目标导向液体治疗对老年髋关节置换术术中循环影响的研究

Investigate of the influence of goal-directed fluid therapy on intraopretive haemodynamic changes in elderly patients with hip fractures

目的探讨目标导向液体治疗在老年髋关节置换术中对循环稳定方面的优势。方法将40例择期行髋关节置换手术的老年患者,随机分为目标导向治疗组(A组)和经典输液治疗组(B组)。A组给予胶体液冲击使每搏输出量(SV)最大化,保证容量处于理想状态。具体方案为10min内给予约200ml胶体液(万汶)冲击,若SV迅速升高超过10%,提示前负荷过低,继续液体冲击,直到SV升高<10%,此时SV处于最大化,停止进一步的液体冲击。B组患者按经典输液方案进行术中补液。观测和记录两组入室、麻醉后、术始、骨水泥前后、术毕时的动脉血压、心率、心输出量(CO)以及SV。记录术中血管活性药物的应用、失血量以及出入量等情况。结果 A组SV较B组[(62.5±5.4)mlvs.(54.8±8.7)ml]显著增高(P<0.05),但应用骨水泥后两组SV变化差异无统计学意义。两组应用骨水泥后收缩压(SBP)、平均动脉压(MAP)均显著下降(P<0.05),但A组血压下降的持续时间较B组短(1minvs.3min);A组胶体量用量较B组增多[(682.5±96.3)mlvs.(387.5±45.5)ml,P<0.05]。结论目标导向液体治疗与经典液体治疗相比,能够使心脏前负荷处于更理想的充盈状态并提供相对更平稳的血流动力学,但是并不能完全改善骨水泥导致的心血管反应。

Objective To perform intraoperative goal-directed fluid therapy with FloTrac/Vigileo monitoring, and to evaluate intraopretive haemodynamic changes compared to conventional intra-operative fluid management. Methods Forty elderly patients scheduled for hip fracture were randomly divided into two groups. Goal-directed fluid therapy group（Group A） or conventional intra-operative fluid management group （Group B）. Colloid was given in intraoperative fluid infusion of Group A depending on ASV. First, 200 ml colloid （Voluven） was admitted in 10 minutes, if the SV rapidly increased to above 10%, colloid was given until the increasement of SV was below 10%. At this time point, SV reach the peak value. Crystalloids or colloids were infused intraoperatively to Group B based on Miller＇s Anesthesia （6th ed）. SBP, MAP, HR, CO, SV were recorded at different time points. The use of vasoactive agents, intraoperative blood loss, lipid intake and out- put were also recorded. Results After goal-directed fluid therapy, SV of Group A [（62.5±5.4）ml] was significantly higher than SV of Group B [（54.8±8.7）ml, P 〈 0.05]. However, after the implantation of bone cements, there was no difference of SV between two groups. After the implantation of bone cements, SBP and MAP dropped significantly （P 〈 0.05）. But the decline in Group A was milder than Group B, and the duration of low blood presser was shorter in Group A （ 1 min） than in Group B （3 min）. The use of colloids in Group A was more frequent than Group B[ （682.5±96.3）ml vs. （387.5±45.5）ml, P 〈 0.05]. Conclusions Goal-directed fluid therapy can maintain better preload and provide more stable hemodynamic status compared with conventional lipid treatment for fluid resuscitation. But goal-directed fluid therapy can not completely improve the cardiovascular response induced by implantation of bone cements.