基于每搏量变异的容量管理策略在梗阻性黄疸患者手术麻醉管理中的应用

Stroke volume variation-based volume management in anesthesia management in surgeries for malignant obstructive jaundice: a randomized controlled trial

目的探讨基于每搏量变异(stroke volume variance,SVV)为导向的容量管理策略对梗阻性黄疸患者围术期麻醉管理临床应用价值。方法纳入2015年11月至2017年3月我院肝胆外科接受手术治疗的恶性梗阻性黄疸患者50例,其中男性41例,女性9例,年龄(53.3±8.5)岁,体质量(59.8±9.0)kg,随机分为对照组和SVV组(n=25)。两组患者采用相同的麻醉诱导与维持方式。对照组根据有创血压、中心静脉压(central venous pressure,CVP)和麻醉医师的经验进行液体输注和血管活性药物使用;SVV组根据FloTrac/Vigileo分析得到的SVV值指导液体输注和血管药物的使用,维持SVV在13%以下。对比分析两组患者术中血流动力学指标、血气分析指标、术中液体及血管活性药物的使用情况、术后肾脏功能、PACU及ICU停留时间。结果 SVV组患者术中血压稳定,手术结束时乳酸水平无明显增高[(2.48±0.26)mmol/L vs(1.48±0.89)mmol/L,P<0.05];氧合指数显著高于对照组,氧合异常发生率显著低于对照组(20%vs 52%,P<0.05);术中晶体液的使用量显著少于对照组[(1 150±235)mL vs(1 981±808)mL,P<0.01],去甲肾上腺素的使用率高于对照组(72%vs 44%,P<0.05),多巴酚丁胺的使用率高于对照组(n=25,36%vs 8%,P<0.05),ICU停留时间显著低于对照组[(1.18±0.63)d vs(3.38±1.36)d,P<0.01],肾功能异常发生率组间比较差异无统计学意义(P>0.05)。结论 SVV的容量管理策略能优化梗阻性黄疸患者术中循环状态,减少容量过负荷和血管活性药物滥用的潜在危害,改善微循环灌注,降低呼吸系统并发症的发生率及ICU停留时间。

Objective To evaluate the clinical effectiveness of stroke volume variation（SVV）-based strategy of volume management in patients undergoing surgeries for malignant obstructive jaundice. Methods Fifty patients with malignant obstructive jaundice（including 41 male and 9 female patients,mean age 53. 3 ± 8. 5 years,mean body mass 59. 8 ± 9. 0 kg） undergoing surgeries in our hospital between November,2015 and March,2017 were enrolled in this trial. A computer-generated randomization sequence（at a 1 ∶ 1 ratio） was used to randomly assign patients into control group and SVV group（n = 25）. All the patients received induction and maintenance anesthesia following the same protocols. The patients in the control group were given perioperative fluid replacement and vasoactive drugs according to the invasive artery pressure,central venous pressure（CVP） and the experience of anesthesiologists. In SVV group,a target SVV below13% was maintained and the fluid volume and use of vasoactive drugs were adjusted according to the perioperative SVV value. The intraoperative hemodynamic indexes,blood gas analysis indexes,intraoperative fluid volume,dose of vasoactive drugs used,postoperative renal function,PACU and ICU stay time were compared between the 2 groups. Results Compared with those in the control group,the patients in SVV group showed a more stable intraoperative blood pressure without significantly increased lactic acid level at the end of the operation（2. 48 ± 0. 26 vs 1. 48 ± 0. 89 mmol/L,P〈0. 05）. The PaO2/FiO2 ratio was significantly higher in SVV group,and the incidence of oxygenation abnormalities was significantly lower in SVV group than in the control group（20% vs 52%,P〈0. 05）. Compared with the control group,the SVV group had a significantly less intraoperative fluid volume（1 981 ± 808 vs 1 150 ± 235 mL,P〈0. 05） and higher rates of norepinephrine use（44% vs 72%,P〈0. 05） and dobutamine use（n = 25,8% vs 36%,P〈0. 05）. The duration of ICU stay was significantly shorter in SVV group than in the control group（1. 18 ± 0. 63 vs 3. 38 ±1. 36 d,P〈0. 01）. The incidence of renal dysfunction was not significantly different between the 2 groups（P〉0. 05）. Conclusion In patients undergoing surgeries for malignant obstructive jaundice,SVV-based fluid management can optimize the hemodynamic status and thus helps to reduce the incidence of respiratory and renal dysfunction and shorten the duration of ICU stay to improve the patients＇ prognosis.