BJA：新生儿手术中输注低张液导致低钠血症

南粤麻医

http://www.ncbi.nlm.nih.gov/pubmed/24193323

2014年3月出版的BJA杂志刊登来自法国巴黎Paris Diderot University关于新生儿容量治疗的研究

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南粤麻医

[size=0.8465em]Br J Anaesth. 2014 Mar;112(3):540-5. doi: 10.1093/bja/aet374. Epub 2013 Nov 4.
Postoperative decrease in plasma sodium concentration after infusion of hypotonic intravenous solutions in neonatal surgery.[size=0.923em]Edjo Nkilly G[size=0.8461em]1, Michelet D, Hilly J, Diallo T, Greff B, Mangalsuren N, Lira E, Bounadja I, Brasher C, Bonnard A, Malbezin S, Nivoche Y, Dahmani S.
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AbstractBACKGROUND:

Hypotonic i.v. solutions can cause hyponatraemia in the context of paediatric surgery. However, this has not been demonstrated in neonatal surgery. The goal of this study was to define the relationship between infused perioperative free water and plasma sodium in neonates.

METHODS:

Newborns up to 7 days old undergoing abdominal or thoracic surgery were included in this prospective, observational study. Collected data included type and duration of surgery, calculated i.v. free water intake, and pre- and postoperative plasma sodium. Statistical analyses were performed using the Pearson correlation, Mann-Whitney test, and receiver operating characteristic analysis with a 1000 time bootstrap procedure.

RESULTS:

Thirty-four subjects were included. Postoperative hyponatraemia occurred in four subjects (11.9%). The difference between preoperative and postoperative plasma sodium measurements (ΔNaP) correlated with calculated free water intake during surgery (r=0.37, P=0.03), but not with preoperative free water intake. Calculated operative free water intake exceeding 6.5 ml kg(-1) h(-1) was associated with ΔNaP≥4 mM with a sensitivity and specificity [median (95% confidence interval)] of 0.7 (0.9-1) and 0.5 (0.3-0.7), respectively.

CONCLUSIONS:

Hypotonic solutions and i.v. free water intake of more than 6.5 ml kg(-1) h(-1) are associated with reductions in postoperative plasma sodium measurements ≥4 mM. In the context of neonatal surgery, close monitoring of plasma sodium is mandatory. Routine use of hypotonic i.v. solutions during neonatal surgery should be questioned as they are likely to reduce plasma sodium.

KEYWORDS:

fluids, hypotonic, i.v., neonatal surgery, neonates, postoperative hyponatraemia

Ø背景：小儿术中使用低张液体可导致低钠血症。然而，新生儿手术中低张液体的作用尚不清楚。本研究观察新生儿围术期补液量（输入自由水）与血浆钠间的关系

Ø方法：7d内新生儿接受腹部或胸部手术，采集资料包括手术类型及持续时间、计算的补液量、术前与术后血浆钠浓度

Ø结果：34名患儿，4名出现术后低钠血症（11.9%），手术前后血浆钠浓度差（△NaP）与术中计算的补液量明显相关（r=0.37，P=0.03），但与术前补液量无关。计算的补液量超过6.5ml/k/h，与△NaP≥4mM相关，具有敏感性与特异性

Ø结论：低张液体与补液量超过6.5ml/k/h时与术后血浆钠浓度降低≥4mM相关。新生儿手术中，必须密切监测血浆钠浓度。因为低张液体可能降低血浆钠浓度，因此新生儿术中常规使用低张盐水值得商榷

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南粤麻医

Ø研究发现新生儿低钠血症可能导致远期神经认知功能发展延迟，而接受输液治疗的早产儿低钠血症的发生率最高可达24%

ØSyndrome of inappropriate antidiuretic hormone (ADH)抗利尿激素分泌不足综合征在小儿脊髓手术常见，可能因素：疼痛、机械通气、使用阿片剂。

Ø复杂低钠血症的外科手术患儿，如果接受低张液体，风险更高，可能导致脑水肿、coning、死亡或永久性残障。围术期低张液体仍在使用的原因是考虑等渗液体对细胞外间隙的扩容作用及患儿肾脏未成熟

Ø接受胸或腹部手术的7d内患儿，术前未机械通气及血流动力学支持，无心血管畸形。异丙酚或硫喷妥钠3-5mg/kg、司可林2mg/kg，气管插管后舒芬太尼0.2ug/kg，七氟烷0.8-1MAC维持麻醉，FiO2为50%（空氧混合），PSV，无PEEP，PETCO2维持在30-35mmHg。当HR或MAP超过基础值20%时给予舒芬太尼0.1ug/kg。术中保温，术毕前30min静注对乙酰氨基酚10mg/kg，术毕局部阻滞镇痛，术后每6h给予对乙酰氨基酚10mg/kg、护士控制的纳布啡或吗啡镇痛方法

Ø液体治疗：术前摄入包括5-10%葡萄糖在内的各种液体100-120ml/kg/d。围术期液体摄入包括维持量4ml/kg/h、手术丢失液体补偿量（4-20ml/kg/h）。容量治疗为盐水、RL或含有1%葡萄糖的RL10ml/kg 15min。首次容量治疗为麻醉诱导后，此后根据血流动力学变化（HR增加或MAP下降20%）、尿量减少、术野出血或腹部手术时间延长、麻醉医生考虑可重复容量治疗。对20ml/kg容量治疗产生抵抗的顽固性低血压与心动过缓（HR<100bpm）时静注阿托品20ug/kg。NaP<135mmol/L为低钠血症

Ø34例患儿，3例术前即有低钠血症（NaP=133mM），术中血钠正常。4例术后发现低钠血症（1例133mM，3例134mM）， △NaP1-9mmol/L。

Ø△NaP与术中补液量之间有相关性，但术前补液量与其无关；而术前、术后血浆钠浓度与补液量（术前或术中）也没有明显相关

Ø新生儿手术期间使用低张液体与术后血钠降低有关，低钠血症的发生率为12%，△NaP与补液量有关，△NaP>4mM与术中补液量增加明显相关

Ø导致血钠降低>4mM的低张液体理论平均输注速度>6.5ml/kg/h（6.5-18ml/kg/h）。而等张液体如生理盐水、RL、B66则需要更高的输注速度，分别为不受限制、87ml/kg/h、44ml/kg/h