碳酸氢钠林格液对老年患者腹腔镜肝切除术后急性肾损伤的影响

Effect of sodium bicarbonate Ringer′s solution on acute kidney injury following laparoscopic hepatectomy in elderly patients

目的评价碳酸氢钠林格液对老年患者腹腔镜肝切除术后急性肾损伤(AKI)的影响。方法择期行腹腔镜肝切除术老年患者362例,ASA分级Ⅱ或Ⅲ级,年龄65~79岁,BMI 18~28 kg/m^(2),采用随机数字表法分为2组(n=181):碳酸氢钠林格液组(BR组)和乳酸钠林格液组(LR组),自入室至出PACU 2组患者分别输注碳酸氢钠林格液或乳酸钠林格液。手术均在全身麻醉联合腹部筋膜阻滞下进行,通过控制性低中心静脉压和间歇性肝门阻断等减少术中出血。于麻醉诱导前5 min(T_(0))、肝门阻断后20 min(T_(1))、肝切除完成止血后10 min(T_(2))、手术结束时(T_(3))和出PACU时(T_(4))采集桡动脉血进行血气分析并记录乳酸(Lac)浓度;于入院时(T_(A))、术后24 h(T_(24))和术后48 h(T_(48))时采集肘静脉血,测定血清Cr浓度;于T_(A)、T_(4)、T_(24)和T_(48)时采用超声多普勒测定肾动脉阻力指数(RRI)。根据2012 KDIGO标准中Cr判断并计算术后48 h内AKI发生率。记录术后48 h内恶心、呕吐等不良反应和切口感染等并发症的发生情况。结果与T_(0)时比较,2组T_(1~4)时Lac浓度升高(P<0.01);与T_(A)时比较,2组患者T_(24)和T_(48)时Cr浓度升高,T_(4)、T_(24)和T_(48)时RRI升高(P<0.01);与LR组比较,BR组术后48 h内AKI发生率、T_(3,4)时Lac浓度、T_(24)和T_(48)时血清Cr浓度、T_(4)、T_(24)和T_(48)时RRI降低(P<0.05或0.01)。2组患者术后48 h内恶心、呕吐、切口感染、谵妄、胆漏及肺部感染等发生率比较差异均无统计学意义(P>0.05)。结论碳酸氢钠林格液可降低老年患者腹腔镜肝切除术后AKI的发生。

Objective To evaluate the effect of sodium bicarbonate Ringer′s solution on acute kidney injury(AKI)following laparoscopic hepatectomy in elderly patients.Methods A total of 362 American Society of Anesthesiologists Physical Status classificationⅡorⅢelderly patients,aged 65-79 yr,with body mass index of 18-28 kg/m^(2),scheduled for elective laparoscopic hepatectomy,were divided into 2 groups(n=181 each)using a random number table method:bicarbonate Ringer′s solution group(BR group)and lactated Ringer′s solution group(LR group).Bicarbonate Ringer′s solution and lactated Ringer′s solution were intravenously infused in BR group and LR group,respectively.All operations were performed under general anesthesia combined with abdominal fascia block,and the methods of controlled low central venous pressure and intermittent hepatic inflow occlusion were applied to reduce intraoperative bleeding.Radial artery blood samples were collected for blood gas analysis at 5 min before anesthesia induction(T_(0)),20 min after occluding liver hilus(T_(1)),10 min after hepatectomy and hemostasis(T_(2)),at the end of surgery(T_(3))and at postanesthesia care unit discharge(T_(4)),and lactate value(Lac)was recorded.Blood samples from cubital vein were collected on admission to hospital(T_(A))and at 24(T_(24))and 48 h after operation(T_(48))for determination of serum creatinine(Cr)concentrations.Doppler-based renal resistive index(RRI)was measured at T_(A),T_(4),T_(24)and T_(48).The incidence of AKI was calculated within 48 h after operation according to the Kidney Disease:Improving Global Outcomes criteria in 2012 for Cr concentration.Adverse reactions(such as nausea and vomiting)and complications(such as incision infection)within 48 h after operation were recorded.Results Compared with the baseline at T_(0),Lac concentrations were significantly increased at T_(1-4) in both groups(P<0.01).Cr concentrations were significantly increased at T_(24)and T_(48),and RRI was increased at T_(4),T_(24)and T_(48)than at T_(A) in both groups(P<0.01).Compared with group LR,the incidence of AKI within 48 h after operation,Lac concentrations at T_(3,4),Cr concentrations at T_(24)and T_(48),and RRI at T_(4),T_(24)and T_(48)were significantly decreased in group BR(P<0.05 or 0.01).There was no significant difference in the incidence of nausea,vomiting,incision infection,delirium,bile leakage and pulmonary infection within 48 h after operation among the two groups(P>0.05).Conclusions Sodium bicarbonate Ringer′s solution can decrease the development of AKI following laparoscopic hepatectomy in elderly patients.