纠正左室射血时间和每搏量指导单肺移植术中容量治疗的效果：经食道超声多普勒监测

Efficacy of corrected left ventricular ejection time and stroke volume in guiding volume therapy during single lung transplantation： transesophageal Doppler monitoring

目的评价采用经食道超声多普勒监测的纠正左室射血时间（LVETc）和每搏量（SV）指导单肺移植术中容量治疗的效果。方法选取行单肺移植术患者26例，年龄32-55岁，BMI 18.0-24.6 kg/m^2，ASA分级Ⅲ或Ⅳ级。采用随机数字表法分为2组（n＝13）：对照组（C组）和LVETc＋SV组（LS组）。置入双腔支气管导管后，LS组置入经食道超声探头监测LVETc和SV；C组经右颈内静脉穿刺置入Swan-Ganz导管监测CVP。C组根据CVP指导术中补液，维持CVP 6-12 cmH2O；LS组根据LVETc和SV指导术中补液，维持LVETc 0.35-0.40 s，SV波动幅度小于补液前水平的10%。分别于单肺通气前5 min（T1）、单肺通气30 min（T2）、肺动脉阻断30 min（T3）、肺动脉开放30 min（T4）及手术结束即刻（T5）时，采取桡动脉血样进行血气分析，记录乳酸水平，计算氧和指数；记录肺动脉阻断前（单肺通气后至肺动脉阻断前）、肺动脉阻断期间和肺动脉开放期间（自开放心房钳至手术结束）的液体出入量；记录术中间羟胺和呋塞米的用量；记录术后咽部黏膜损伤、食管穿孔、出血或局部血肿的发生情况。结果与C组比较，LS组T3-5时氧合指数升高，血乳酸水平降低，肺动脉阻断前和肺动脉阻断期间晶体液和胶体液的用量增加，肺动脉开放期间晶体液和胶体液的用量减少，各时段尿量增加，术中间羟胺用量减少（P〈0.05）。2组患者术后均未见食管穿孔、出血或局部血肿的发生，仅LS组有1例患者术后发生咽部黏膜损伤。结论经食道超声多普勒监测的LVETc和SV用于单肺移植术患者不仅能维持有效的循环血容量和组织灌注，还能维持术中血流动力学相对稳定。

Objective To evaluate the efficacy of corrected left ventricular ejection time （LVETc） and stroke volume （SV） monitored by transesophageal Doppler in guiding volume therapy during single lung transplantation.Methods Twenty-six American Society of Anesthesiologists physical status Ⅲ or Ⅳ patients, aged 32-55 yr, with body mass index of 18.0-24.6 kg/m^2, scheduled for elective single lung transplantation, were divided into 2 groups （n=13 each） using a random number table： control group （group C） and LVETc plus SV group （group LS）. After implanting double lumen endobronchial tube, a transesophageal probe was inserted to monitor LVETc and SV in group LS, and Swan-Ganz catheter was inserted via the right internal jugular vein puncture to monitor CVP in group C. Fluid infusion was given according to CVP, and CVP was maintained at 6-12 cmH2O in group C. In group LS, fluid infusion was given according to LVETc and SV, LVETc was maintained at 0.35-0.40 s, and the fluctuation of SV was less than 10% of the baseline before fluid replacement.At 5 min before one-lung ventilation, 30 min of one-lung ventilation, 30 min of pulmonary artery occlusion and 30 min of pulmonary artery unclamping and at the end of operation, blood samples were collected from the radial artery for blood gas analysis, blood lactate levels were recorded, and oxygenation index was calculated.The liquid intake and output volume was recorded before pulmonary artery occlusion （from the end of one-lung ventilation until the time point before pulmonary artery occlusion）, during pulmonary artery occlusion and during pulmonary artery unclamping （from removal of atrial clamp until the end of operation）. The consumption of intraoperative furosemide and metaraminol was recorded.The development of pharyngeal mucosal membrane injury, esophageal perforation, hemorrhage or local hematoma was recorded after operation.Results Compared with group C, the oxygenation index was significantly increased and blood lactate concentrations were decreased at 30 min of pulmonary artery occlusion, 30 min of pulmonary artery unclamping and at the end of operation, the amount of crystalloid and colloid solution infused was increased before and during pulmonary artery occlusion and reduced during pulmonary artery unclamping, the urine output was increased in each period, and the consumption of intraoperative metaraminol was reduced in group LS （P〈0.05）. No postoperative esophageal perforation, bleeding or local hematoma was found in two groups, and only one patient had pharyngeal mucous membrane injury after operation in group LS. Conclusion LVETc and SV monitored by transesophageal Doppler can not only keep circulation capacity and tissue perfusion effective, but also maintain hemodynamics relatively stable during operation for patients undergoing single lung transplantation.