腹部手术患者麻醉诱导期间液体治疗对皮肤微循环灌注的影响

Effect of fluid therapy on skin microcirculatory perfusion during induction of general anesthesia in patients undergoing major abdominal surgery

目的观察腹部手术患者麻醉诱导期间静脉输注羟乙基淀粉和乳酸钠林格氏液后皮肤微循环灌注的变化，比较晶体液和胶体液治疗方案对微循环灌注的影响。方法择期拟行腹部手术患者36例，ASAⅠ或Ⅱ级，年龄18—64岁，随机分为2组（n=18）：羟乙基淀粉组（HES组）和乳酸钠林格氏液组（RL组）。HES组和RL组分别静脉输注6％羟乙基淀粉130／0．4或乳酸钠林格氏液各7ml／kg补充麻醉致血管扩容量。同时均静脉输注乳酸钠林格氏液8ml·kg^-1·h^-1补充生理需要量和禁食禁饮丢失量。液体治疗后40min静脉注射异丙酚．罗库溴铵．芬太尼麻醉诱导，气管插管，20min后开始手术。于液体治疗前（T0基础状态）、气管插管后即刻（T1）、手术开始前即刻（T2）行动脉血气分析，同时记录患者前额皮肤的微循环灌注量（SMP）和CVP，计算各时点SMP较基础值的变化率（ASMP）。结果与RL组比较，HES组T1时CVP和ASMP升高（P〈0．05或0．01），血气分析各指标差异无统计学意义（P〉0．05）。与T0时比较，HES组T1时△SMP升高（P〈0．01），RL组差异无统计学意义（P〉0．05），两组T2时ASMP均降低（P〈0．01），两组T1,2时CVP和PaO2／FiO2升高，Hb降低（P〈0．05）。与T1时比较，两组T2时ASMP均降低（P〈0．01）。结论腹部手术患者麻醉诱导期间静脉输注6％羟乙基淀粉130／0．4较乳酸钠林格氏液可更好地改善机体微循环灌注。

Objective To investigate the changes in skin microcirculatory perfusion during induction of general anesthesia and the effects of two fluid therapy regimens in patients undergoing abdominal surgery. Methods Thirty-six ASA I or II patients aged 18-64 yr scheduled for elective major abdominal surgery were randomized to receive either 6% hydroxyethyl starch （130/0.4） 7 ml/kg （HES group, n = 18） or lactated Ringer＇s solution 7 ml/kg （RL group, n = 18） for compensatory intravascular volume expansion （CVE） before tracheal intubation. Meanwhile both groups received continuous intravenous infusion of RL at a rate of 8 ml·kg^-1·h^-1. Tracheal intubation was performed at 40 min after the onset of infusion. Anesthesia was maintained with sevoflurane, remifentanil and rocuronium. Operation was started at 20 min after tracheal intubation. The microcireulatory perfusion was measured on forehead skin by using laser Doppler perfusion imaging system （LDPI） at the onset of fluid infusion （T0, baseline）, the end of endotracheal intubation （T1） and the onset of skin incision （T2）. Results The MAP, HR, blood gases and body temperature were within the normal range during the experiment and there was no significant difference between the 2 groups. The skin microcireulatory perfusion and CVP at T1 were significantly higher in group HES than in group RL （P 〈 0.05 or 0.01 ）. Compared with the baseline value at T0, the skin microcirculatory perfusion at TI was significantly increased in group HES （P 〈 0.01 ）, but there was no significant change in the skin nficroeirculatory perfusion at T1 in group RL （ P 〉 0.05 ）, the skin microcireulatory perfusion at T2 was significantly decreased in both groups （ P 〈 0.01 ）, and CVP and PaO2/FiO2 at T1.2 were significantly increased, while Hb at T1.2 was significantly decreased in both groups （P 〈 0.05 ）. The skin microcirculatory peffusion in both groups was significantly lower at T2 than at T1 （ P 〈 0.01 ）. Conclusion The infusion of 6% HES 130/0.4 can improve the skin microcirculatory perfusion and the effect is better than that of RL during induction of general anesthesia in patients scheduled for abdominal surgery.