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近年来经食管超声心动图(transesophageal echocardiography,TEE)以其实时、准确、无创、快捷的优势,广泛应用于指导术中目标导向液体治疗(goal-directed fluid therapy,GDFT),进而改善病人术后的转归[1-2]。除容量对血压的影响,全身麻醉后容量血管扩张所导致的回心血量减少也是术中低血压的一个重要原因,大部分麻醉药物具有负性肌力作用并可引起血管扩张。在麻醉状态下,血管的容积会大大增加。单纯靠补充液体来维持正常生理状态,即使有GDFT作为指导,手术病人也极有可能会输入比正常生理状态更多的液体。去甲肾上腺素可收缩血管,对抗麻醉药物所致的扩血管不良反应,配合适当的容量治疗后,可补充因麻醉药引起的相对性循环容量不足,从而维持重要器官血流灌注,减少对输液的过度依赖[3]。本文旨在探讨经TEE为导向的GDFT联合小剂量去甲肾上腺素用于老年腹腔镜结直肠手术与传统补液方法的比较, 通过观察病人术后重要脏器相关检查指标及不良反应和并发症情况,为临床麻醉提供参考。
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2组病人性别、年龄、体质量指数(BMI)、人工气腹时间、失血量及NT值差异均无统计学意义(P>0.05)(见表 1)。
分组 n 男 女 年龄/岁 BMI/(kg/m2) 人工气腹时间/min 失血量/mL NT值 N组 25 19 5 68±6 21.9±1.9 132±34 330±22 35±10 C组 25 21 4 66±4 22.1±1.7 139±30 310±31 37±8 t — 0.19* 1.39 0.39 0.77 2.63 0.78 P — >0.05 >0.05 >0.05 >0.05 < 0.05 >0.05 *示χ2值 表 1 2组病人一般情况比较(x±s)
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N组术中尿量、平衡液输注量明显少于C组(P<0.01和P<0.05),聚明胶肽输注量多于C组(P<0.05)(见表 2)。2组病人HR、MAP在T1、T2时间点均较麻醉诱导前T0时间点降低(P < 0.05~P < 0.01),CVP在T1时间点较T0时间点增高(P < 0.01)。与C组比较,N组HR在T4、T5时间点升高(P < 0.01),CVP在T3、T4、T5时间点降低(P < 0.01),MAP在各时间点差异均无统计学意义(P>0.05)(见表 3)。
分组 n 尿量 平衡液 聚明胶肽 总量 N组 25 610±33 1631±834 955±526 2586±1360 C组 25 815±40 2107±1014 638±412 2745±1426 t — 19.77 2.04 2.37 0.40 P — < 0.01 < 0.05 < 0.05 >0.05 表 2 2组病人术中输液量及尿量的比较(x±s; mL)
分组 T0 T1 T2 T3 T4 T5 F P MS组内 HR/(次/分) N组 78±10 67±4** 67±9** 76±9 76±4 71±4** 359.21 < 0.01 51.667 C组 81±9 69±3** 67±8** 78±4 72±3** 67±6** 24.47 < 0.01 35.833 t 1.11 2.00 0.00 1.02 4.00 2.77 — — — P >0.05 >0.05 >0.05 >0.05 < 0.01 < 0.01 — — — CVP/mmHg N组 5.20±1.23 9.15±0.26** 6.45±1.21** 7.67±1.24** 8.70±1.45** 9.91±0.46** 68.17 < 0.01 1.149 C组 4.83±1.64 8.80±0.32** 5.62±1.33** 10.64±1.50** 11.52±1.33** 12.71±1.24** 153.17 < 0.01 1.686 t 0.90 4.24 2.31 7.63 7.17 10.59 — — — P >0.05 < 0.01 < 0.05 < 0.01 < 0.01 < 0.01 — — — MAP/mmHg N组 81±8 63±5** 57±5** 89±34 91±23 90±21 14.83 < 0.01 373.333 C组 84±3 65±4* 58±6** 83±34 89±32 87±34 7.34 < 0.01 566.167 t 1.76 1.56 0.64 0.62 0.25 0.38 — — — P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — q检验:与T0时间点比较*P < 0.05, **P < 0.01 表 3 2组病人各记录时间点监测数据比较(x±s)
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术前,N组ALT水平高于C组(P < 0.01),其他指标在2组间差异均无统计学意义(P>0.05);与术前比较,术后N组的ALT水平升高(P < 0.01),AST和BUN水平下降(P < 0.01),Cr差异无统计学意义(P>0.05);与术前比较,术后C组的ALT、AST、BUN、Cr差异均无统计学意义(P>0.05)(见表 4)。
分组 n ALT/(U/L) AST/(U/L) BUN/(mmol/L) Cr/(mmol/L) 术前 N组 25 12.0±5.1 19.7±4.2 5.8±1.0 65.1±17.0 C组 25 20.1±8.4 21.3±15.5 5.5±1.8 67.2±11.2 t — 4.12△ 0.49△ 0.73 0.52 P — < 0.01 >0.05 >0.05 >0.05 术后 N组 25 18.5±8.3** 14.4±4.7** 3.9±1.4** 63.5±16.1 C组 25 16.2±4.1 19.7±5.1 5.9±1.3 68.4±10.7 t — 1.24 3.82 5.23 1.27 P — >0.05 < 0.01 < 0.01 >0.05 △示t′值; 与术前比较**P < 0.01 表 4 2组病人肝肾功能指标的比较(x±s)
