目标导向液体治疗在幕上肿瘤切除术中的应用研究

Application of the goal-directed fluid therapy in supratentorial tumor resection

目的探讨以CVP、MAP及局部脑氧饱和度(regional cerebral oxygen saturation, rSO2)作为监测指标的目标导向液体治疗(goal-directed fluid therapy, GDFT)在幕上肿瘤切除术中的指导作用。 方法择期全身麻醉下行幕上肿瘤切除术的患者60例,按随机数字表法分为2组(每组30例):GDFT组(G组)和常规性输液组(C组)。C组按照《米勒麻醉学(第6版)》术中常规补液方案进行输液;G组从建立静脉通道后60 min输入累积缺失量的1/2,之后输液速度为4 ml·kg^-1·h^-1,每15 min测1次CVP,维持CVP在5~7 cmH2O(1 cmH2O=0.098 kPa)、MAP≥65 mmHg(1 mmHg=0.133 kPa)、rSO2 55%~75%、尿量>0.5 ml·kg^-1·h^-1。分别记录两组患者术中晶体液量、胶体液量、总输液量、失血量、尿量和血管活性药物的使用情况,记录麻醉诱导前(T1)、气管插管即刻(T2)、切开硬脑膜时(T3)、切开硬脑膜后1 h(T4)、术毕即刻(T5)的心率、MAP、CVP、rSO2及乳酸(lactic acid, Lac)水平,记录术前(基础状态)和术后24 h的Hb和生化指标,记录术后首次排气时间、住院时间、术后并发症发生情况。 结果与C组比较,G组患者术中晶体液量、胶体液量、总输液量、尿量减少(P<0.05);血管活性药物使用率G组高于C组(P<0.05)。与T1比较,T3~T5时C组CVP升高,两组患者Lac水平均降低,T2~T5时两组患者rSO2均升高,T2时两组MAP均降低(P<0.05)。与C组比较:G组T3~T5时CVP降低,G组术后24 h Hb、血清白蛋白增高,G组术后首次排气时间、住院时间缩短,差异均有统计学意义(P<0.05)。两组患者术后肝功能、肾功能指标与术后并发症发生情况差异无统计学意义(P>0.05)。 结论GDFT在幕上肿瘤切除术中的应用能够维持患者有效循环血容量,维持脑氧供需平衡,改善预后,符合加速康复外科的要求。

Objective To explore the application of the goal-directed fluid therapy (GDFT) in supratentorial tumor resection with central venous pressure(CVP), mean arterial pressure (MAP) and regional cerebral oxygen saturation(rSO2) as monitoring indicators. Methods A total of 60 patients undergoing supratentorial brain tumor resection under general anesthesia were selected and divided into two groups according to the random number table method(n=30): GDFT group(group G) and routine infusion group(group C). Group C was infused according to the routine rehydration protocol in Miller′s Anesthesia, 6 th edition. Meanwhile, group G received half of a cumulative lossfor 60 min after establishment of intravenous channels, with an infusion rate of 4 ml·kg^-1·h^-1, where CVP was measured every 15 min to maintain at 5-7 cmH2O(1 cmH2O=0.098 kPa), MAP≥65 mmHg (1 mmHg=0.133 kPa), rSO2 55%-75%, urine output>0.5 ml·kg^-1·h^-1. The volumes of crystal solution, colloidal solution, total infusion, blood loss, and urine and vasoactive agent doses were recorded. The values of heart rate, MAP, CVP, rSO2 and lactic acid(Lac) were recorded before anesthesia induction (T1), at the moment of intubation (T2), at the moment of opening the dura mater (T3), 1 h after opening the dura mater (T4), and at the end of surgery (T5). The concentration of hemoglobin (Hb) and laboratory parameters were recorded before and 24 h after the surgery. The first exhaust time, hospitalization stay and postoperative complications were recorded. Results Compared with group C, remarkably decreased volumes of infusion and urine and increased use of vasoactive agents were found in group G(P<0.05). Meanwhile, group C demonstrated increased CVP at T3-T5, compared with those at T1. Compared with group C, decreased CVP was found in group G at T3-T5. Both groups presented marked increases in rSO2(within the normal range) and decreases in Lac at T3-T5 (P<0.05). There was no significant difference in heart rate, MAP and rSO2 between the two groupsat each time point(P>0.05). Compared with group C, group G showed remarkable increases in 24 h Hb after surgery and serum albumin, and decreases in exhaust time and hospitalization stay(P<0.05). There was no significant difference in hepatic and renal function indicators and postoperative complications between the two groupsat each time point(P>0.05). Conclusions The application of GDFT in supratentorial tumor resection can maintain effective circulation blood volume, maintain the balance of cerebral oxygen supply and demand, improve prognosis, and meet the requirements of accelerated rehabilitation surgery.