三种容量治疗方法对肺切除术猪血流动力学及氧供需平衡的影响

Effects of different volume therapies on hemodynamics and oxygen supply-demand balance in pigs after pulmonary lobectomy

目的对行肺叶切除术猪实施3种容量治疗方法,观察其血流动力学和氧合功能的变化,并对3种容量治疗方案进行评价,以期对临床容量管理提供指导。方法选择成年贵州小型香猪20只,随机分为容量限制组(S组,7只)、正常容量组(M组,6只)及大容量组(L组,7只)。S组持续静脉滴注5 mL.kg-1.h-1乳酸钠林格注射液;M组按基础需要量+禁食丧失量+术中丢失和第3间隙损失量补液,基础需要量+禁食丧失量根据4-2-1法则以乳酸钠林格注射液补充,第3间隙损失量采用乳酸钠林格注射液以5 mL.kg-1.h-1计算;L组除给予M组的量外再给予10 mL.kg-1.h-1的羟乙基淀粉130/0.4(万汶)负荷量。在有创操作完成后稳定10 min(T1)、单肺通气1 h(T2)、单肺通气2 h(T3)、单肺通气3 h(T4)及恢复双肺通气1 h(T5)5个时间点记录血流动力学指标,并抽取桡动脉和肺动脉血进行动脉血气分析,计算氧供(DO2)和氧耗(VO2)。结果L组在T3～T5时间点的心率(HR)显著高于T1时间点(P值均<0.05),在T2～T5时间点的中心静脉压(CVP)、心指数(CI)显著高于T1时间点(P值均<0.05),在T4～T5时间点的肺动脉压(PAP)显著高于T1时间点(P值分别<0.05、0.01),在T3～T5时间点的外周循环阻力(SVR)显著低于T1时间点(P值分别<0.05、0.01)。L组在T2～T4时间点的平均动脉压(MAP)显著高于M组同时间点(P值分别<0.05、0.01),在T2～T5时间点的CVP、CI显著高于M组同时间点(P值分别<0.05、0.01),在T4～T5时间点的PAP显著高于M组同时间点(P值分别<0.05、0.01);L组在T2～T5时间点的MAP、CVP、PAP、CI显著高于S组(P值分别<0.05、0.01),在T3～T5时间点的SVR显著低于S组同时间点(P值分别<0.05、0.01)。L组在T2～T5时间点的动脉血氧分压(PaO2)显著低于T1时间点,且在T5时间点显著低于S组及M组同时间点(P值分别<0.05、0.01);L组在T2～T5时间点的DO2较T1时间点显著升高(P值分别<0.05、0.01)。S组及M组在T2～T4时间点的PaO2显著低于T1时间点(P值分别<0.05、0.01)。结论在心肺功能良好的健康猪行肺切除术中,容量限制及正常容量治疗方案均能维持血流动力学的稳定及氧供需平衡,而大容量治疗方案则呈现循环亢进的表现,虽然能维持机体氧供需平衡,但是可能导致肺组织氧合功能障碍。

Objective To observe the effects of three different volume therapies on hemodynamics and oxygenation in pigs after pulmonary Iobectomy, so as to provide evidence for clinical volume management. Methods Twenty adult Guizhou miniature pigs were randomly assigned to 3 groups： volume restriction group （group S, n = 7）, normal volume group （group M, n = 6） and volume expansion group （group L, n = 7）. Group S received continuous Ringer＇s solution administration （5 mL·kg-1·h-1）; group M requirement was determined according to basic requirement, preoperative fast, intraoperative loss and third space loss. The basic requirement and preoperative fast were administered with Ringer＇s solution according to rule 4-2-1. The third space loss was adminstered with Ringer＇s solution at 5 mL·kg-1·h-1. Group L was administered with of hydroxyethyl starch 130/0.4 （Voluven） at 10mL·kg-1·h-1 in addition to the regimen of M group. Perioperative hemodynamics data were recorded at 10 min after invasive operation （T1）, one-lung ventilation 1 hour （T2）, one-lung ventilation 2 hour （T3） ,one-lung ventilation 3 hour（T4 ） and resumption of bilateral pulmonary ventilation 1 hour（T5 ）. Arterial and venous blood gas parameters were determined, and the oxygen supply （DO2） and oxygen consumption （VO2） were calculated. Results Heart rate （HR） in group L was increased at T3 -T5 compared with that at T1 （all P〈 0.05） ; and central venous pressare （CVP）, cardiac index （CI） were increased at T2 - T5 compared with that at T1 （P〈0.05, 0.01）; pulmonary artery pressure （PAP） was increased at T4 -T5 compared with that at T1 （all P〈, 0.05）; and systemic vascular resistance （SVR） was decreased at T3 -Ts compared with that at T1 （P〈O. 05, 0.01）. Mean arterial pressure （MAP） at T2-T4 in group L was significantly higher than that of group M （P〈 0.05, 0.01） ; CVP and CI at T2 - T5 was significantly higher than those of group M （P〈0.05, 0.01）; PAP at T4 -T5 was significantly higher than that of Group M （P〈O. 05, 0.01 ）; and CI at T2 -T5 was significantly higher than that of Group M （P〈O. 05, 0.01）. MAP, CVP, PAP, and CI at T2 -T5 in group L were significantly higher than those of group S （P〈0.05, 0.01 ）; SVR at T3 -T5 was significantly lower than that of group S （P〈O. 05, 0.01 ）. Pressure of oxygen in arterial blood （PaO2） at T2 -T5 in group L was markedly lower than that at T~, and that in group L at T5 was significantly lower than those in group S and M （P〈O. 05, 0.01 ）. PaO2 at T2- T4 in group S and M was significantly lower than that at T1 （ P〈O. 05, 0.01 ）. DO2 at T2 - T5 in group L was significantly higher than that at T1 （P〈0.05, 0.01）. Conclusion Both volume restriction and normal volume therapies can maintain the stability of Hemodynamics and oxygen supply-demand balance in healthy pigs receiving pulmonary Iobectomy. Volume expansion therapy may lead to hyperfunction in circulation and lung tissue oxygenation dysfunction after fluid infusion. （Shanghai Med J, 2009, 32= 973-977）