以每搏变异率为指导的目标导向液体治疗在大面积烧伤手术患者术中的应用

Application of goal-directed fluid therapy guided by stroke volume variation in the patients extensive burns treated with crustectomy

目的 探讨在每搏变异率(SVV)指导下,目标导向液体治疗(GDFT)对切痂术治疗的大面积烧伤患者围术期微循环的影响。方法 选取2020年2月至2023年2月于我院行切痂术治疗的Ⅲ度烧伤患者为研究对象,随机分为SVV 13%指导GDFT的研究组(n=60)和常规液体治疗的对照组(n=60)。比较两组术中液体出入量,麻醉诱导前30 min(T1)、切痂术开始后1 h(T2)、术毕时(T3)、术毕24 h(T4)的血流动力学、氧代谢及心肌标志物指标;采用广义估计方程回归分析多时间点下重复测量数据;随访统计ICU停留时间及术后7 d并发症。结果 两组晶体输注量、平均动脉压(MAP)、心率(HR)、中心静脉压(CVP)、心脏指数(CI)、心脏每搏指数(SVI)、血糖(Glu)、氧耗指数(VO_(2)I)、术后ICU停留时间、并发症比较差异无统计学意义(P>0.05);研究组胶体输注量、输液总量、输血量、失血量、尿量、T2~T4时中心静脉血氧饱和度(ScvO_(2))、T2~T4时氧输送指数(DO_(2)I)显著高于对照组,而T3~T4时血管外肺水指数(EVLWI)、T4时血乳酸(Lac)、T2~T4时心肌肌钙蛋白I(cTnI)显著低于对照组(P<0.05)。广义估计方程显示,随着时间变化,研究组ScvO_(2)、DO_(2)I的增长幅度分别比对照组高了0.576、0.135,而血Lac、cTnI的增长幅度分别比对照组低了0.825、0.654,研究组对围术期微循环的改善程度优于对照组。结论 SVV指导GDFT在大幅提升ScvO_(2)、DO_(2)I的同时有效抑制了血Lac、cTnI的升高,SVV指导GDFT能有效改善大面积烧伤患者围术期微循环,取得较好的有效循环血容量维持效果。

Objective To investigate the effect of goal-directed fluid therapy(GDFT) guided by stroke volume variation(SVV) on perioperative microcirculation in the patients with extensive burns treated with crustectomy.Methods Patients with third-degree burns who underwent scab incision treatment in our hospital from February 2020 to February 2023 were randomly divided into research group with GDFT guided by SVV 13%(n=60) and control group with conventional fluid therapy(n=60).The intraoperative fluid intake and output of the two groups,the hemodynamics,oxygen metabolism and myocardial markers of 30 min before anesthesia induction(T1),1 h after the start of scab incision(T2),at the end of the operation(T3),and 24 h after the end of surgery(T4) were compared.Generalized estimation equation regression was used to analyze repeated measurement data at multiple time points.ICU stay time and 7 d postoperative complications were calculated during the follow-up period.Results There were no significant differences between the two groups in crystal infusion volume,MAP,HR,CVP,CI,SVI,Glu,VO_(2)I,postoperative ICU stay time,and complications(P>0.05).The colloidal infusion amount,total infusion amount,blood transfusion volume,blood loss,urine output,ScvO_(2) and DO_(2)I at T2-T4 in the study group were higher than those in the control group,but EVLWI at T3-T4,Lac at T4,and cTnI at T2-T4 in the study group were lower than those in the control group(P<0.05).The generalized estimation equation showed that with the change of time,the growth ranges of ScvO_(2) and DO_(2)I in the study group were 0.576 and 0.135 higher than those in the control group,respectively,while the growth ranges of Lac and cTnI were 0.825 and 0.654 lower than those in the control group.The study group improved perioperative microcirculation to a greater extent than the control group.Conclusions SVV-guided GDFT effectively inhibits the increase of Lac and cTnI while greatly increasing ScvO_(2) and DO_(2)I,can improve perioperative microcirculation in the patients with large-scale burns and achieve a better effect in maintaining effective circulating blood volume.