晚期肿瘤患者全身热疗期间血液动力学和氧代谢的变化

Hemodynamic changes and oxygen metabolism in patients with malignant tumor during whole-body hyperthermia therapy

目的观察恶性肿瘤患者在全身热疗(WBH)期间的血液动力学和氧代谢的变化。方法 20例晚期肿瘤患者,年龄22～58岁,ASA Ⅰ～Ⅱ级,心肺功能基本正常。麻醉前用药:咪达唑仑O.05 mg·kg-1、东莨菪碱0.3 mg肌注。麻醉诱导:静注氟哌利多5 mg、芬太尼0.1 mg、维库溴铵0.15 mg·kg-1、异丙酚2 mg·kg-1 ,气管内插管后控制呼吸,吸入纯氧,呼吸频率10～12次./min,潮气量8～12 ml·kg-1。(据PETCO2值调整)。采用微量泵持续输注异丙酚2～4 mg·kg-1·h-1、芬太尼2 μg·kg-1·h-1,间断静注维库溴铵、咪达唑仑及吸入1％～1.5％异氟醚维持麻醉。麻醉完成后采用ET-Speac远红外线辐射仓进行WBH治疗,当食管温度达41.8℃后维持2 h,随后停止加温,待自然降温至38.5℃时行麻醉复苏处理。分别于加温前、39℃、40℃、41℃、41.8℃1 h、41.8℃2 h、降温至40℃、降温至38.5℃及拔管后15 min等时点,采用Swan-Ganz导管技术和反向Fick法测定血液动力学和氧代谢指标。结果WBH治疗开始后,随着体温的升高,HR明显加快、CI、SI、CVP、MPAP、PCWP,明显增加,MAP、PVRI和SVRI明显降低(P<0.01),DO2,和VO2在39℃时分别增加35％和18％,40℃时增加55％和23％,41℃时增加70％和28％,41.8℃时增加88％和31％。WBH期间O2ER、PVO2、P(a-v)CO2和pH(a-v)维?

Objective To evaluate the hemodynamic changes and oxygen metabolism during whole body hyperthermia (WBH) therapy in patients with malignant tumor. Methods Twenty ASA Ⅰ - Ⅱ patients with advanced cancer aged 22-58 yr were enrolled in the study. The patients were premedicated with midazolam 0.05 mg ·kg-1 and scopolamine 0.3 mg im. Anesthesia was induced with intravenous droperidol 5 mg, fentanyl 100 μg, propofol 2 mg·kg-1 and vecuronium 0.15 mg·kg-1 . The patients were mechanically ventilated after tracheal intubation (FiO2 = 100%, RR=10-12bpm, VT = 8-12 ml·kg-1 ) and fentanyl (2μg·kg-1 · h-1 ), 1%-1.5% isoflurane inhalation and intermittent iv boluses of vecuronium and midazolam. Swan-ganz catheter was placed in the pulmonary artery for hemodynamic monitoring. Radial artery was cannulated for direct BP monitoring and arterial blood gas analysis. ECG and PaO2 were continuously monitored. Body temperature probes were placed in esophagus, rectum, naso-pharynx and body surface. Body temperature was warmed to 41.8t and maintained for 2 h. Stroke volume(SV), cardiac output(CO), mean pulmonary artery pressure (MPAP), vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), oxygen delivery (DO2), oxygen consumption (VO2) and oxygen extraction rate (O2ER) were calculated before warming (T0), at 39℃ ,40℃ ,41℃ , 41.8℃,41.8 ℃(1 h), 41.8℃(2 h) and when T0 was decreased to 40℃ and 38.5t (T1-8) .Results HR, CI, SI, CVP, MPAP and PCWP significantly increased with increasing body temperature, while MAP, PVRI and SVRI significantly decreased. DO2 and VO2 increased by 35% and 18% at 39℃ , 55% and 23% at 40℃ , 70% and 28% at 41℃ and by 88% and 31% at41.8℃.During WBH O2ER, PvO2 P(a-v)CO2 and pH (a-v) were maintained within normal range. At 41. 8℃ (2h) pH was lower than the normal range, at the end of WBH, hemodynamic and O2 metabolism parameters gradually returned to baseline levels. Conclusion The balance between oxygen delivery and oxygen consumption can be well maintained during WBH therapy under general anesthesia.