每搏变异度指导术中限制性输液对肝叶切除术病人肝肾功能的影响

Effect of stroke volume variability-guided intraoperative fluid restriction on liver and renal function in patients undergoing hepatic lobectomy

目的 评价每搏变异度指导术中限制性输液对肝叶切除术病人肝肾功能的影响.方法 择期开腹下行肝叶切除术病人40例,年龄33～60岁,ASA分级Ⅰ～Ⅲ级,性别不限,采用随机数字表法,将病人随机分为2组（n=20）：常规输液组（A组）和限制性输液组（B组）.麻醉诱导：静脉注射利多卡因、芬太尼和顺阿曲库铵,靶控输注异丙酚.气管插管后行机械通气,麻醉维持：吸入七氟醚,间断追加芬太尼和顺阿曲库铵,维持BIS值40～60.术中静脉输注复方电解质注射液和6%羟乙基淀粉130/0.4,晶体液和胶体液的比例为2∶1,A组和B组输液速率分别为10～20和5～12 ml·kg^-1·h^-1,分别维持每搏变异度值5～7和11～13.术中监测血液动力学指标.记录术中异体输血情况、出血量和尿量.分别于术前（基础状态）、术后1、3、5 d时采集静脉血样,测定血清ALT、AST、总蛋白（TP）、白蛋白（ALB）、总胆红素（TBIL）、直接胆红素（DBIL）、尿素氮、肌酐和乳酸的水平;同时测定Hb和Hct.结果 2组术中血液动力指标均在正常范围内.与A组比较,B组异体输血率降低,输血量、出血量和尿量减少,术后1 d时血清TP和ALB的浓度升高（P＜0.05）.与基础值比较,2组术后血清ALT、AST、TBIL和DBIL的水平升高,血清TP、ALB的浓度、Hb和Hct降低（P＜0.05）,其它指标差异无统计学意义（P＞0.05）.结论 每搏变异度值能够有效地指导肝叶切除术病人限制性输液.

Objective To investigate the effect of stroke volume variability （SVV）-guided intraoperative fluid restriction on liver and renal function in patients undergoing hepatic lobectomy. Methods Forty ASAⅠ - Ⅲ patients of both sexes aged 33-60 yr weighing 52-80 kg undergoing elective hepatic lobectomy were randomly divid- ed into 2 groups （ n = 20 each） ： group A routine fluid administration and group B restricted fluid administration. Anesthesia was induced with iv lidocaine, fentanyl and TCI of propofol （target plasma concentration 3-4 μg/ml）. Tracheal intubation was facilitated with cisatracurium 0.2 mg/kg. The patients were mechanically ventilated. PET CO2 was maintained at 32-38 mm Hg. Anesthesia was maintained with 1%-2 % sevoflurane inhalation and intermittent iv boluses of fentanyl and cisatracurium. BIS value was maintained at 40-60. Radial artery was cannulated and connected to continuous cardiac output monitor （Edwards Lifesciences, USA）. ECG, MAP, CVP and SVV were monitored. The ratio between the amount of crystalloid solution and colloid solution infused was 2 ： 1. The fluid was infused at 10-20 ml·kg^-1·h^-1 in group A and at 5-12 ml·kg^-1·h^-1 in group B. SVV value was maintained at 5-7 in group A and 11-13 in group B. Blood loss, urine output and the amount of RBC and plasma infused during operation were recorded. Serum levels of alanine aminotransferase （ALT）, aspartate aminotransferase （AST）, total protein （TP）, albumin （ALB）, total bilirubin （TBIL）, direct bilirubin （DBIL）, blood urea nitrogen （BUN）, creatinine （Cr） and lactate and Hb, Hct were measured the day before surgery （baseline） and at day 1,3 and 5 after operation. Results The hemodynamic parameters were maintained within normal limits during operation in both groups. The blood loss, the amount of RBC and plasma infused and urine output during operation were significantly less, while the serum TP and ALB concentrations were higher on the 1 st postoperative day in group B than ingroup A. The serum levels of ALT, AST, TBIL and DBIL were significantly increased and serum concentrations of TP and ALB and Hb,Hct decreased, but there was no significant change in serum BUN and Cr concentrations and lactate after operation as compared with the baseline values before operation in both groups. There were no significant differences in serum levels of ALT, AST, TBIL, DBIL, BUN, Cr, lactate,Hb and Hct after operation between the 2 groups. Conclusion SVV can guide effectively intraoperative fluid restriction in patients undergoing hepatic lobectomy.