脊柱侧凸患儿围手术期的液体管理及电解质监测

An audit of perioperative fluid management and electrolyte monitoring in children undergoing surgery for scoliosis

目的观察2009年中华医学会麻醉学分会儿科麻醉学组颁布关于小儿围术期液体和输血管理指南前后1年的临床实施情况。方法分析总结2010年在北京协和医院择期行脊柱侧凸手术14岁以下患儿的基本特征、住院天数、术前合并症、手术及麻醉情况、围术期禁饮食期间开具的液体治疗、电解质监测等资料，并与2008年进行比较。结果235例美国麻醉医师协会（ASA）Ⅰ～Ⅱ级患儿，其中75例术前输注了5％葡萄糖氯化钠；在6岁以下儿童，麻醉医师术中更偏爱5％葡萄糖氯化钠（2008年：15例／2010年：15例），在6～14岁患儿，术中更常输注乳酸林格液（2008年：84例／2010年：94例）；没有一例患儿应用低张溶液；82．3％（2008年）、94．3％（2010年）患儿进行了术前电解质检测，27／122例（2008年）、13／113例（2010年）在术后没有检测电解质，并且所有患儿在液体治疗前均未评估血浆电解质水平。术后分别有82．3％（2008年）、70．5％（2010年）患儿只有1次电解质检测；与术前Na^＋浓度比较，术后第1天Na^＋浓度平均降低2．0mmol／L，2010年术后第1天低钠血症的发生率约26．2％，与2008年相比，差异有统计学意义（P=0．044），而高血糖发生率差异无统计学意义（P=0．306）。结论小儿围术期液体管理和电解质监测以及相关指南尚需进一步落实与完善。

Objective To audite and compare the perioperative practices of intravenous fluids and electrolyte ＆ glucose monitoring in children undergoing operations for scoliosis in 2008, 2010, prior to and after the publication of guideline in 2009. Methods Retrospective audit was conducted at Peking Union Medical College Hospital, a tertiary referral teaching hospital in Beijing, China. Children under 14 years old with seoliosis treated surgically in 2008 and 2010 were recruited. The following data were collected from medical files： age, gender, weight, duration of hospitalization, concurrent illness, operation, anesthesia, fluid prescribed during perioperative fasting period, electrolyte monitoring and postoperative pain control, etc. Results Among 235 American Society of Anesthesiologists （ASA） Ⅰ - Ⅱ cases, 75 children received dextrose 5% or saline 0. 9% during the preoperative fasting period. Intraoperatively, the anesthesiologists preferred dextrose 5% or saline 0.9% in children under 6 years old （n = 15, 2008; n = 15, 2010） and Ringer＇s solution in those aged 6 - 14 years （ n = 84, 2008 ; n = 94, 2010） and hypotonic fluid was not used. And 82.3% and 94.3% of them received electrolyte examinations preoperatively. The electrolyte results were unavailable postoperatively in 27/122 （in 2008 ） and 13/113 （in 2010） and serum electrolytes were not assessed before fluid treatment postoperatively. Electrolytes were monitored only once in 82.3% （ in 2008 ） and 70.5% （ in 2010） patients. Compared with the preoperative concentration of sodium ion, the mean decrease was approximately 2.0 mmol/L at Day 1 postoperation. Hyponatremia at Day 1 postoperation in 2010 was more common than that in 2008 （ 26.2% vs 23.6% ; P = 0. 044 ）. But no significant difference existed between the incidence of hyperglycemia of the same day in 2008 and that in2010 （P = 0. 306）. Conclusion Compared with that in 2008, our recent practice of intravenous fluid prescription and electrolyte monitoring is ill-consistent with the recommendations in 2009. Implementation of optimal perioperative fluid management is warranted.