目标导向液体治疗在胃肠外科ERAS术中容量管理的应用

GDFT on fluid management in patients undergoing laparoscopic colorectal resection with an ERAS program

目的评价在腹腔镜下胃肠道肿瘤手术加速康复外科(ERAS)中应用目标导向液体治疗(GDFT)对术中容量管理的作用。方法选取32例拟在全身麻醉下择期行腹腔镜辅助结直肠肿瘤切除手术成年患者,术中采用GDFT策略通过监测心输出量(CO)、心脏指数(CI)、每搏量(SV)和每搏量变异度(SVV)指导液体治疗,观察术中各时间点气管插管后(T1)、切皮时(T2)、气腹后60 min(T3)、开腹后5 min(T4)、手术结束(T5)时患者平均动脉压(MAP)、心率(HR)、CO、CI、SV和SVV等各项指标变化,记录术中补液量(晶/胶体液)、出血量、尿量及血管活性药物使用情况;术后疼痛、镇静评分;术后患者恢复情况及不良反应发生情况。结果与T1相比,T2~T5时MAP明显升高(P<0.05),T2、T3时CO明显降低,T4、T5时CO明显升高(P<0.05),T3~T5时SV明显升高(P<0.05);与T2相比,T1与T3~T5时HR、CI明显升高(P<0.05);与T3时比较,T1、T2、T4、T5时SVV明显降低(P<0.05),T4、T5时CO、SV明显升高;56%患者术中使用血管活性药物;出血量(81.87±41.48)mL,尿量(294.37±210.33)mL,补液量(1 129.68±227.04)mL;术后住院时间(4.6±2.17)d。结论 ERAS理念下GDFT有助于结、直肠肿瘤根治术术中的容量管理,术后恢复良好。注意气腹及术中的体位对GDFT中参数的影响。

Objective To investigate the effect of goal-directed fluid therapy（ GDFT） on fluid management in patients undergoing laparoscopic colorectal resection with an enhanced recovery after surgery（ ERAS） program. Methods Thirty-two patients undergoing laparoscopic colorectal resection,were received monitor with Vigileo. cardiac output.The hemodynamic parameters including cardiac index（ CI）,stroke volume（ SV） and stroke volume variation（ SVV） were used to guide fluid therapy. The variation of mean arterial pressure（ MAP） 、heart rate（ HR） 、CO、CI、SV and SVV at the different time points including after anesthesia induction（ T1）,beginning of surgery（ T2）,one hour after pneumoperitoneum（ T3）,five minutes after laparotomy（ T4） and the end of the surgery（ T5） were recorded. The total volume of fluid including crystalloid and colloid,blood loss,urine output,requirement for vasoactive agents during operation were recorded. Visual Analogue Scale,Ramsay Sedation Score,recovery and operation-related complications after operation were recorded. Results MAP at time points T2 - T5 were higher than that at T1 time point（ P 〈 0. 05）,CO at T2 and T3 were lower than that at T4 and T5（ P 〈 0. 05）,while SV at T3 - T5 were higher（ P 〈 0. 05）. HR、CI at T1、T3 - T5 was higher than that at T2（ P 〈 0. 05）. SVV at T1、T2、T4、T5 were lower than that at T3（ P 〈 0. 05）,while CO、SV at T4 and T5 were higher（ P 〈 0. 05）. 56% of patients used vasoactive agents during the operations,bleeding volume（ 81. 87 ± 41. 48） mL,urine volume（ 294. 37 ± 210. 33） mL,total volume of fluid infused（ 1 129. 68 ± 227. 04） mL; the length of hospital stay after operation（ 4. 6 ± 2. 17） d.Conclusion GDFT based on ERAS program applied to patients undergoing laparoscopic can significantly promote fluid management and postoperative rehabilitation. Noting the influence of the pneumoperitoneum and patients position on the parameters of GDFT during the operations.