目标导向液体治疗对肝硬化门脉高压症手术患者短期预后的影响

Effects of different levels of stroke volume variation following goal-directed fluid therapy on short terms of prognosis in cirrhotic patients with portal hypertension under general anesthesia

目的观察不同每搏量变异度（stroke volume variation,SVV）水平下的液体治疗方案,对肝硬化门脉高压症脾切断流术患者短期预后产生的影响。方法选取行择期脾切断流术患者作为研究对象,纳入标准：年龄18~65岁,美国麻醉医师协会（ASA）麻醉风险分级Ⅰ~Ⅱ级,男女不限;排除标准：严重心肺肾及血液系统疾病,术中出血大于血容量的20%,容量治疗期间血流动力学不稳定者。将患者随机分为高水平（9%≤SVV≤13%）、中水平（5%≤SVV〈9%）、低水平（1%≤SVV〈5%）3组,在全麻下应用Flow Trac-Vigileo系统提供的动态容量参数SVV进行目标导向液体治疗,并按相应分组实施不同的补液方案。观察各组术中液体出入量、乳酸、术后肝肾功能、胃肠道功能恢复情况、拆线时间、术后住院时间、术后并发症发生率等短期预后指标。结果本研究共纳入99例患者,每组33例。3组患者术中晶体量、胶体量、总入量的差异有统计学意义（P〈0.05）,高水平组的上述指标均显著高于中水平组和低水平组,中水平组的上述指标均显著高于低水平组;3组患者术中出血量、乳酸的差异无统计学意义（P〉0.05）。3组拆线时间总体差异有统计学意义（P〈0.05）,组间比较只有高、中水平组相比差异有统计学意义。3组术后门脉系统血栓、胸腔积液的发生率无明显差异,但中水平组门脉血栓发生率较低。高、中、低水平组分别有8、3、10例发生术后感染,中水平组明显低于其他2组（P〈0.05）。结论中水平（5%≤SVV〈9%）液体治疗方案更适用于肝硬化门脉高压患者术中液体管理,可能有相对快的胃肠功能恢复以及相对更少的并发症发生率,可以作为围术期补液的最佳目标。

Objective To observe the effects of different levels of stroke volume variation（SVV）following goal-directed fluid therapy on short- term prognosis in cirrhotic patients.Methods The patients,18- 65 years old,ASA Ⅰ- Ⅱgrade,undergoing pericardial devascularization surgeries were enrolled in the study.The patients were excluded if they had cardiopulmonary dysfunction,coagulopathy,or renal diseases and developed a condition of blood loss more than20% of blood volume and hemodynamic instability.The patients were randomly divided into three groups：high level group（9% ≤SVV≤13%）,middle level group（5% ≤SVV 9%）and low level group（1% ≤SVV 5%）.SVV provided by Flow Trac-Vigileo system was a goal for fluid therapy after general anesthesia.The fluid intake and output,lactic acid,postoperative liver and renal function,gastrointestinal function recovery time,stitche time,hospital stay,complication and other short-term prognostic factors were observed.Results Ninty-nine patients were included in the study,33 patients in each group.Crystal volume,colloid volume,total fluid intake of each group were statistically significantly different（P〈0.05）.These indicators of the high level group were significantly higher than the other two groups（P〈0.05）,and those of the middle level group were significantly higher than the low level group（P〈0.05）.There were no significant differences in blood loss and lactic acid among the three groups.The stitche time in the three goups was significantly different（P〈0.05）.Difference was statistically significant only between the high and low level group.The incidence of portal vein thrombosis and pleural effusion were not significantly different,but the middle level group had a lower incidence of portal vein thrombosis than the other two groups.There were 8,3 and 10 cases developed of postoperative infection in the high,middle and low group patients respectively.The infection rate in the middle level group was significantly lower than the other two groups（P〈0.05）.Conclusion The middle level（5%≤SVV9%）is more suitable for fluid management in cirrhotic patients with portal hypertension,may have a relatively quick recovery of gastrointestinal function and relatively fewer complications.It is the best regimen for perioperative fluid management.