不同晶胶比例目标导向液体治疗对老年食管癌根治术患者围术期血管外肺水指数及血乳酸的影响

Effect of Goal-Directed Fluid Therapy with Different Crystalloid-Colloid Rations on Extravascular Lung Water Index and Blood Lactic Acid in Esophageal Cancer Patients Undergoing Esophagectomy

目的探讨不同晶胶比例目标导向液体治疗(goal-directed fluid therapy,GDFT)对老年食管癌根治术患者血管外肺水指数及血乳酸的影响。方法选择择期行食管癌根治术患者50例,所有患者术中均行单肺机械通气且术式相同,以晶胶比例3∶1为界,随机分为低晶胶比例组(A组,n=25)和高晶胶比例组(B组,n=25)。术中液体治疗以维持正常范围内的胸内血容量指数(intrathoracic blood volume index,ITBVI)为目标,通过脉搏指示连续心排出量(pulse indicator continuous cardiac output,Pi CCO)监护仪记录术前(T0)、气管插管后5 min(T1)、双肺通气15 min(T2)、单肺通气15 min(T3)、肺复张后双肺通气15 min(T4)和术毕(T5)时患者的心率(heart rate,HR)、平均动脉压(mean artery pressure,MAP)、心脏指数(cardiac index,CI)、血管外肺水指数(extravascular lung water index,EVLWI)、ITBVI等指标。记录所有患者术前、术毕和术后6 h血乳酸含量以及术中使用糖皮质激素、血管活性药物及呋塞米情况,输液总量,失血量,尿量,手术时间。结果术中两组无一例应用糖皮质激素,A组术中1例应用去氧肾上腺素,1例应用呋塞米,B组术中2例应用去氧肾上腺素。共46例纳入统计分析,其中A组23例、B组23例。术中各组GDFT均能维持血流动力学稳定。与T0时比较,两组T1时MAP、CI均显著降低(P<0.05);A组在T5时CI显著高于T0时(P<0.05),且显著高于B组(P<0.05)。B组T5时EVLWI显著高于T0时,且显著高于A组(P<0.05)。两组在各时点血乳酸含量与术前比较差异均无统计学意义(P>0.05),术毕时A组血乳酸含量明显低于B组(P<0.05)。结论食管癌根治术患者术中GDFT应用低晶胶比例补液方案,有利于维持血流动力学稳定、改善组织灌注,且不增加肺水肿的风险。

Objective To investigate the effects of goal-directed fluid therapy （GDFT） with different crystalloid-colloid ratios on extravascular lung water index and blood lactic acid in esophageal cancer patients undergoing esophagectomy. Methods A total of 50 esophageal cancer patients would undergo esophagectomy, and were randomly divided into low colloid radio group （ group A, n = 25 ） and high colloid radio group （ group B, n = 25 ） based on crystalloid-colloid ratio （3： 1 ） as the boundary line. All patients were given the one-lung mechanical ventilation and same surgical procedure during the surgery. The intraoperative fluid therapy was to maintain intrathoracic blood volume index （ITBVI） within the normal range. The heart rate （HR）, mean artery pressure （MAP）, cardiac index （CI）, extravascular lung water index （EVLWI） and ITBVI were recorded using pulse indicator continuous cardiac output （PiCCO） monitor before the operation （T0 ）, 5 min after intubation （T1 ）, 15 min after both lungs ventilation （ T2 ）, 15 min after one-lung ventilation （T3 ）, 15 min after pulmonary reexpansion of both lungs ventilation （T4 ） and at the end of operation （T5 ）. Contents of blood lactic acid of all patients were measured before the operation, at the end of operation and 6 h after the operation.The usages of glucocorticoids, vasoactive drugs and Furosemide, the total volume of fluid, the volume of blood loss, urinary volume and the operation time were also recorded. Results There was no intraoperative use of glucocorticoid in the two groups. There were 1 patient with Furosemide and 1 with Phenylephrine in group A, and 2 patients with Phenylephrine in group B during the operation. A total of 46 cases were included in the statistical analysis, which included 23 cases in group A and 23 cases in group B. The intraoperative GDFT administration in the two groups could maintain stable hemodynamics. Compared with those at To , MAP and CI values in the two groups were significant decreased at T1 （P 〈 0.05 ） ; CI value at T5 was significantly higher in group A （ P 〈 0.05 ） , and the value was significantly higher than that in group B （ P 〈 0. 05 ）. EVLWI value at T5 in group B was significantly higher than that at TO in the same group and at the same time point in group A （P 〈 0. 05）. Compared with those before the operation, there were no significant differences between the two groups in contents of blood lactic acid at each time point （ P 〉 0.05 ）. Content of blood lactic acid in group A was significantly lower than that in group B at the end of operation （ P 〈 0.05 ）. Conclusion GDFT with low crystal-colloid ratio can not only maintain intraoperative stable hemodynamics and improve tissue perfusion without increasing the risk of pulmonary edema in esophageal cancer patients undergoing esophagectomy.