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本研究中病人术后不良反应主要包括恶心呕吐和谵妄,C组发生恶心呕吐6例、谵妄1例,N组发生恶心呕吐4例、谵妄无;术后并发症主要包括切口感染、切口裂开、肺部感染、非计划转入ICU,C组以上并发症分别发生1、1、5、1例,N组分别发生1、0、1、0例。N组不良反应发生率16.0%(4/25)与C组不良反应发生率28.0%(7/25)差异无统计学意义(χ2=1.05,P>0.05),N组并发症发生率8.0%(2/25)明显低于C组并发症发生率32.0%(8/25)(χ2=4.50,P < 0.05)。
TEE指导GDFT联合小剂量去甲肾上腺素用于老年腹腔镜结直肠癌手术的临床观察
Value of GDFT guided by TEE combined with small dose of norepinephrine in the application of laparoscopic colorectal cancer surgery in elderly patients
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摘要:
目的观察经食管超声心动图(transesophageal echocardiography,TEE)指导的术中目标导向液体治疗(goal-directed fluid therapy,GDFT)联合小剂量去甲肾上腺素对老年腹腔镜结直肠手术病人的术中循环管理和术后恢复的影响。 方法60岁以上择期行乙状结肠或直肠癌根治术的病人50例,ASA分级Ⅰ~Ⅱ级,随机分为2组,每组25例,观察组为TEE指导下GDFT联合小剂量去甲肾上腺素组(N组),对照组为常规液体治疗组(C组)。N组麻醉后根据TEE监测降主动脉的纠正血流时间和每搏输出量调整液体和去甲肾上腺素用量。C组按照传统方法补液。比较2组病人麻醉诱导前(T0)、气管插管前(T1)、建立人工气腹后即刻(T2)、肿物切除(T3)、停止气腹后(T4)、拔管后(T5)的平均动脉压(MAP)、心率(HR)、中心静脉压(CVP)。术后记录晶体/胶体比例及总量、尿量、天门冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)、血浆尿素氮(BUN)及肌酐(Cr)水平,术后恢复期不良反应和并发症发生情况。 结果N组术中尿量、平衡液输注量明显少于C组(P < 0.01和P < 0.05),聚明胶肽输注量多于C组(P < 0.05);2组HR、MAP在T1、T2时间点均较麻醉诱导前T0降低(P < 0.05~P < 0.01),CVP在T1时间点较T0增高(P < 0.01)。与C组比较,N组HR在T4、T5时间点升高(P < 0.01),CVP在T3、T4、T5时间点降低(P < 0.01);与术前比较,术后N组的ALT水平上升(P < 0.01),AST和BUN水平下降(P < 0.01),术后C组的ALT、AST、BUN、Cr水平差异均无统计学意义(P>0.05);N组不良反应发生率16.0%与C组不良反应发生率28.0%差异无统计学意义(P>0.05),N组并发症发生率8.0%明显低于C组并发症发生率32.0%(P < 0.05)。 结论TEE指导GDFT联合小剂量去甲肾上腺素用于腹腔镜结直肠手术病人术后恢复有优势。 Abstract:ObjectiveTo observe the effects of goal-directed fluid therapy(GDFT) guided by transesophageal echocardiography(TEE) combined with small dose of norepinephrine on intraoperative circulation management and postoperative recovery in elderly patients treated with laparoscopic colorectal surgery. MethodsFifty patients over 60 years scheduled by radical resection of colorectal cancer, ASA grade Ⅰto Ⅱ, were randomly divided into the observation group and control group(25 cases each group).The observation group was treated with GDFT guided by TEE combined with small doses of norepinephrine, and the control group was treated with conventional liquid.The amounts of liquid and norepinephrine in observation group after anesthesia were adjusted according to the blood flow time corrected(FTc) and stroke volume(SV) of the descending aorta monitored by TEE, and the control group was treated with the traditional method fluid infusion.The mean artery pressure(MAP), heart rate(HR) and central venous pressure(CVP) between two groups were compared before anesthesia induction(T0) and tracheal intubation(T1), at