CHANGES OF BLOOD COAGULATION-FIBRINOLYSIS ACTIVITY DURING PROLONGED OPERATION

背景：虽然手术时间过长被认为是导致全身高凝状态的因素之一，但围术期凝血-纤溶系统的变化尚未见报道。本研究的目的是利用分子标记技术，探讨口腔癌患者长时间手术前后凝血纤溶活性的变化及肝素治疗的效果。方法：口腔癌患者手术时间超过10h，采用游离组织瓣切除重建肿瘤。将受试者随机分为两组，肝素组和对照组，肝素组从显微手术开始至麻醉结束持续静脉滴注肝素，对照组不用肝素治疗，肝素剂量由激活的部分凝血活酶时间(APTT)控制，范围为50~70s。测定凝血酶原时间(PT)、部分凝血活酶时间(APTT)、纤维蛋白原抗凝血酶…凝血酶-抗凝血酶Ⅲ复合体(ATIII)、凝血酶-抗凝血酶Ⅲ复合体(TAT)、纤维蛋白肽A(FPA)、凝血酶原片段1-2(F1-2)、可溶性纤维蛋白单体复合体(SFMC)、D-二聚体、纤溶酶-A2纤溶酶抑制物复合体(PIC)和肝素浓度。肝素组在肝素输注开始后，肝素抗凝作用明显。肝素组也有3例出现纤溶激活，但激活程度较对照组轻。肝素浓度在0.2U/ml以下，APTT与肝素浓度呈轻度正相关(r=0.62)。结论：延长手术早期即可激活凝血-纤溶系统，术中持续静脉输注肝素是有效的抗凝治疗方法。较少

Background : Although it is thought that prolonged operation is one of the factors to cause systematic hypercoaglability, the perioperative alternation of blood coagulation-fibrinolysis system has not been reported. The aims of this study were to clarify the changes of coagulation-fibrinolysis activity during prolonged operation and the effect of heparin therapy by using molecular markers.Method : The subjects were the patients with oral cancer who underwent the operation which took more than 10 hours and included tumor excision and reconstruction using a free flap. The subjects were divided into two random groups, heparin group consisting of continuous intravenous heparin infusion which was administrated from the starting point of micro surgery to the end of anesthesia and control group ; without heparin therapy.The dose of heparin was controlled by activated partial thromboplastin time (APTT) showing the range 50-70sec. We measured prothrombin time (PT), APTT,fibrinogen antithrombin … More III (ATIII), thrombin-antithrombin IIIcomplex (TAT), fibrinopeptide A (FPA), prothrombin fragment1+2 (F1+2), soluble fibrin monomer complex (SFMC), D-dimer, plasmin-a2 plasmin inhibitor complex (PIC) and heparin concentration from the stating point to the end point of anesthesia.Result : Coagulation markerlevels increased remarkably depending on the progress of the operation in all cases of the control group, and 3 cases of control group showed the activation of fibrinolysis. In the heparin group, anticoagulant effect by heparin appeared clearly after the start of heparin infusion. Also 3 cases of heparin group showed the activation of fibrinolysis, but the degree of the activation was slighter than in control group. Heparin concentration was showing underneath 0.2U/ml, and there was slight crrelation between APTT and heparin concentration(r=0.62).Conclusion : It is clear that blood coagulation-fibrinolysis system is activated from the early stage of prolonged operation, and continuous intravenous heparin infusion is effective as an anticoagulant therapy during operation. Less