目标导向液体治疗对老年人直肠癌术后肠道功能恢复的影响

Effect of goal-directed fluid therapy on postoperative intestinal function recovery in the aged patients with rectal cancer

目的通过FloTrac/Vigileo监测系统用于目标导向液体治疗(GDFT),观察术中常规补液方案与GDFT方案对老年人直肠癌术后肠道功能恢复的影响。方法选择大同市第三人民医院2018年8月至2019年5月行腹腔镜下直肠癌前侧切除术(Dixon手术)患者60例,采用随机数字表法分为GDFT组(G组,n=30)和对照组(C组,n=30)。C组术中按照常规方案进行液体治疗,术中输入液体总量=生理需要量+累计缺失量+继续损失量+第三间隙丢失量。G组术中液体治疗目标:心脏指数(CI)2.5~4.0 L·min-1·(m2)-1,每搏量变异度(SVV)<13%,平均动脉压(MAP)65~110 mmHg;当CI<2.5 L·min-1·(m2)-1、SVV>13%时,快速输注乳酸钠林格注射液3 mL/kg(输注时间10 min);当CI<2.5 L·min-1·(m2)-1、SVV<13%时,静脉输注多巴酚丁胺使CI≥2.5 L·min-1·(m2)-1;当MAP<65 mmHg、CI≥2.5 L·min-1·(m2)-1时,输注去甲肾上腺素使MAP>65 mmHg;两组持续背景输注乳酸钠林格注射液3 mL·kg-1·h-1;术中等容量输注6%羟乙基淀粉补充失血量。记录术中总液体入量、出血量、尿量、术后住院天数、术后肠道功能恢复情况(术后排气及进食时间)、术后肠道并发症(术后炎性肠梗阻、吻合口瘘、吻合口出血)发生率,分别于诱导前(T0)、手术结束时(T1)、术后2 h(T2)、术后24 h(T3)采集静脉血2 mL,使用酶联免疫试剂盒测定肠型脂肪酸结合蛋白(iFABP)。结果术中液体入量,C组(2051±466)mL,G组(1811±413)mL,两组差异有统计学意义(t=2.111,P=0.039)。G组术后排气时间28.6(23.3,32.1)h、住院天数10.2(9.9,12.1)d,均短于C组的32.6(27.1,40.9)h、11.6(10.7,12.2)d(Z=2.321,P=0.020;Z=2.435,P=0.015)。C组术后并发症发生率为13%(4/30),G组为10%(3/30),差异无统计学意义(P>0.05)。C组患者术后T1、T2时点iFABP均明显高于G组,差异均有统计学意义(t=2.445、3.098,P=0.018、0.003)。结论GDFT可减少术中晶体液输注,促进老年直肠癌患者术后肠道功能早期恢复,减轻围术期肠黏膜缺血性损伤。

Objective To investigate the effect of intraoperative routine fluid therapy and goal-directed fluid therapy(GDFT)by FloTrac/Vigileo monitoring system on the recovery of intestinal function in aged patients with rectal cancer.Methods Sixty ASAⅠ~Ⅲpatients undergoing laparoscopic anterior resection of rectal cancer(Dixon operation),who were treated in the Third People's Hospital of Datong from August 2018 to May 2019 were selected and randomly divided into two groups according to the digital table,with 30 cases in each group.Group C received routine intraoperative fluid administration,and the total rate of fluid=deficit+maintenance administration+loss+third space losses.Group G fluid therapy goal:cardiac index(CI)2.5~4.0 L·min-1·(m2)-1,stroke volume variability(SVV)<13%,mean arterial pressure(MAP)65~110 mmHg;if CI<2.5 L·min-1·(m2)-1,SVV>13%,rapidly infused sodium lactate Ringer's injection 3 mL/kg(within 10 min via an infusion pump);if CI<2.5 L·min-1·(m2)-1,SVV<13%,infused dobutamine;if MAP<65 mmHg,CI≥2.5 L·min-1·(m2)-1,infused norepinephrine.Two groups were continously infused sodium lactate Ringer's injection 3 mL·kg-1·h-1.Equivalent volume 6%hetastarch was infused to supplement the blood loss.During the operation,Hb<80 g/L and red blood cells were transfused when bleeding continued.The total fluid intake,bleeding volume,urine volume,postoperative hospital stay days,postoperative intestinal function recovery(postoperative flatus time and eating time),the incidence of postoperative intestinal complications(postoperative inflammatory bowel obstruction,anastomotic leakage and anastomotic bleeding)were recorded.Intestinal fatty aid binding protein(iFABP)was measured at T0(before the induction),T1(at the end of surgery),T2(2 h after surgery),T3(24 h after surgery)by using ELISA kits.Results The intraoperative fluid intake was(2051±466)mL in group C,and(1811±413)mL in group G,there was statistically significant difference between the two groups(t=2.111,P=0.039).The postoperative exhaust time and hospitalization days in group G were 28.6(23.3,32.1)h and 10.2(9.9,12.1)d,respecticely,which were shorter than those in group C[32.6(27.1,40.9)h and 11.6(10.7,12.2)d](Z=2.321,P=0.020,Z=2.435,P=0.015).The incidence of postoperative complications was 13%(4/30)in group C,and 10%(3/30)in group G,there was no statistically significant difference(P>0.05).The iFABP of group C at T1 and T2 after operation was significantly higher than those of group G(t=2.445,3.098,P=0.018,0.003).Conclusion GDFT can reduce intraoperative crystalloid infusion,promote early intestinal function recovery in elderly patients with rectal cancer,and reduce perioperative intestinal mucosal ischemic injury.