无创经食道多普勒超声引导目标导向液体治疗在老年全髋置换术中的应用

Application of noninvasive transesophageal Doppler echocardiography guided fluid therapy in elderly patients undergoing total hip arthroplasty

目的：用氧动力学参数评价无创经食道多普勒超声引导下的目标导向液体治疗对老年患者术中组织灌注的改善程度,评价液体治疗的有效性和对术后恢复及认知功能的影响。方法：选择40例年龄65~85岁行全髋置换术的患者,随机分为常规补液组（C组）和目标导向液体治疗组（G组）各20例,抽取麻醉前（T0）、切皮前（T1）、手术开始后1h（T2）、手术结束时（T3）的动静脉血气,计算中心静脉氧饱和度（ScvO_2）、中心静脉-动脉二氧化碳分压差（Pcv-aCO_2）和氧摄取率（OER）,并记录术中总液体量,胶体量,麻黄素的用量,拔管时间,恢复室时间和术后24h MMSE评分。结果：①2组患者T0时Pcv-aCO_2〉6mmHg（1mmHg=0.133kPa）,ScvO_2〈65%,OER〉33%,组间差异无统计学意义。T1时,2组Pcv-aCO_2和OER显著降低,ScvO_2显著增高（P〈0.05）,G组较C组变化幅度稍大,但组间差异无统计学意义。T2时,C组较T1时Pcv-aCO_2和OER显著升高,ScvO_2显著下降（P〈0.05）,G组虽然有相同的变化趋势,但Pcv-aCO_2和OER均低于C组,ScvO_2稍高于C组,仅Pcv-aCO_2有组间差异。T3时,2组均与T2时变化不大,组间差异无统计学意义。②2组输入液体总量无差异,但G组胶体用量明显增加,麻黄素用量减少,差异均有统计学意义（P〈0.05）。G组术后拔管时间,恢复室时间较短于C组,但不明显。术后MMSE评分降低≥3分者为早期术后认知功能障碍（POCD）的患者,G组少于C组,差异有统计学意义（P〈0.05）。结论：老年患者全髋手术前都有明显的容量不足和组织低灌注,无创经食道超声指导的GDFT能改善组织灌注,增加机体对创伤和出血的缓冲能力,有利于促进术后恢复和减少术后POCD的发生,但以Pcv-aCO_2为主的氧代谢指标监测仍发现组织灌注不足,导向指标应有更严格的阈值。

Objective：This study was conducted to evaluate the effect of fluid therapy on the improvement of tissue perfusion and prognosis in elderly patients undergoing total hip arthroplasty（THA）after goal-directed fluid therapy（GDFT）guided by noninvasive transesophageal doppler echocardiography（TEE）.Method：Forty patients aged 65~85years old undergoing THA were randomized divided into two groups,group of conventional fluid therapy（C）and group of goal-directed fluid therapy（GDFT）.Analysis arterial and central venous blood gas separately before anesthesia（TO）,before skin incision（T1）,after 60minutes（T2）and at the end of surgery（T3）.Calculate central venous oxygen saturation（ScvO_2）,central venous-arterial carbon dioxide difference（Pcv-aCO_2）and oxygen extraction ratio（OER）.Record the total volume of liquid,volume of colloid,the dosage of ephedrine,extubation time,recovery room time and MMSE score 24 hours after operation.Result：① When TO,two groups of patients with Pcv-aCO_2〉6mmHg,ScvO_2〈65%,OER〉33%,no significant difference between groups.When T1,Pcv-aCO_2 and OER of two groups significantly decreased,ScvO_2 significantly increased（P〈0.05）,group G changed slightly than group C,but there was no difference between the groups.When T2,in group C,Pcv-aCO_2 and OER significantly increased,ScvO_2 significantly decreased（P〈0.05）.Although group G had the same change trend,only Pcv-aCO_2 had differences between groups（P〈0.05）.When T3,three was no significant change in the data of two groups compared with T2,and no difference between the groups.②There is no difference between total volume of liquid,but colloid volume of group G increased,the dosage of ephedrine was significantly reduced（P〈0.05）.Extubation time and recovery room time of group G is shorter than that of group C,but not obviously.The incidence of POCD in group G was lower than in group C,there were statistically significant differences（P〈0.05）.Conclusion：Elderly patients have obvious hypovolemia and tissue hypoperfusion before THA.Noninvasive transesophageal echocardiography guided GDFT can improve tissue perfusion,increase buffering capacity to trauma and bleeding,promote postoperative recovery and reduce the incidence of POCD after operation.However,tissue perfusion is still found insufficient by Pcv-aCO_2 monitoring,and the guidance index should have a more strict threshold.