有创心排量监测指导高龄骨科手术患者全麻期间血流动力学管理的临床分析

Clinical Analysis of Hemodynamic Management during General Anesthesia Based on Invasive Cardiac Output Monitoring in the Elderly Undergoing Orthopaedic Surgery

目的利用有创心排血量监测指导高龄骨科手术患者全身麻醉期间的血流动力学管理,以提高麻醉的安全性。方法选择美国麻醉医师协会ASAⅢ级以上,择期行骨科手术的高龄患者100例,年龄85～97岁。随机分成对照组(n=50)和观察组(n=50)。所有患者均行右颈内静脉穿刺,监测中心静脉压(central venous pressure, CVP),麻醉诱导前静脉输注乳酸钠林格氏液(5～7 m L/Kg)。对照组根据CVP和平均动脉压(mean arterial pressure, MAP)行补液治疗,当CVP<5 cm H2O、MAP<65 mm Hg时适当加速补液,至CVP>5 cm H2O、MAP>65 mm Hg时停止补液。观察组麻醉诱导前局麻下行桡动脉穿刺置管术,监测中心排血量(cardiac output, CO)、心脏指数(cardiac index, CI)、每搏量变异率(stroke volume variation, SVV)。当CI<2.5 L/min/m^2、SVV>13%时适当加速补液,同时注射麻黄碱0.2 mg/kg,至SVV<13%时停止补液。分别于入室时、插管前、插管后、切皮时、手术60 min时和缝合时记录2组MAP、HR和CVP。结果与对照组相比,观察组经目标治疗导向液体补液和小剂量升压药后MAP和CVP恢复较快,差异有统计学意义(P<0.05)。观察组插管后,切皮时和手术60 min时MAP及CVP基本接近入室时水平;对照组插管后HR和MAP高于观察组。对照组切皮时HR和MAP低于观察组,血流动力学波动较大(P<0.05)。缝合时2组患者的MAP、HR和CVP基本接近入室时水平。结论高龄患者全身麻醉期间,在有创心排量监测下,通过有效补液和应用升压药,CVP可以很快回升,而HR和血压波动较小,有助于维持高龄患者术中血流动力学稳定。

Objective To evaluate hemodynamic management during general anesthesia based on invasive cardiac output monitoring in the elderly undergoing orthopaedic surgery so to promote the anesthesia safety.Methods 100 elderly,aged from 85 to 97 years,undergoing selective orthopaedic surgery(ASA III and over)were enrolled and randomly divided into 2 groups:control group and observation group,50 in each;all the elderly received right internal jugular vein puncture and their central venous pressures(CVP)were measured;Lactated Ringer’s solution(5~7 mL/Kg)was infused before anesthesia induction;the elderly in control group received fluid infusion according to the results of CVP and mean arterial pressure(MAP),when CVP<5 cmH2O and MAP<65 mmHg,fluid infusion was speeded up until CVP >5 cmH2O and MAP >65 mmHg and then fluid infusion was stopped;the elderly in observation group underwent radial artery catheterization under local anesthesia before anesthesia induction and their center output(CO),cardiac index(CI),stroke volume variation(SVV)were monitored;Ephedrine was injected(0.2 mg/kg)when CI<2.5 L/min/m^2 and SVV >13%,fluid infusion was speeded up and ephedrine(0.2 mg/kg)was injected,fluid infusion was stopped when SVV<13%;MAP,HR and CVP were recorded at the time point of entering operation room,before intubation,after intubation,skin incision,60 minutes after operation start and closure.Results After target-directed fluid infusion and small dose of pressor agents,MAP and CVP of the elderly in observation group recovered faster than those in control group,the difference was of statistical significance(P<0.05);MAP and CVP of the elderly in observation group at the time point of after intubation,skin incision,and 60 minutes after operation start were at the levels close to those at the time point of entering operation room;HR and MAP of the elderly in control group were higher at the time point of after intubation but lower at the time point of skin incision than those in observation group,the hemodynamic fluctuations were greater in control group than in observation group(P<0.05);MAP,HR and CVP of the elderly in both groups at the time point of closure were close to those at the time point of entering operation room.Conclusions Under the monitoring of invasive cardiac output,CVP can recover quickly through effective fluid replacement and application of pressor drugs with slight fluctuations of HR and BP,which is helpful in maintaining hemodynamic stability during general anesthesia in the elderly.