目标导向液体治疗在快通道老年髋部骨折术中的应用

Application of Goal-Directed Fluid Therapy in Fast Track Hip Fracture in Elderly Patients

目的探讨目标导向液体治疗(GDFT)对快通道老年髋部骨折术的影响。方法选择2016年10月至2017年6月北京积水潭医院收治的120例老年、美国麻醉医师协会分级Ⅱ～Ⅲ级的髋部骨折蛛网膜下腔麻醉下手术患者为研究对象,采用随机数字法分为对照组和观察组,每组60例。对照组根据患者术中心电图、心率、有创动脉血压(IBP)等进行常规液体治疗,观察组在Flo Trac/Vigileo监护仪监测每搏量变化(ΔSV)以及心排血指数(CI)下行GDFT。分别于手术开始前(T0)、蛛网膜下腔阻滞后(T_1)、蛛网膜下腔阻滞5 min(T_2)、手术开始15 min(T_3)、手术30 min(T_4)记录患者的心率、平均动脉压(MAP)变化,观察低血压发生率。记录患者术后并发症[肺部感染、低氧血症、血栓形成和术后3 d认知功能障碍(POCD)]发生率。结果两组患者T_1、T_2、T_3、T_4心率呈下降趋势,MAP呈下降趋势,观察组T_1、T_2、T_3、T_4高于对照组,MAP更平稳,两组心率、MAP在组间、组间和时点间交互作用比较差异有统计学意义(P <0. 01)。观察组术中低血压发生率低于对照组[13. 3%(8/60)比28. 3%(17/60)](P <0. 05),观察组深静脉血栓、术后3 d POCD发生率低于对照组[1. 7%(1/60)比13. 3%(8/60),8. 3%(5/60)比26. 7%(16/60)](P <0. 05)。结论老年髋部骨折患者围术期治疗过程中,以ΔSV及CI为指导的目标导向液体管理可以减少术中低血压发生,降低患者术后深静脉血栓、短期POCD的发生率。

Objective To explore the effect of goal-directed fluid therapy(GDFT)on fast track hip fracture in elderly patients.Methods A total of 120elderly patients with hip fracture under intraspinal anesthesia,American Society of Anesthesiologists gradeⅡ-Ⅲ,admitted in Beijing Jishuitan Hospital between Oct.2016and Jun.2017,were divided into two groups(n=60)according to the random number method:a control group given routine liquid treatment based on the use of electrocardiogram,hear rate(HR),invasive arterial blood pressure(IBP),an observation group given GDFT through the Flotrac/Vigileo monitored stroke volume variation(ΔSV)and cardiac index(CI).The changes of HR and mean arterial pressure(MAP)were recorded at5different time points of before operation(T0),subarachnoid block(T1),subarachnoid block5min(T2),15min after operation start(T3)and30min after operation start(T4),and the incidence of hypotension was recorded.The incidence of postoperative complications[pulmonary infection,hypoxemia,thrombosis and postoperative cognitive dysfunction(POCD)]were recorded.Results The HR of the two groups was decreasing and MAP was decreasing at T1,T2,T3,T4.The MAP of the observation group was higher than that of the control group at T1,T2,T3,and the MAP was more stable.There were significant differences in HR and MAP between groups,and interaction of groups and time points(P<0.01).The incidence of intraoperative hypotension in the observation group was lower than that in the control group[13.3%(8/60)vs28.3%(17/60)](P<0.05),the incidence of deep venous thrombosis,POCD3days after operation in the observation group were lower than those in the control group[1.7%(1/60)vs13.3%(8/60),8.3%(5/60)vs26.7%(16/60)](P<0.05).Conclusion During the perioperative period of the elderly hip fracture,GDFT guided by CI andΔSV can reduce the incidence of intraoperative hypotension,and the incidence of deep venous thrombosis,short-term POCD after operation.