食管超声多普勒监测仪指导下目标导向液体治疗在大肠癌手术应用的临床观察

The calinical observiation of the goal-directed therapy directed by transesophageal echocardiography on the patients with operation of cutting colon cancer

目的观察食管超声多普勒监测仪（transesophageal echocardiography，TEE）指导下目标导向液体治疗（goaldirected therapy，GDT）对大肠癌手术患者术中循环、组织灌注及术后恢复的影响。方法65岁以下择期硬膜外复合全麻大肠癌根治术患者60例，美国麻醉医师协会（ASA）分级Ⅰ-Ⅱ级，按随机数字表法分为两组（每组30例）：TEE指导下GDT组（T组）和传统液体治疗组（C组）。麻醉后T组根据每搏量（stroke volume，SV）和纠正左室射血时间（corrected left ventricular ejection time，LVETc）指导液体输入，C组按传统方法补液。记录两组患者麻醉前（T1）、插管前（T2）、开腹探查（T3）、肿物切除（T4）、关腹（T5）和拔管后（L）平均动脉压（mean artery pressure，MAP）、心率（heart rate，HR）、中心静脉压（central venous pressure，CVP）的变化，各时点输液量、液体总量和尿量。分别在手术开始前、肿物切除后、术毕测定血清D晋L酸（lactic acid，LAC）含量，观察术后排气、排便时间，进流食时间，术后恶心呕吐发生率，住院天数及其他并发症。结果MAP、HR两组组内T2、T3较麻醉前（T1）降低（P〈0．01），CVP组内比较，T2较T1增高（P〈0．01）；与T组比较，C组CVP在T4、T5、T6时点增高（P〈0．01）。C组补液量在T1低于T组，T4、T5、T6高于T组（P〈0．05），C组液体总量多于T组（P〈0．01），尿量T组少于C组（P〈0．05）。LAC各时点组内组间比较，差异无统计学意义（P〉0．05）。T组术后排气、排便时间[（3．2±0．7）、（4．5±0．9）d]明显短于C组[（4．7±0．3）、（5．9±0．7）d]（P〈0．05），进流食时间T组[（2．84±0．14）d]早于C组[（3．95±0．72）d]（P〈0．05）。C组术后恶心呕吐发生率、住院天数[30％、（11．3±2．3）d]高于T组[13％、（8．2±3．4）d]（P〈0．05）。结论硬膜外复合全麻肠癌手术中采用GDT在合理输液和加速患者术后胃肠功能恢复上具有优势。

Objective To observe the application of goal-directed therapy （GDT） directed by transesophageal eehocardiography （TEE） in patients of cutting colon cancer operation. Methods Sixty scheduled colon cancer patients with epidural plus general anesthesia were randomly divided into routine fluid therapy group （group C） and GDT group monitered with TEE （group T） using random digits table （n=30）. The patients of group C were infused routinely after anesthesia, the patients of group T were infused under monitered stroke volume （SV） and corrected left ventricular ejection time （LVETe） with TEE. Mean artery pressure （MAP）, heart rate （HR）, the amount of infused fluid , central venous pressure （CVP） of two groups were recorded before anesthesia （T1）, tracheal intubation （T2）, the time point of abdomen exploration （T3）, cuting goiter （T4）, closing abdomen （T5） and after extuhation （T6）. The total amount of infusion fluid and urine volume were recorded at the end of operation. The plasma amount of D-lactic acid were monitered at the time point of preoperation, after outing goiter and the end of operation. Postoperation time of air bleed , defecate Liquid Diet were monitored. Postoperative nausea emesia, various complications, the time to take food, hospital day were observed. Results The MAP and HR of T2 and T3 were lower than before anesthesia （P〈0.01）, there were no significant difference among other time. The CVP of all groups at T2 were higher than T1, the CVP of group T was higher than group C at the point of T4,T5 and T6 （P〈0.01）. There were significantly diffferent between two groups about amount of fluid replacement at the time point of T3,T4,T5 and T6 （P〈0.05）. The urine volume of group T was less than that of group C. There were no significant difference about LAC between two groups. The morbidity of nausea of C group [（4.7±0.3） d] was higher than group T [（3.2±0.7） d]（P〈0.05）. The air bleed, defecate time of group T [（2.84±0.14） d] were significant shorter than group C [（3.95±0.72） d]（P〈0.05）, liquid diet time of group T [（4.5±0.9） d] was earlier than group C [（5.9±0.7） d）]（P〈0.05）, the incidence of postoperative nausea and vomiting and the inhospital day of group T [ 13%, （8.2±3.4） d ] was less than that of group C [ 30%, （11.3±2.3 ） d ）] （P〈0.05）. Conclusions GDT provides obviously dominant postoperative outeome for patients with operation of cutting colon cancer.