每搏量变异度联合CI及CVP对胃肠道肿瘤手术患者容量治疗的指导效果

Effect of stroke volume variation combined with cardiac index and central venous pressure in guiding volume therapy in patients undergoing resection of gastrointestinal tumor

目的评价每搏量变异度（SVV）联合CI及CVP对胃肠道肿瘤手术患者容量治疗的指导效果。方法择期胃肠道肿瘤手术患者60例，ASA分级I或Ⅱ级，年龄40～64岁，体重55～80kg，采用随机数字表法，将其分为3组（n=20）：常规补液组（R组）、SVV指导补液组（s组）和SVV联合CI、CVP指导补液组（C组）。R组输入液体总量=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。s组以羟乙基淀粉130／0．4氯化钠注射液维持SVV10％～15％。C组依据SVV、CI和CVP指导容量治疗。于麻醉诱导前（R）和术毕（T2）采集肘静脉血样，测定血清β2-微球蛋白（β2-MG）、IL-4、IL培和TNF-α的浓度；于气管插管后即刻（L）和R时记录CO，采集中心静脉血样和动脉血样行血气分析，检测乳酸（Lac）浓度并计算氧供（DO2）、氧耗（VO2）和氧摄取率（ERO2）；记录术中心血管不良事件的发生情况、术后肠蠕动恢复时间及并发症的发生情况。结果与R组比较，s组和C组．T2时TNF—α、IL-8、β2-MG和Lac浓度降低，DO2、VO2、ERO2和IL-4浓度升高，术中心动过缓和低血压的发生率降低，术后肠蠕动恢复时间缩短（P〈0．05）；S组和C组上述指标比较差异无统计学意义（P〉0．05）；3组术后并发症发生率比较差异无统计学意义（P〉0．05）。结论单纯SVV指导下的容量治疗用于胃肠道肿瘤手术患者，不仅能维持有效的循环血容量和组织灌注，还能减轻机体炎性反应，有助于改善预后；无需联合cI及CVP指导容量治疗。

Objective To evaluate the effect of stroke volume variation （SVV） combined with cardiac index （CI） and central venous pressure （CVP） in guiding volume therapy in patients undergoing resection of gastrointestinal tumor. Methods Sixty ASA physical status Ⅰ or Ⅱ patients, aged 40-64 yr,weighing 55-80 kg,scheduled for elective resection of gastrointestinal tumor, were randomly assigned into 3 groups （ n = 20 each） ： routine fluid replacement group （group R）, SVV-guided volume therapy group （group S） and volume therapy guided by SVV in combination with CI and CVP group （group C ）. Anesthesia was induced with iv injection of fentanyl, propofol, and cisatracurium. The patients were mechanically ventilated after endotracheal intubation. Anesthesia was maintained with inhalation of sevoflurane, target-controlled infusion of remifentanil and intermittent iv boluses of cisatracurium. Routine fluid replacement included compensatory volume expansion, physiological requirement, cumulative loss, continued loss （intraoperative blood loss）, and 3rd space losses in group R. In group S, hydroxyethyl starch 130/0.4 was used to maintain SVV at 10%-15% . Fluid therapy was guided by SVV, CI and CVP in group C. Venous blood samples were collected before induction of anesthesia （ TO ） and at the end of the surgery （T2 ） for determination of serum β-microglobulin （T2-MG）, TNF-α, IL-4 and IL-8 concentrations. Cardiac output was recorded immediately after endotracheal intubation （T1） and at T2. Blood samples were collected from the central vein and artery for blood gas analysis. The concentration of lactic acid was measured. Oxygen delivery （DO2）, oxygen consumption （VO2） and O5 extraction rate （ERO2） were calculated. The intraoperative adverse cardiovascular events and recovery time of intestinal peristalsis and complications after operation were recorded. Results Compared with group R, the concentrations of TNF-a, IL-8, β2-MG and lactic acid were significantly decreased, while DO2, VO2, EROs and IL-4 concentration were increased at T2, the incidences of bradycardia and hypotension were decreased, and the recovery time of intestinal peristalsis was shortened in groups S and C （ P 〈 0.05）. There were no significant differences in the parameters mentioned above between groups S and C （ P 〉 0.05 ）. There was no significant difference in postoperative complications among the three groups （ P 〉 0.05 ）. Conclusion Volume therapy guided by SVV alone can not only maintain effective circulating blood volume and tissue perfu- sion, but also reduce the inflammatory response, and is helpful in improving the prognosis in patients undergoing resection of gastrointestinal tumor. It is not required for SVV to combine with CI and CVP in guiding volume therapy.