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目标导向血流动力学管理策略对非体外循环冠状动脉搭桥手术患者预后的影响 被引量:17

Effects of goal-directed hemodynamic management therapy on prognosis of patients undergoing off-pump coronary artery bypass surgery
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摘要 目的心脏手术患者液体治疗策略历来存有争论。文中旨在观察目标导向血流动力学管理策略对非体外循环冠状动脉搭桥手术患者预后的影响。方法选取安徽医科大学第一附属医院2016年1-12月择期行非体外循环冠状动脉搭桥术的98例患者纳入研究。以2016年6月20日进行质量改进为截点。质量改进前56例患者纳入对照组、质量改进后42例患者纳入试验组。质量改进措施为采用以每博量变异和心脏指数为目标导向液体治疗输注液体,标准化使用血管活性药物,优化血流动力学。通过电子病历系统采集术中和术后数据,比较两组患者的液体出入量、术后住院天数和并发症、术后苏醒时间、24小时胸腔引流量、6小时内拔管率、ICU驻留时间、术后第1天肌钙蛋白I水平、30天病死率以及半年病死率。结果采用目标导向血流动力学管理后,试验组较对照组液体总入量差异无统计学意义,其中万汶输注量显著增加[(676.79±380.90)mL vs(890.48±222.58)mL]、晶体输注量显著减少[(663.84±224.97)mL vs(430.24±201.76)mL]、尿量显著增加[(516.07±224.87)mL vs(695.24±311.53)mL],液体正平衡显著减少[(683.82±556.08)mL vs(456.43±505.36)mL],差异均有统计学意义(P<0.05);自体血回输、红细胞输注比例、出血量两组间差异无统计学意义(P>0.05)。两组术后苏醒时间、24小时胸腔引流量、6小时内拔管率、术后第1天肌钙蛋白I水平、ICU驻留时间无统计学差异(P>0.05)。两组术后住院天数试验组较对照组显著减少(11.81 d vs 13.82 d,P<0.05)。对其对数转换后进行多元线性回归分析,得出质量改进措施的标准化系数B为-0.296(SE=0.061,P<0.05),说明其他条件相同时,采用目标导向血流动力学管理能减少术后住院天数19.4%(95%CI 7.3%~31.5%)。术后并发症从41.07%下降至16.67%,差异有统计学意义(P<0.05)。结论非体外循环冠状动脉搭桥术中采用目标导向血流动力学管理策略可有效降低术后并发症、减少术后住院天数,改善患者短期预后。 Objective Fluid therapy strategy on cardiac surgical patients has always been disputing. The aim of the present study was to observe the effects of goal-directed hemodynamic management strategy on the prognosis of patients undergoing off-pump coronary artery bypass graft. Methods The study was a prospective quality improvement study. Patients who underwent elective offpump coronary artery bypass grafting in our hospital from January to December 2016 were included in the study,and the implementation of improvement approach was started on June 20,2016. A total number of 98 patients were included:56 cases before the improvement (control group)and 42 cases after the improvement(experimental group). The approach of optimizing hemodynamic was standardized vasoactive usage based on the goal-directed fluid therapy taking SVV(Stroke Volume Variation)and CI(Cardiac Index)as the target. Intraoperative and postoperative data were collected through the medical record system. Comparison was done between two groups in the aspects of liquid intake and output,length of postoperative stay in hospital and complications,postoperative awaken time,volume of thoracic drainage in 24h,extubation rate in 6h,time of ICU stay,concentration of Troponin I on the first day after surgery,mortality rate within 30 days and 6 months. Results There was no statistically difference in total fluid intake after the improvement,while the volume of voluven(676.79± 380.90 mL vs 890.48 ±222.58mL,P < 0.05)and urine volume(516.07±224.87 mL vs 695.24± 311.53mL,P < 0.05)increased significantly,the volume of crystal decreased significantly(663.84 ±224.97mL vs 430.24 ±201.76mL, P < 0.001). The positive liquid balance of intake and output volume was significantly reduced(683.82 ± 556.08ml vs 456.43 ± 505.36ml,P < 0.05). There were no significant differences in proportion of autologous blood or erythrocyte transfusion and volume of blood loss between the two groups(P > 0.05). There were no significant differences between the two groups in postoperative awaken time,volume of thoracic drainage within 24h,extubation rate within 6,concentration of Troponin I on the first day after surgery and ICU stay(P > 0.05). After the improvement,the length of postoperative stay in hospital was reduced compared with the control group (11.81 vs 13.82,P < 0.05). Multiple linear regression analysis was performed after the logarithmic transformation,and the standardized coefficient B of the improvement was -0.296(SE=0.061,P < 0.05),indicating that the goal-directed hemodynamic management would reduce the length of postoperative stay in hospital by 19.4 %( 95%CI 7.3%~31.5%)with other conditions being equal. Postoperative complications decreased from 41.07% to 16.67 %( P < 0.05). Conclusion The implementation of goal-directed hemodynamic management strategy can reduce postoperative complications,postoperative hospital stay and improve short-term prognosis of patients undergoing off-pump coronary artery bypass surgery.
作者 曹袁媛 吴昊 张雷 程新琦 赵庆 刘学胜 顾尔伟 CAO Yuan-yuan;WU Hao;ZHANG Lei;CHENG Xin-qi;ZHAO Qing;LIU Xue-sheng;GU Er-wei(Department of Anesthesiology,the First Affiliated Hospital of Anhui Medical University,Hefei 230022,Anhui,China)
出处 《医学研究生学报》 CAS 北大核心 2019年第5期518-522,共5页 Journal of Medical Postgraduates
基金 安徽高校省级自然科学研究项目(KJ2012Z144)
关键词 目标导向血流动力学管理 非体外循环冠状动脉搭桥术 手术后并发症 goal-directed hemodynamic management off-pump coronary artery bypass grafting postoperative complications
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