诱导期急性超容量液体填充对腹腔镜结肠直肠手术老年病人内脏灌注的影响

Effects on splanchnic perfusion of acute hypervolemic fluid infusion during induction of general anesthesia in elderly patients undergoing laparoscopic colorectal surgery

目的：观察全麻诱导期应用晶体液或胶体液行急性超容量液体填充（acute hypervolemic fluid infusion,AHFI）对腹腔镜结肠直肠手术老年病人内脏灌注的影响。方法：腹腔镜结肠直肠手术老年病人30例,ASAⅠ～Ⅱ级,男17例,女13例,年龄65～85岁,随机分为乳酸钠林格液组（R组）、琥珀酰明胶组（G组）和高渗氯化钠羟乙基淀粉40注射液组（H组）,每组各10例,全麻诱导开始后30 min内分别输注乳酸钠林格液、琥珀酰明胶12 mL/kg,或高渗氯化钠羟乙基淀粉40注射液3.5 mL/kg。在诱导前即刻（T0）,AHFI结束时（T1）,气腹后5 min（T2）、15 min（T3）、30 min（T4）、60 min（T5）,结束气腹后5 min（T6）、15min（T7）、25min（T8）时监测并记录血流动力学指标、动脉血气分析结果和胃黏膜张力计测定值。结果：3组胃黏膜-血二氧化碳分压（Pg-aCO2）在T1时低于基础值;在T2降至最低点,且G组明显低于R组;随后,3组Pg-aCO2较T2逐渐升高,且R组T4~7和H组T6时Pg-aCO2高于基础值。3组胃黏膜pH随着气腹时间的延长而逐渐降低,R和H组pHi在T5~8低于7.32,但G组pHi在各时点均高于7.32。R组心指数和心室收缩加速指数在T2明显低于基础值,T6时中心静脉压明显低于G和H组。H组T1～7Na＋高于R和G组。结论：诱导期AHFI能改善腹腔镜结肠直肠手术老年病人内脏器官的血流灌注。与R和H比较,G在较长时间气腹（60 min）仍能维持良好的内脏灌注。

Objective To investigate the effects on splanchnic perfusion of acute hypervolemic fluid infusion（AHFI） with different plasma substitutes during induction of general anesthesia in elderly patients undergoing laparoscopic colorectal surgery.Methods Thirty ASA Ⅰ-Ⅱelderly patients of both sexes（17 male,13 female）,65-85 years of age,undergoing laparoscopic colorectal surgery,were enrolled in this study.During induction of general anesthesia,they were randomized to receive 12 mL/kg of sodium lactated Ringer＇s solution（group R,n=10）,succinylated gelatin（group G,n=10） or 3.5 mL/kg of hypertonic saline hydroxyethyl starch 40（group H,n=10）,within 30 min.Artery blood gas analysis and gastric tonometry were recorded before induction of anesthesia（T0,baseline）,after AHFI（T1）,5 min（T2）,15 min（T3）,30 min（T4） and 60 min（T5） after CO2 pneumoperitoneum,5 min（T6）,15 min（T7） and 25 min（T8） after the end of pneumoperitoneum.Results CVP was significantly increased and gastric intramucosal-arterial PCO2 gradient（Pg-aCO2） decreased at T1 compared with the baseline value（T0） in all groups.Pg-aCO2 was the lowest at T2,then gradually increasd after T2 in all groups.Pg-aCO2 at T2 in group G was significantly lower than that of group R.As compared to the baseline values,Pg-aCO2 was significantly increased at T4-7 in group R and increased at T6 in group H.Gastric intramucosal pH（pHi）gradually decreased after CO2 pneumoperitoneum in all groups.pHi was less than 7.32 at T5-8 in groups R and G,whereas it was higher than 7.32 in group H.In group R,cardiac index and accelerated contraction index were significantly decreased at T2,as compared with T0.CVP was significantly decreased at T6 in group R,showing differences with group G and H.Serum natrium concentration was significantly increased at T1-7 in group H,as compared with group R and G.Conclusions Acute hypervolemic fluid infusion with different plasma substitutes during induction of general anesthesia improves splanchnic perfusion in elderly patients undergoing laparoscopic colorectal surgery.As compared with sodium lactated Ringer＇s solution and hypertonic saline hydroxyethyl starch 40,succinylated gelatin maintains a better status of splanchnic perfusion while sustaining a long duration of CO2 pneumoperitoneum.