CAJ | 학술논문

目的评价每搏量变异度(Svv)联合CI及CVP对胃肠道肿瘤手术患者容量治疗的指导效果.方法择期胃肠道肿瘤手术患者60例,ASA分级Ⅰ或Ⅱ级,年龄40 ～ 64岁,体重55 ～ 80 kg,采用随机数字表法,将其分为3组(n=20):常规补液组(R组)、SVV指导补液组(S组)和SVV联合CI、CVP指导补液组(C组).R组输入液体总量=补偿性扩容量+生理需要量+累计缺失量+继续损失量+第三间隙丢失量.S组以羟乙基淀粉130/0.4氯化钠注射液维持SVV 10％～15％.C组依据SVV、CI和CVP指导容量治疗.于麻醉诱导前(T0)和术毕(T2)采集肘静脉血样,测定血清β2-微球蛋白(β2-MG)、IL-4、IL-8和TNF-α的浓度；于气管插管后即刻(T1)和T2时记录CO,采集中心静脉血样和动脉血样行血气分析,检测乳酸(Lac)浓度并计算氧供(DO2)、氧耗(VO2)和氧摄取率(ERO2)；记录术中心血管不良事件的发生情况、术后肠蠕动恢复时间及并发症的发生情况.结果与R组比较,S组和C组T2时TNF-α、IL-8、β2-MG和Lac浓度降低,DO2、VO2、ERO2和IL-4浓度升高,术中心动过缓和低血压的发生率降低,术后肠蠕动恢复时间缩短(P＜0.05)；S组和C组上述指标比较差异无统计学意义(P＞0.05)；3组术后并发症发生率比较差异无统计学意义(P＞0.05).结论单纯SVV指导下的容量治疗用于胃肠道肿瘤手术患者,不仅能维持有效的循环血容量和组织灌注,还能减轻机体炎性反应,有助于改善预后；无需联合CI及CVP指导容量治疗.
목적 평개매박량변이도(Svv)연합CI급CVP대위장도종류수술환자용량치료적지도효과.방법 택기위장도종류수술환자60례,ASA분급Ⅰ혹Ⅱ급,년령40 ～ 64세,체중55 ～ 80 kg,채용수궤수자표법,장기분위3조(n=20):상규보액조(R조)、SVV지도보액조(S조)화SVV연합CI、CVP지도보액조(C조).R조수입액체총량=보상성확용량+생리수요량+루계결실량+계속손실량+제삼간극주실량.S조이간을기정분130/0.4록화납주사액유지SVV 10％～15％.C조의거SVV、CI화CVP지도용량치료.우마취유도전(T0)화술필(T2)채집주정맥혈양,측정혈청β2-미구단백(β2-MG)、IL-4、IL-8화TNF-α적농도；우기관삽관후즉각(T1)화T2시기록CO,채집중심정맥혈양화동맥혈양행혈기분석,검측유산(Lac)농도병계산양공(DO2)、양모(VO2)화양섭취솔(ERO2)；기록술중심혈관불량사건적발생정황、술후장연동회복시간급병발증적발생정황.결과 여R조비교,S조화C조T2시TNF-α、IL-8、β2-MG화Lac농도강저,DO2、VO2、ERO2화IL-4농도승고,술중심동과완화저혈압적발생솔강저,술후장연동회복시간축단(P＜0.05)；S조화C조상술지표비교차이무통계학의의(P＞0.05)；3조술후병발증발생솔비교차이무통계학의의(P＞0.05).결론 단순SVV지도하적용량치료용우위장도종류수술환자,불부능유지유효적순배혈용량화조직관주,환능감경궤체염성반응,유조우개선예후；무수연합CI급CVP지도용량치료.
Objective To evaluate the effect of stroke volume variation (SVV) combined with cardiac index (CI) and central venous pressure (CVP) in guiding volume therapy in patients undergoing resection of gastrointestinal tumor.Methods Sixty ASA physical status Ⅰ or Ⅱ patients,aged 40-64 yr,weighing 55-80 kg,scheduled for elective resection of gastrointestinal tumor,were randomly assigned into 3 groups (n =20 each):routine fluid replacement group (group R),SVV-guided volume therapy group (group S) and volume therapy guided by SVV in combination with CI and CVP group (group C).Anesthesia was induced with iv injection of fentanyl,propofol,and cisatracurium.The patients were mechanically ventilated after endotracheal intubation.Anesthesia was maintained with inhalation of sevoflurane,target-controlled infusion of remifentanil and intermittent iv boluses of cisatracurium.Routine fluid replacement included compensatory volume expansion,physiological requirement,cumulative loss,continued loss (intraoperative blood loss),and 3rd space losses in group R.In group S,hydroxyethyl starch 130/0.4 was used to maintain SVV at 10％-15％.Fluid therapy was guided by SVV,CI and CVP in group C.Venous blood samples were collected before induction of anesthesia (T0) and at the end of the surgery (T2) for determination of serum β2-microglobulin β2-MG),TNF-α,IL-4 and IL-8 concentrations.Cardiac output was recorded immediately after endotracheal intubation (T1) and at T2.Blood samples were collected from the central vein and artery for blood gas analysis.The concentration of lactic acid was measured.Oxygen delivery (DO2),oxygen consumption (VO2) and O2 extraction rate (ERO2) were calculated.The intraoperative adverse cardiovascular events and recovery time of intestinal peristalsis and complications after operation were recorded.Results Compared with group R,the concentrations of TNF-α,IL-8,β2-MG and lactic acid were significantly decreased,while DO2,VO2,ERO,and IL-4 concentration were increased at T2,the incidences of bradycardia and hypotension were decreased,and the recovery time of intestinal peristalsis was shortened in groups S and C (P ＜ 0.05).There were no significant differences in the parameters mentioned above between groups S and C (P ＞ 0.05).There was no significant difference in postoperative complications among the three groups (P ＞ 0.05).Conclusion Volume therapy guided by SVV alone can not only maintain effective circulating blood volume and tissue peffusion,but also reduce the inflammatory response,and is helpful in improving the prognosis in patients undergoing resection of gastrointestinal tumor.It is not required for SVV to combine with CI and CVP in guiding volume therapy.