Flotrac/Vigileo系统在腹腔镜肝部分切除术患者围术期血流动力学监测中的应用

Clinical application of Flotrac / Vigileo system in monitoring perioperative hemodynamic after laparoscopic partial hepatectomy

目的将Flotrac/Vigileo系统应用于腹腔镜肝部分切除术患者监测心输出量（CO）,观察不同输液量对第一肝门阻断开放后患者血流动力学变化。方法选择36例择期全麻下行腹腔镜肝部分切除术患者,按照随机数字表法分为3组,每组12例,各组形成气腹的压力相同（12 mm Hg）。在第一肝门阻断开放前,各组均输入0.9%氯化钠注射液500 mL,羟乙基淀粉130/0.4氯化钠注射液500 mL（羟乙基淀粉）做为基础量。Ⅰ组为正常输液组（基础量）;Ⅱ组输液增加羟乙基淀粉500 mL;Ⅲ组输液增加羟乙基淀粉1000 mL。Philips MP60监护仪监测中心静脉压（CVP）、心率（HR）、心电图（ECG）、血氧饱和度（SpO2）,通过Flotrac传感器监测桡动脉有创动脉血压（MAP）,Vigileo监护仪连接Flotrac传感器连续监测CO、心指数（CI）、每搏量（SV）及每搏量变异率（SVV）的变化。分别记录麻醉诱导前10 min（T0）、气管插管后5 min（T1）、建立气腹后5 min（T2）、第一肝门阻断即刻（T3）、第一肝门开放即刻（T4）、第一肝门开放后5 min（T5）、第一肝门开放后20 min（T6）、气管插管拔出后5 min（T7）各时间点的MAP、HR及CO等指标,观察并记录术中术后并发症。结果 3组患者一般情况、手术时间、第一肝门阻断时间比较差异无显著性意义（P〉0.05）。T1-T7时间点中,T3、T4、T5、T6时间点3组患者的MAP、CVP、HR、CO、SVV等指标组间比较差异有显著性意义（P〈0.05）。T5时CI、SVV变化较为突出,Ⅰ-Ⅱ组间及Ⅱ-Ⅲ组间均存在差异,具有显著性意义（P〈0.05）。结论 Flotrac/Vigileo系统应用于腹腔镜肝部分切除术可持续有效地监测患者术中血流动力学变化,及时准确地指导术中液体治疗,优化围术期麻醉管理。

Objective To apply Flotrac/Vigileo system in monitoring cardiac output during laparoscopic partial hepatectomy and study hemodynamic changes in association with different fluid volume infusion before and after the hepatic portal vein block. Methods 36 patients who received elective laparoscopic partial hepatectomy under general anesthesia were randomly divided into three groups with 12 cases in each group. The pneumoperitoneum pressure in each group was controlled at the same level of 12 mm Hg. Each group patients received 0. 9% sodium chloride injection 500 m L and hydroxyethyl starch 130 /0. 4 500 m L as the basis amount before hepatic portal vein was blocked. Group I was the control group with the basis amount; Group II with increased infusion of hydroxyethyl starch 500 m L; Group III with increased infusion of hydroxyethyl starch 1000 m L. Central venous pressure（ CVP）,heart rate（ HR）,electrocardiogram（ ECG）,oxygen saturation（ SPO2） were monitored. Instant cardiac output（ CO）,cardiac index（ CI） and stroke volume variation rate（ SVV）were calculated by Vigileo system based on invasive arterial blood pressure（ MAP） obtained by Flotrac sensors. These data were recorded at seven time points： before the beginning of anesthesia induction（ T0）,5 minutes after intubation（ T1）,5minutes after pneumoperitoneum（ T2）,time hepatic portal vein blocked（ T3）,time portal vein released（ T4）,5 minutes after portal vein released（ T5）,20 minutes after portal vein released（ T6）,and 5 minutes after endotracheal extubation（ T7）. Results The general status,operative duration and the hepatic portal vein blocking duration among three groups had no significant difference. The total fluid volume of three groups before portal vein block were different from each other（ P〈0. 05）. MAP,CVP,HR,CI and SVV of the three groups were significantly different（ P〈0. 05） at T3,T4,T5 and T6time points. Conclusion Application of Flotrac / Vigileo system in laparoscopic partial hepatectomy is sensitive in monitoring intraoperative hemodynamic. Thus,it is capable of guiding intraoperative fluid infusion more precisely,and optimizing anesthetic management.