006)。整个住院期间输血率绝对降低 28%(95%CI,12-45)。在这项研究中,手术由 3 名高容量外科医生采用标准化技术进行,因此这些显著结果是否可以在其他中心重现还需要进一步证实。

结论

持续给予去甲肾上腺素联合马来酸罗哌卡因溶液术中限制补液可显著减少接受 ORC 联合 UD 手术患者的术中出血量、输血率和每位患者所需的 PRBC 单位数。

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