Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After Pancreaticoduodenectomy Results of a Prospective Randomized Trial of Acute Normovolemic Hemodilution Compared With Standard Intraoperative Management
Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After Pancreaticoduodenectomy Results of a Prospective Randomized Trial of Acute Normovolemic Hemodilution Compared With Standard Intraoperative Management
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DOI：
10.1097/sla.0b013e3181ff36b1
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发表时间：
2010-12-01
影响因子：
9
通讯作者：
Jarnagin, William R.
中科院分区：
文献类型：
--
作者：
Fischer, Mary;Matsuo, Kenichi;Jarnagin, William R.
背景：胰十二指肠切除术（PD）可能会导致大量失血和输血需求，并可能带来短期和长期的不良后果。本研究的目的是确定急性等容血液稀释 (ANH)（一种已建立的血液保存技术）是否可以减少接受 PD 的患者围手术期同种异体输血。方法：130 名接受 PD 的患者被随机分配至 ANH 或标准管理 (STDM)。 ANH组术中采血至目标血红蛋白为8.0 g/dL；使用晶体液和胶体液进行容量置换。术中和术后均采用严格的输血触发措施。前瞻性评估围手术期并发症并对其严重程度进行分级。结果：从2005年7月至2009年5月，登记了209名患者，79名患者被排除，65名患者被随机分配至ANH，65名患者被随机分配至STD。这些组在人口统计学、手术和组织病理学变量方面均匹配良好。与接受 STD 的患者（3900 mL，范围 2000-9000）相比，接受 ANH 的患者在术中接受了超过 2 L 的液体（6250 mL，范围 2000-11850）（P < 0.001）。输血率相似（ANH = 16.9%，30 单位 vs STD = 18.5%，33 单位；P = 0.82），总体围手术期发病率也相似（ANH = 49.2% vs STD = 47%，P = 0.86）。然而，接受 ANH 的患者有更多 3 级并发症的趋势（32% vs 23.1% STD，P = 0.17），并且 ANH 组中与胰腺吻合相关的并发症（渗漏/瘘管/脓肿）显着较高（21.5% vs 7.7%，P = 0.045）。无论随机组如何（ANH 6000 mL，范围 2800-11350 mL vs STD 5000 mL，范围 2000-11850 mL，P < 0.042），所有患有胰腺吻合并发症的患者的术中液体量较高（n = 19）。结论：在这项接受 PD 患者的随机试验中，ANH 并未减少同种异体输血，并导致更多的胰腺输血。吻合口并发症，可能与术中输液量增加有关。 ANH 的好处并不一定适用于所有手术，PD 期间限制性静脉输液管理可能有助于改善术后结果。
Background: Pancreaticoduodenectomy (PD) can be associated with significant blood loss and transfusion requirements, with potential adverse short-and long-term consequences. The aim of this study was to determine whether acute normovolemic hemodilution (ANH), an established blood conservation technique, reduces perioperative allogeneic transfusions in patients undergoing PD.Methods: One hundred thirty patients undergoing PD were randomized to ANH or standard management (STDM). In the ANH group, intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL; crystalloid and colloid were used for volume replacement. Strict transfusion triggers were applied during and after operation. Perioperative complications were prospectively assessed and graded for severity.Results: From July 2005 to May 2009, 209 patients were registered, 79 excluded, 65 were randomized to ANH, and 65 to STD. The groups were well matched for demographic, operative, and histopathologic variables. Patients undergoing ANH received over 2 L more fluid intraoperatively (6250 mL, range 2000-11850) compared with patients undergoing STD (3900 mL, range 2000-9000) (P < 0.001). Transfusion rates were similar (ANH = 16.9%, 30 units vs STD = 18.5%, 33 units; P = 0.82), as was overall perioperative morbidity (ANH = 49.2% vs STD = 47%, P = 0.86). There was, however, a trend toward more grade-3 complications in patients undergoing ANH (32% vs 23.1% STD, P = 0.17), and complications related to the pancreatic anastomosis (leak/fistula/abscess) were significantly higher in the ANH group (21.5% vs 7.7%, P = 0.045). The intraoperative fluid volume was higher for all patients with pancreatic anastomotic complications (n = 19), regardless of randomization arm (ANH 6000 mL, range 2800-11350 mL vs STD 5000 mL, range 2000-11850 mL, P < 0.042).Conclusion: In this randomized trial of patients undergoing PD, ANH did not reduce allogeneic transfusions and resulted in more pancreatic anastomotic complications, likely related to greater intraoperative fluid administration. The benefits of ANH do not necessarily extend to all procedures, and restrictive intravenous fluid management during PD may help improve postoperative outcome.