每搏量变异度和中心静脉压指导老年胃肠手术术中液体管理的比较

Comparsion of stroke volume variation with central venous pressure for guiding intraoperative fluid management in elderly patients undergoing gastrointestinal surgery

目的 观察每搏量变异度（stroke volume variation， SVV）用于指导老年胃肠手术液体管理是否可行以及对术后胃肠道功能恢复和患者预后的影响。 方法 选择择期老年胃肠手术40例［美国麻醉医师协会（ASA）分级Ⅰ~Ⅱ级］， 按序列号随机分为两组，SVV组和中心静脉压（central venous pressure， CVP）组，每组20例。SVV组根据SVV值进行补液，维持SVV〈10％，同时维持CVP在正常范围。当SVV值〉10％，输入羟乙基淀粉130/0.4氯化钠注射液，至SVV稳定〈10％，之后维持适当补液速度，并保证SVV〈10％，CVP在正常范围，循环稳定。CVP组根据CVP值进行补液，维持CVP 8 mmHg^12 mmHg（1 mmHg=0.133 kPa）。当CVP〈8 mmHg时，输入羟乙基淀粉130/0.4氯化钠注射液至CVP稳定在8 mmHg^12 mmHg，之后维持适当输液速度，并保证CVP 8 mmHg^12 mmHg，循环稳定。两组患者采用相同的麻醉方案。记录麻醉前（T0）、麻醉诱导后（T1）、切皮后（T2）、打开腹腔时（T3）、肠吻合时（T4）以及关闭腹腔时（T5）患者的血流动力学情况，记录手术时间、术中出血量和尿量以及输血输液量。测定患者手术前1 d和手术后1 d的血红蛋白（hemoglobin， Hb）、血球压积（hematocrit， Hct）、肌酐、尿素氮。记录患者术后排气、恢复进食流质时间和术后住院时间。 结果 与SVV组比较，CVP组T5时点CVP值［（11.6±2.0） cmH2O（1 cmH2O=0.098 kPa）］显著上升（P〈0.05），T4、T5时点SVV值［（4.5±1.5）%、（4.2±1.4）%］显著下降（P〈0.05），平均动脉压（mean artery pressure， MAP）、心率（heart rate， HR）、心输出量（cardiac output， CO）、每搏量（stroke volumn， SV）等血流动力学指标在两组间差异无统计学意义（P〉0.05）。与T0比较，两组T1时点MAP、CO、SV［SVV组：（74±13） mmHg、（3.7±1.0） L/min、（59±11） ml/b；CVP组：（71±12） mmHg、（3.8±1.1） L/min、（58±13） ml/b］均显著下降（P〈0.05），T4、T5时点HR［SVV组：（61±8）、（61±9） 次/min；CVP组：（60±7）、（61±9） 次/min］均显著下降（P〈0.05）。SVV组总输液量［（2 560±462） ml］明显少于CVP组［（3 153±823） ml］（P〈0.05），两组出血量、尿量差异无统计学意义（P〉0.05）。两组术后Hb、Hct均较术前明显下降（P〈0.05），CVP组术后尿素氮值［（4.0±2.0） mmol/L］较术前明显下降（P〈0.05），肌酐值差异无统计学意义（P〉0.05）。SVV组肌酐、尿素氮值较术前无明显改变（P〉0.05），两组之间差异无统计学意义。SVV组术后排气时间［（2.6±1.2） d］，恢复进流质时间［（4.0±1.7） d］明显较CVP组短（P〈0.05），两组术后住院时间差异无统计学意义（P〉0.05）。 结论 以SVV指导老年胃肠手术液体管理减少了术中输液量，有利于改善患者预后，不失为一种较为理想的容量管理方案。

Objective To investigate the applicability of stroke volume variation（SVV） as an index for guiding fluid management in gastrointestinal surgery in elderly patients and the effect of SVV-guided volume management on gastrointestinal functional recovery and postoperative outcome. Methods Forty ASAⅠorⅡ elderly patients undergoing gastrointestinal surgery were randomized into two groups[group SVV and group central venous pressure（CVP）, 20 patients in each group]. The patients in group SVV received fluid therapy with Hydroxyethyl Starch depending on SVV which was maintained〈10% and kept CVP in normal range. The patients in group CVP received fluid therapy with Hydroxyethyl Starch depending on CVP which was maintained at 8 mmHg-12 mmHg（1 mmHg=0.133 kPa） and circulatory stability. All patients were given same anaesthesia protocol. Hemodynamic parameters were recorded at instant time before induction（T0）, before intubation（T1）, after intubation（T2）, after the abdominal cavity opened（T3）, after bowel anastomose（T4）, after abdomen wall closure（T5）. Duration of surgery, intravenous fluid volume, blood loss,urine output were also recorded. The laboratory data such as hemoglobin（Hb）, hematocrit（Hct）,creatinine,blood urea nitrogen were examined the day before and after surgery. The time of passing gas,liquid intake time after surgery,length of hospital stay was examined. Results Compared with group SVV, CVP in group CVP was higher at T5[（11.6±2.0） cmH2O（1 cmH2O=0.098 kPa）, P〈0.05）], SVV was lower at T4, T5 [（4.5±1.5）%,（4.2±1.4）%, P〈0.05]. No differences in mean artery pressure（MAP）, heart rate（HR）, cardiac output（CO）, stroke volumn（SV） between groups were found（P〉0.05）. Compared with T0, MAP, CO, SV in both groups were lower at T1[Group SVV：（74±13） mmHg, （3.7±1.0） L/min, （59±11） ml/b. Group CVP：（71±12） mmHg,（3.8±1.1） L/min,（58±13） ml/b]（P〈0.05）, HR in both groups was lower at T4 and T5[Group SVV：（61±8）,（61±9） bpm. Group CVP：（60±7）,（61±9） bpm）]（P〈0.05）. The intraoperative intravenous fluid volume in group SVV[（2 560±462） ml] was less than in group CVP[（3 153±823） ml]（P〈0.05）. Urine output showed no difference between groups（P〉0.05）. Postoperative Hb, Hct were significantly lower than that in preoperative. Creatinine,blood urea nitrogen in group SVV did not differ between pospoperative and preoperative, while in group CVP, blood urea nitrogen[（4.0±2.0） mmol/L] is significant lower postoperatively than preoperatively（P〈0.05）. The time of passing gas[（2.6±1.2） d] liquid intake time[（4.0±1.7） d] in group SVV were significant shorter than in group CVP（P〈0.05）. The length of hospital stay did not differ between the two groups（P〉0.05）. Conclusions Stroke volume variation could be used for guiding fluid management in elderly patients undergoing gastrointestinal surgery, which could reduce introperative fluid administration, result in more stable hemodynamic, improve postoperative outcomes.