微白蛋白尿在腹部手术后病人的液体治疗中的价值

Value of microalbuminuria in fluid balance after abdominal surgery

目的 探讨腹部手术后微白蛋白尿的变化与手术创伤应激程度、液体正负平衡的关系。方法腹部择期手术病人191例，根据手术类型分为4组：腹腔镜胆囊切除术组（I组），开腹胆囊切除胆道手术组（Ⅱ组），结直肠癌根治性手术组和胃癌根治术（m组）、胰十二指肠切除术组（Ⅳ组），手术创伤应激评分（sss）评判手术创伤严重度。术后动态监测尿微白蛋白的变化，方差分析比较4组术后0、6h平均尿微白蛋白／尿肌酐比值（ACR）的差异，对ACR与SSS评分进行相关性分析。在肿瘤手术两组监测术后体重变化，计算手术日24h液体正平衡量，观察手术1324h液体正平衡量与0、6hACR变化值（AACR）的相关性，比较ACR恢复至正常或术前水平与体重达峰值的时间差异。结果4组术后ACR均升高，I组ACR的升高幅度最小，ACR0：（14．364±14．39）mg／mmol，ACR0：（8．62±6．03）mr／mmol，在Ⅱ组ACR0：（28．94±8．31）mg／mmo]，ACR6：（12．66±3．92）mg／mmol和Ⅲ组ACR0：（30．46±13．74），ACR6：（11．67±5．55）mg／mmol升高幅度居中，Ⅳ组ACR的升高幅度最大，ACR0：（40．84±8．80），ACR6：（21．47±3．68）mg／mmol。方差分析：4组0、6hACR差异均有统计学意义（P〈0．001）。0、6hACR值与SSS评分呈正相关。Ⅳ组手术13液体正平衡量较Ⅲ组明显增加，0、6hAACR与手术日液体正平衡量正相关，表明液体正平衡量与创伤程度正相关。ACR恢复至正常或术前水平较体重达峰值的时间提前。结论腹部手术后病人的ACR的升高与手术创伤、液体正平衡量正相关，能反映手术的创伤程度。ACR恢复正常或术前水平较体重达峰值的时间提前，预示其是负平衡出现较体重测定更敏感的指标。

Objective To evaluate the relationship among the microalbuminuria, surgical stress and postoperative fluid balance after abdominal surgery. Methods A total of 191 patients undergoing an elective abdominal operation were studied. According to the extent of operative trauma, all patients were divided into 4 groups. Group I ： laparoscopic cholecysteetomy （n = 64） ; Group Ⅱ ： laparotomy of cholecyst and biliary tract （n = 36） ; Group m ： radical surgery of colorectal cancer （n = 43） ; Group IV： distal subtotal gastrectomy （I）2） or total gastectomy （D3 ） or pancreaticoduodeneetomy （ n = 48 ）. The operative severities were predicated by surgical stress score （SSS）. Urine albumin-creatinine ratio （ACR） was measured at both pre- and post-operation. The levels of ACR were compared by ANOVA among these 4 groups. The correlation of ACR and SSS was analyzed. In GroupsⅢ and IV, body weight was measured by weight-bed simultaneously. The correlation of variation of ACR at 0 and 6 hours post-operation （AACR） and the volume of positive fluid balance in the first 24 hour post-operation were studied. We also compared the varied durations of ACR levels returning to normal or the pre-operative level and body weight reaching peak values. Results The levels of ACR increased in all groups. The level of ACR was the highest in Group IV and the lowest in Group I , significantly different from the levels of group 1] and m. There was a significant positive correlation between the increase in ACR and the severity of surgical trauma as measured by SSS. A positive correlation was observed between the volume of positive fluid balance in the first 24 hour post-operation andAACR at 0 and 6 hours post-operation. The varied duration of ACR levels returning normal or the pre- operative level was earlier than that of reaching the peak values. Conclusion ACR has a positive correlation with the extent of surgical stress and volume of positive fluid balance. The fact that the ACR comes earlier than the change of body weight indicates that the change of ACR is a more sensitive and simpler oarameter than body weight to oredict the onset of negative fluid balance.