the time of establishing artificial pneumoperitoneum(T2), after resecting tumor(T3), after stopping pneumoperitoneum(T4) and after extubation(T5).The crystal/gel ratio and total amount, urine volume, levels of aspertate aminotransferase(AST), alanine aminotransferase(ALT), blood urea nitrogen(BUN) and creatinine(Cr), and incidence rates of adverse reaction and complications during postoperative recovery were recorded in two groups. ResultsThe amounts of intraoperative urine and balance solution infusion in observation group were significantly less than those in control group(P < 0.01 and P < 0.05), and the amount of polygelatin peptide infusion in observation group was significantly more than that in control group(P < 0.05).The HR and MAP in two groups at T1 and T2 decreased compared with at T0(P < 0.05 to P < 0.01), and the CVP in two groups at T1 increased compared with at T0(P < 0.01).Compared with the control group, the HR in observation group increased at T4 and T5(P < 0.01), and the CVP in observation group decreased at T3, T4 and T5(P < 0.01).Compared with before operation, the ALT level increased, and the levels of AST and BUN decreased in observation group after operation(P < 0.01).The differences of the levels of ALT, AST, BUN and Cr in control group were not statistically significantly between before and after operation(P>0.05).There was no statistical significance in the incidence rate of adverse reaction between observation group(16.0%) and contorl group(28.0%), and the incidence rate of complications in observation group(8.0%) was significantly lower than that in control group(32.0%)(P < 0.05). ConclusionsThe GDFT guided by TEE combined with small dose of norepinephrine has advantages in the postoperative recovery of patients treated with laparoscopic colorectal surgery. -
表 1 2组病人一般情况比较(x±s)
分组 n 男 女 年龄/岁 BMI/(kg/m2) 人工气腹时间/min 失血量/mL NT值 N组 25 19 5 68±6 21.9±1.9 132±34 330±22 35±10 C组 25 21 4 66±4 22.1±1.7 139±30 310±31 37±8 t — 0.19* 1.39 0.39 0.77 2.63 0.78 P — >0.05 >0.05 >0.05 >0.05 < 0.05 >0.05 *示χ2值 表 2 2组病人术中输液量及尿量的比较(x±s; mL)
分组 n 尿量 平衡液 聚明胶肽 总量 N组 25 610±33 1631±834 955±526 2586±1360 C组 25 815±40 2107±1014 638±412 2745±1426 t — 19.77 2.04 2.37 0.40 P — < 0.01 < 0.05 < 0.05 >0.05 表 3 2组病人各记录时间点监测数据比较(x±s)
分组 T0 T1 T2 T3 T4 T5 F P MS组内 HR/(次/分) N组 78±10 67±4** 67±9** 76±9 76±4 71±4** 359.21 < 0.01 51.667 C组 81±9 69±3** 67±8** 78±4 72±3** 67±6** 24.47 < 0.01 35.833 t 1.11 2.00 0.00 1.02 4.00 2.77 — — — P >0.05 >0.05 >0.05 >0.05 < 0.01 < 0.01 — — — CVP/mmHg N组 5.20±1.23 9.15±0.26** 6.45±1.21** 7.67±1.24** 8.70±1.45** 9.91±0.46** 68.17 < 0.01 1.149 C组 4.83±1.64 8.80±0.32** 5.62±1.33** 10.64±1.50** 11.52±1.33** 