每搏量变异度指导容量管理在肺叶切除术中的应用

Application of stroke volume variation directed fluid therapy in patients under one-lung ventilation

目的:探讨不同水平每搏量变异度(SVV)指导容量管理,对肺叶切除术单肺通气时血流动力学的影响。方法:选取全麻下胸腔镜行肺叶切除的冠心病患者60例,其中男性38例,女性22例,年龄55~82岁,ASAⅡ或III级。患者入室后进行全身麻醉并行单肺通气,术中用FloTrac/Vigileo系统行SVV监测,用乳酸林格液持续输注、通过羟乙基淀粉(130/0.4)调整SVV。术中根据SVV管理目标值随机将患者分为三组:高水平组(12%≤SVV≤13%,H组)、中水平组(10%≤SVV≤11%,M组)、低水平组(8%≤SVV≤9%,L组),并按相应分组实施不同的补液方案。记录患者术中液体出入量、血管活性药物使用情况;分别于侧卧位单肺通气时(T2)、平卧位双肺通气时(T3)记录患者心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、每搏输出量(SV)。结果:在手术期间,H组同其他组相比,液体输入量、尿量较少,差异有统计学意义(P=0.001、0.040);其他一般情况各组间,差异无统计学意义(P<0.05)。在T3,同T2相比,H组的心率、平均动脉压变化较大,差异有统计学意义(P=0.016、0.004),M组、H组的中心静脉压变化较大,差异有统计学意义(P=0.002、0.000),L组、M组的每搏量变化较大,差异有统计学意义(P=0.006、0.039)。各组间动脉血氧分压、动脉血二氧化碳分压、肺顺应性、气道峰压在不同时刻的差异无统计学意义(P>0.05)。在手术期间,同H组相比,L组的多巴胺、去甲肾上腺素用量较低,差异有统计学意义(P=0.01、0.001),其他血管活性药用量差异无统计学意义。结论:肺叶切除术的患者在单肺通气期间设置SVV于8%≤SVV≤9%行容量管理,有利于维护患者术中血流动力学稳定。

Objective: To investigate different levels of stroke volume variation directed fluid therapy in patients under one-lung ventilation. Methods: 60 patients undergoing thoracoscopic lobectomy under general anesthesia(male 38 cases, female 22 cases, aged 55-82 years, ASA grade Ⅱ or III) were randomized into three groups according to the different level of SVV directed fluid therapy. High level group(12%≤SVV≤13%)(group H), middle level group(10%≤SVV≤11%)(group M), and low level group(8%≤SVV≤9%)(group L). After general anesthesia induction, one-lung ventilation was set up, FloTrac/Vigileo was used to monitor SVV, Lactated Ringer’s solution was used to maintain physiological requirement, and Hydroxyethyl Starch was used to adjust SVV. Perioperative intake and outtake volume, vasoactive agents usage was recorded. Heart rate(HR), mean arterial pressure(MAP), central venous pressure(CVP), and stroke volume(SV) were recorded both during one-lung ventilation(T2) in lateral position, and two-lung ventilation(T3) in supine position. Results: During operation, compared with other group, H group has less intake volume and urine volume, and the difference was statistically significant.(P=0.001, 0.040)There is no statistical significant difference in other conditions compared in these group(P<0.05). Compared with T2, there is a larger variation of HR and MAP during T3 in H group, which has statistically significance(P=0.016, 0.004). There is a larger variation of CVP during T3 in M and H group, which has statistically significance(P=0.002, 0.000). There is a larger variation of SV during T3 in L and M group, which has statistically significance(P=0.006, 0.039). There is no significant difference in arterial partial pressure of O2 and CO2, lung compliance, and airway peak pressure during different period(P>0.05). During operation, compared with group H, there is less dopamine and noreadrenaline usage in group L, which has statistically significance(P=0.01, 0.001). There is no statistically significance in other vasoactive drug usage. Conclusions: Applying 8%≤SVV≤9% directed fluid therapy under one-lung ventilation might help to maintain hemodynamic stability in patients.