基于rSO2-BIS-目标导向血流动力学多模式监测的麻醉管理对心脏瓣膜置换术后急性肾损伤的影响

Effect of anesthesia management based on rSO2-BIS-goal-directed hemodynamic multi-modal monitoring on acute kidney injury after cardiac valve replacement

目的评价基于局部脑氧饱和度(rSO2)-脑电双频谱指数(BIS)-目标导向血流动力学多模式监测的麻醉管理对心脏瓣膜置换术后急性肾损伤(AKI)的影响。方法择期心脏瓣膜置换术患者238例,年龄18~75岁,体重45~95 kg,ASA分级Ⅲ或Ⅳ级,心功能分级Ⅱ或Ⅲ,采用随机数字表法分为2组:常规经验组(C组,n=122)和多模式监测组(M组,n=116)。C组监测桡动脉有创血压、CVP、ECG、SpO2、PETCO2;M组在C组监测基础上监测rSO2、BIS、每搏变异度(SVV)、心脏指数(CI)和每搏量指数(SVI)。M组BIS值达50左右时行气管插管,术中维持BIS值45~55,rSO2不低于基础值的20%或绝对值不低于55%,MAP波动幅度不超过基础值的20%,维持SVI>25 ml/m^2、CI>2.5 L·min^-1·m^-2,特殊情况下不低于诱导前基础值。记录术中液体用量、异体血用量、异丙酚用量、CPB时间、主动脉阻断时间、麻醉时间、手术时间、术后48 h内AKI的发生情况、肾替代治疗情况、气管拔管时间、ICU驻留时间、术后住院时间、其它术后严重并发症的发生情况及术后30 d病死率。结果与C组比较,M组AKI发生率降低,血浆用量和异丙酚用量减少,气管拔管时间、ICU驻留时间和术后住院时间缩短(P<0.05),肾替代治疗率、AKI程度构成比、其它术后严重并发症发生率、术后30 d病死率差异无统计学意义(P>0.05)。结论基于rSO2-BIS-目标导向血流动力学多模式监测的麻醉管理可降低心脏瓣膜置换术后AKI的发生。

Objective To evaluate the effect of anesthesia management based on regional cerebral oxygen saturation(rSO2)-bispectral index(BIS)-goal-directed hemodynamic multi-modal monitoring on acute kidney injury(AKI)after cardiac valve replacement.Methods A total of 238 patients of both sexes,aged 18-75 yr,weighing 45-95 kg,of American Society of Anesthesiologists physical statusⅢorⅣ(New York Heart Association classⅡorⅢ),undergoing elective cardiac valve replacement,were assigned into routine experience group(group C,n=122)and multi-mode monitoring group(group M,n=116)using a random number table method.After admission to the operating room,the invasive blood pressure of radial artery,central venous pressure,electrocardiogram,SpO2 and end-tidal pressure of carbon dioxide were recorded in group C,and rSO2,BIS,stroke volume variation,cardiac index and stroke volume index were monitored based on the monitoring in group C.The patients were tracheally intubated when BIS value was about 50.BIS value was maintained between 45 and 55,rSO2 was maintained not less than 20%of the baseline value or the absolute value not less than 55%,and fluctuation in mean arterial pressure did not exceed 20%of the baseline value,and stroke volume index was maintained>25 ml/m^2 and cardiac index>2.5 L·min^-1·m^-2,maintaining not lower than the baseline value before induction in special conditions.The intraoperative volume of fluid infused,infusion of allogeneic blood,consumption of propofol,time of cardiopulmonary bypass,aortic cross-clamping time,anesthesia time,operation time,occurrence of AKI within 48 h after operation,renal replacement therapy,extubation time,duration of intensive care unit stay,postoperative length of hospital stay,development of other serious postoperative complications and fatality rate at day 30 after operation were recorded.Results Compared with group C,the incidence of AKI was significantly decreased,the volume of plasma infused and consumption of propofol were reduced,the extubation time,duration of intensive care unit stay and postoperative length of hospital stay were shortened(P<0.05),and no significant change was found in the rate of renal replacement therapy,constituent ratio of AKI degree,incidence of other serious postoperative complications or mortality rate at day 30 after operation in group M(P>0.05).Conclusion Anesthesia management based on rSO2-BIS-goal-directed hemodynamic multi-modal monitoring can decrease the occurrence of AKI after cardiac valve replacement.