12.71±1.24** 153.17 < 0.01 1.686 t 0.90 4.24 2.31 7.63 7.17 10.59 — — — P >0.05 < 0.01 < 0.05 < 0.01 < 0.01 < 0.01 — — — MAP/mmHg N组 81±8 63±5** 57±5** 89±34 91±23 90±21 14.83 < 0.01 373.333 C组 84±3 65±4* 58±6** 83±34 89±32 87±34 7.34 < 0.01 566.167 t 1.76 1.56 0.64 0.62 0.25 0.38 — — — P >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 — — — q检验:与T0时间点比较*P < 0.05, **P < 0.01 表 4 2组病人肝肾功能指标的比较(x±s)
分组 n ALT/(U/L) AST/(U/L) BUN/(mmol/L) Cr/(mmol/L) 术前 N组 25 12.0±5.1 19.7±4.2 5.8±1.0 65.1±17.0 C组 25 20.1±8.4 21.3±15.5 5.5±1.8 67.2±11.2 t — 4.12△ 0.49△ 0.73 0.52 P — < 0.01 >0.05 >0.05 >0.05 术后 N组 25 18.5±8.3** 14.4±4.7** 3.9±1.4** 63.5±16.1 C组 25 16.2±4.1 19.7±5.1 5.9±1.3 68.4±10.7 t — 1.24 3.82 5.23 1.27 P — >0.05 < 0.01 < 0.01 >0.05 △示t′值; 与术前比较**P < 0.01 -
[1] 王天龙.目标导向液体治疗在围术期的应用[J].北京医学, 2014, (8):620. doi: 10.3969/j.issn.0253-9713.2014.08.003 [2] 解雅英, 于建设, 丁翠霞, 等.食管超声多普勒监测仪指导下目标导向液体治疗在大肠癌手术应用的临床观察[J].国际麻醉学与复苏杂志, 2014, 35(12):1085. doi: 10.3760/cma.j.issn.1673-4378.2014.12.005 [3] 中华医学会麻醉学分会α1激动剂围术期应用专家组.α1肾上腺素能受体激动剂围术期应用专家共识(2017版)[J].临床麻醉学杂志, 2017, 33(2):186. [4] 米勒.米勒麻醉学[M].北京:北京大学医学出版社, 2006:25. [5] ABBAS SM, HILL AG.Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery[J].Anaesthesia, 2008, 63(1):44. [6] DINDO D, EDMARTINES N, CLAVIEN PA.Classification of surgical complications:a new proposal with evaluation in a cohort of 6336 patients and results of a survey[J].Ann Surg, 2004, 240(2):205. doi: 10.1097/01.sla.0000133083.54934.ae [7] GITZELMANN CA, MENDOZA-SAGAON M, TALAMINI MA, et al.Cell-mediated immune response is better preserved by laparoscopy than laparotomy[J].Surgery, 2000, 127(1):65. doi: 10.1067/msy.2000.101152 [8] PENG H, ZHANG J, CAI C, et al.The Influence of carbon dioxide pneumoperitoneum on systemic inflammatory response syndrome and bacterial translocation in patients with bacterial peritonitis caused by acute appendicitis[J].Surg Innov, 2018, 25(1):7. [9] MYLES PS, BELLOMO R, CORCORAN T, et al.Restrictive versus liberal fluid therapy for major abdominal surgery[J].N Engl J Med, 2018, 378(24):2263. doi: 10.1056/NEJMoa1801601 [10] FUTIER E, LEFRANT JY, GUINOT PG, et al.Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery:a randomized clinical trial[J].JAMA, 2017, 318(14):1346. doi: 10.1001/jama.2017.14172 [11] ROLLINS KE, LOBO DN.Intraoperative goal-directed fluid therapy in elective major abdominal surgery:a meta-analysis of randomized controlled trials[J].Ann Surg, 2016, 263(3):465. doi: 10.1097/SLA.0000000000001366 [12] GIRAUDO G, BRACHET CONTUL R, CACCETTA M, et al.Gasless laparoscopy could avoid alterations in hepatic function[J].Surg Endosc, 2001, 15(7):741. doi: 10.1007/s004640090020