目标导向容量治疗对冠状动脉旁路移植术患者全身炎性反应和早期预后的影响

Effects of goal-directed therapy on systemic inflammatory response and early outcomes in patients undergoing coronary artery bypass grafting

目的探讨围术期目标导向容量治疗（goal—directed therapy，GDT）对体外循环（cardiopulmonary bypass，CPB）下冠状动脉旁路移植术（coronary artery bypass grafting，CABG）患者全身炎性反应和早期预后的影响。方法择期行体外循环下CABG的患者60例，随机分为G、C两组，每组各30例。G组患者在脉搏指数连续心排血量（pulse—indicated continuous cardiac output，PICCO）监测指导下行GDT；C组患者根据平均动脉压（MAP）、中心静脉压（CVP）、心率（HR）、尿量等指标进行液体治疗。分别于麻醉诱导前（T0）、转流结束时（T1）、术毕（T2）、术后6小时（T3）、24小时（T4）等5个时间点采取动脉血，测定白细胞介素（IL）石、肿瘤坏死因子（TNF）-α及Toll受体4（TLR4）的浓度，并行血气分析监测Lac及氧合指数（OI）值。结果与T0比较，T1～T3时两组患者IL-6、TNF-α、TLR4以及血乳酸（Lac）的浓度均明显升高，OI值明显降低（P〈0．05）；T1～T3时G组IL-6、TNF-α、TLR4以及Lac的浓度均明显小于C组，而OI明显大于C组（P〈0．05）；G组患者气管导管留置时间、ICU停留时间和术后总住院时间均明显短于C组（P〈0．05）。结论GDT可减轻体外循环下CABG患者围术期的全身炎性反应，有利于改善患者的早期预后。

Objective To explore the effects of goal-directed therapy（GDT） on systemic inflammatory response and early outcomes in patients undergoing coronary artery bypass grafting （CABG） with cardiopulmonary bypass（CPB）. Methods Sixty patients undergoing CABG with CPB were randomly divided into 2 groups（ n = 30 each） ：group G and group C. Patients in group G received GDT guided by PICCO during operation, and those in group C received conventional fluid therapy according to MAP, CVP, HR and urine volume. Artery blood samples were obtained to detect the concentration of interleukin-6 （ IL-6）, tumor necrosis factor-α （TNF-α） , toll-like receptor-4 （TLR4） ,lactic acid （Lac）and blood gas analysis monitored for oxygenation index（OI） at the time of before anesthesia induction（ T0 ）, the termination of CPB （ T1 ） , the end of surgery （ T2 ） , 6h （ T3 ） and 24h after operation （ T4 ）. Results Compared with To, the concentrations of IL6,TNF-α,TLR4 and Lac increased, but OI decreased significantly in both groups at T1 -T3 （P 〈 0.05 ）. The concentrations of IL-6, TNF-α ,TLR4 and Lac in group G were lower than those in group C, but OI in group G was higher than that in group C at T1 -T3 （ P 〈 0.05 ）. The duration of intuba- tion,length of ICU stay and hospital stay after operation in group G were shorter than those in group C （P 〈 0.05）. Conclusion The strategy of perioperative GDT could alleviate the systemic inflammatory response and improve the early outcomes in patients undergoing CABG with CPB.