下腔静脉内径及变异度指导冠状动脉旁路移植术后患者液体管理的临床研究

Clinical study on inferior vena cava diameter and variability guiding patients＆#39; fluid administration after coronary artery bypass grafting

目的 探讨超声测量下腔静脉内径及变异度指导冠状动脉旁路移植术后患者液体管理的可行性.方法 选择2015年11月至2016年7月105例患者,所有患者入住ICU后进行急性生理和慢性健康评分（APACHE Ⅱ）,测定血乳酸、中心静脉血氧饱和度（ScvO2）.将研究患者随机分为对照组和研究组,对照组以中心静脉压（CVP）指导液体管理,研究组采用超声测量下腔静脉内径及其变异度＋CVP指导液体管理.观察两组在入ICU 4、8、12、24 h各时点CVP、平均动脉压（MAP）、氧合指数、ScvO2、乳酸情况;记录两组24 h液体平衡量和正平衡例数,比较两组患者机械通气时间、ICU滞留时间、住院时间及病死率.结果 两组患者年龄、性别、体质量指数、APACHE Ⅱ评分、血流动力学指标、血乳酸、ScvO2等一般情况比较差异未见统计学意义（P＞0.05）;研究组在4、8、12、24 h时点MAP、氧合指数、ScvO2水平明显高于对照组,CVP、乳酸低于对照组,差异有统计学意义（P＜0.05）;研究组24 h液体平衡量和正平衡例数、机械通气时间、ICU滞留时间、住院时间明显降低,差异有统计学意义（P＜0.05）;两组病死率比较差异未见统计学意义（P＞0.05）.结论 超声测量下腔静脉内径及变异度结合CVP指导冠状动脉旁路移植术后患者液体管理,可较准确判断患者的容量状态和容量反应性,改善血流动力学及灌注指标,有较好的临床价值.

Objective To investigate the feasibility of inferior vena cava diameter and variability detected by ultrasonic measurement on guiding patients＇ fluid administration after coronary artery bypass grafting.Methods One hundred and five patients from November 2015 to July 2016 were selected, all the patients were scored by acute physiology and chronic health evaluation （APACHE Ⅱ）, and blood lactic acid and ScvO2 were tested. Further, the patients were divided into control group and experiment group. The fluid administration of control group was guided by CVP, and that of experiment group was guided by inferior vena cava diameter and variability＋CVP using ultrasonic measurement. The indexes such as CVP, MAP, oxygenation index, ScvO2 and lactic acid at 4, 8, 12 and 24 h in ICU were observed. Furthermore, the case number of fluid equilibrium amount and positive equilibrium at 24 h was recorded, and the mechanical ventilation time, ICU residence time, hospital stays length and fatality were compared between the two groups.Results There were no significant differences in general conditions between the two groups, such as age, gender, body mass index, APACHE Ⅱ score, hemodynamic index, blood lactic acid, ScvO2, etc （P〉0.05）. However, CVP, MAP, oxygenation index and ScvO2 level in experiment group at 4, 8, 12 and 24 h were significantly higher than those in control group （P〈0.05）, but lactic acid was significantly lower （P〈0.05）. The case number of fluid equilibrium amount and positive equilibrium at 24 h, mechanical ventilation time, ICU residence time, hospital stays length and fatality in experiment group were significantly lower than those in control group （P〈0.05）.Conclusions Inferior vena cava diameter and variability detected by ultrasonic measurement combined with CVP guiding patients＇ fluid administration after coronary artery bypass grafting can relatively accurately judge the patients＇ volume status and volume responsiveness, improve haemodynamics and perfusion index, which possesses good clinical value and prospects.