不同容量治疗方法对肝癌切除术患者炎性反应的影响

Effects of different methods of volume therapy on inflamnmtory response in patients undergoing fiver cancer resection

目的评价不同容量治疗方法对肝癌切除术患者炎性反应的影响。方法择期行肝癌切除术患者40例，性别不限，年龄40～60岁，体重指数20—25kg／m2，AsA分级I或Ⅱ级，采用随机数字表法，将其随机分为2组（n=20）：常规补液组（I组）和目标管理补液组（Ⅱ组）。I组补液量为补偿性扩容量＋生理需要量＋累计缺失量＋继续损失量＋第三间隙丢失量，补偿性扩容量于麻醉诱导前以乳酸钠林格氏液补充，补液量为5ml／kg，继续损失量按失血量计算，以HES130／0．4等量补充，第三间隙丢失量采用乳酸钠林格式液以5ml·kg·^-1·h^-1补充，生理需要量与累计缺失量根据4—2．1法则以乳酸钠林格式液补充。Ⅱ组补偿性扩容量于麻醉诱导前补充，方法同I组，麻醉诱导后静脉输注乳酸钠林格氏液5ml·kg·^-1·h^-1，同时根据每搏量（SV）和校正左室射血时间（LVETc）指导补液，维持LVETc350～400ms；350ms〈LVETc〈400ms，且SV增加幅度〉10％时，则继续静脉输注6％HES 130／0．4，直至SV增幅≤10％。于麻醉诱导前和术毕时取静脉血样，测定血清TNF-α、IL-2、IL4、IL-6和IL-8的浓度，记录心血管不良反应的发生情况。结果与I组比较，Ⅱ组TNF-α、IL-6及IL-8浓度降低，IL-2和IL-4浓度升高，低血压和心动过速发生率降低（P〈0．05）。两组均未发生心血管不良反应。结论采用LVETc与sV指导容量治疗能维持有效循环血容量，抑制炎性反应，适用于肝癌切除术患者。

Objective To investigate the effects of different methods of volume therapy on the inflammato- ry response in patients undergoing liver cancer resection.Methods Forty ASA I or II patients, aged 40-60 yr, with body mass index 20-25 kg/rn2 , undergoing liver cancer resection, were randomly divided into 2 groups （ n = 20 each） ： routine fluid replacement group （group I ） and goal-directed fluid replacement group （group II ）. The fluid replacement regime in group I = compensatory volume expansion （CVE） ＋ physiological requirements ＋ cumulative loss ＋ continued loss ＋ the third space losses. CVE was replaced with lactated Ringer＇s （LR） solution 5 mg/kg before anesthesia induction. The physiological requirements and cumulative loss were replaced with LR solution according to the principle of 4-2-1. The continued loss equal to the intraoperative blood loss was re- placed with the equal volume of 6% hydroxyethyl starch （HES 130/0.4）. The 3rd space losses were replaced with LR solution 5 ml·kg-1·h-1 . In group II , CVE was replaced with LR sol6ution as in group I . LR solution was infused after anesthesia induction at 5ml·kg-1·h-1 1. 6 % HES was infused to maintain left ventricular ejection time （LVETc） between 350-400 ms. When 350 ms 〈 LVETc 〈 400 ms and the amplitude of stroke volume （SV） ＇increased by 〉 10%, 6% HES was infused continuously until the amplitude of SV increased by ≤ 10%. Blood samples were taken before anesthesia induction and at the end of operation for measurement of serum TNF-α, IL-2,IL-4, IL-6 and IL-8 concentrations. The adverse cardiovascular reactions were recorded.Results Compared with group I , the serum TNF-a, IL-6, IL-8 concentrations were significantly decreased, the serum IL-2 and IL-4 concentrations were siguiticandy increased, and the incidence of hypotension and tachycardia was significantly decreased in group II （ P 〈 0.05）. No adverse cardiovascular reactions were found in both groups. Conclusion LVETc and SV-guided volume therapy canmaintain the blood volume and inhibit the inflammatory response and is suitable for the patients undergoing liver cancer resection.