目标导向容量治疗对沙滩椅体位肩关节镜手术老年患者脑组织氧合和术后认知功能的影响

Effect of goal-directed fluid management on cerebral oxygen saturation and postoperative cognitive function in elderly patients undergoing arthroscopic shoulder surgery in beach chair position

目的评价目标导向容量治疗对沙滩椅体位(beach chair position,BCP)肩关节镜手术老年患者脑组织氧合和术后认知功能的影响。方法前瞻性地选择60例在全身麻醉下接受BCP肩关节镜手术的患者,年龄60~75岁,ASA分级Ⅰ或Ⅱ级,随机分入常规容量治疗组(对照组)和目标导向容量治疗组(治疗组),每组30例。使用FloTrac/Vigileo系统监测患者平均动脉压(MAP)、每搏变异度(SVV)、心脏指数(CI)。对照组采用静脉滴注羟乙基淀粉(130/0.4)(10mL/kg)常规容量治疗;治疗组根据SVV和CI进行目标导向容量治疗。记录麻醉诱导前(T0)、诱导后3 min(T1)、BCP时(T2)、BCP后5 min(T3)、BCP后30 min(T4)、手术结束平卧位(T5)时患者的MAP、SVV、CI,以及术中晶体液、胶体液用量,脑氧饱和度(rSO2)。记录术前、术后1 h和24 h的简易智能精神状态检查量表(MMSE)评分。结果与T1时间点相比,两组患者在T2至T4时间点的MAP、CI均显著降低(P值均<0.05)。在T3、T4时间点,治疗组患者MAP[(79.8±2.6)和(82.3±2.3)mmHg,1 mmHg=0.133 kPa]、CI[(2.9±0.5)和(2.9±0.4)L/(min·m2)]、rSO2[(67.8±1.8)%和(68.5±2.2)%]均显著高于对照组[分别为(76.1±3.5)和(75.8±3.8)mmHg、(2.5±0.6)和(2.5±0.6)L/(min·m2)、(62.2±2.0)%和(63.4±1.8)%],SVV显著低于对照组[(10±2)%比(15±3)%、(10±2)%比(15±4)%],差异均有统计学意义(P值均<0.01)。与对照组相比,治疗组患者术中胶体液使用量和总补液量均显著增加(P<0.01、0.05);而两组间患者术中晶体液使用量的差异无统计学意义(P>0.05)。治疗组患者术后1 h和24 h的MMSE评分为(23.0±2.0)和(26.9±1.9)分,分别显著高于对照组同时间点的(20.0±2.3)和(24.0±2.2)分(P值均<0.01)。结论目标导向容量治疗能减少老年患者肩关节镜手术中BCP引起的血流动力学波动,改善脑组织氧合,减少术后24 h内认知功能障碍的发生。

Objective To evaluate the effect of goal-directed fluid management on cerebral oxygen saturation and postoperative cognitive function in patients undergoing arthroscopic shoulder surgery in the beach chair position(BCP).Methods Sixty patients,aged from 60 to 75 years,American Society of Anesthesiologist(ASA)physical status I or II,scheduled for arthroscopic shoulder surgery in the BCP under general anesthesia,were randomly divided into control group and goal-directed fluid treatment group(n=30).Patients of both groups received hemodynamic monitoring of the FloTrac/Vigileo system,such as the mean arterial pressure(MAP),stroke volume variation(SVV),and cardiac index(CI).Hydroxyethyl starch(130/0.4)(10 mL/kg)was intravenously dropped in 30 min after anesthesia induction in the control group.The patients in the treatment group received goal-directed fluid management according to SVV/CI results offered by FloTrac/Vigileo system.MAP,SVV and CI as well as regional saturation of oxygen(rSO2)were recorded before induction(T0),3 min after induction(T1),at the beginning of BCP(T2),5 min after BCP(T3),30 min after BCP(T4),and at the end of the surgery(T5).The total consumption of crystalloid and colloid fluid during the surgeries were caculated.Mini-mental state examination(MMSE)was performed before operation,1 h and 24 h after operation.Results The MAP and CI at T2-T4 were significantly lower than those at T1 in both groups(all P<0.05).At T3 and T4,patients in the treatment group had significantly higher MAP([79.8±2.6]mmHg,[82.3±2.3]mmHg),CI([2.9±0.5]L/(mi·m2),[2.9±0.4]L/(min·m2)),and rSO2(67.8%±1.8%,68.5%±2.2%),and lower SVV(both 10%±2%)than patients in the control group([76.1±3.5]mmHg,[75.8±3.8]mmHg;both[2.5±0.6]L/(min·m2);62.2%±2.0%,63.4%±1.8%;15%±3%,15%±4%,all P<0.01).The amounts of colloid fluid and total fluid during the surgery in treatment group were significantly increased compared to control group(P<0.01,0.05),while there was no statistical difference in the use of crystalloid fluid between the two groups(P>0.05).The MMSE scores at 1 h and 24 h postoperatively in the treatment group were 23.0±2.0 and 26.9±1.9,which were significantly higher than those in the control group(20.0±2.3 and 24.0±2.2,both P<0.01).Conclusion The goal-directed fluid management according to FloTrac/Vigileo system can decrease the hemodynamic instability and improve the cerebral tissue oxygenation of elderly patients during arthroscopic shoulder surgery in the BCP,which can reduce the incidence of cognitive dysfunction in 24 h after surgery.