腹腔镜结直肠手术中以不同溶液行高容量填充对胃黏膜灌注的影响  

Influence of hypervolemic filling with various solutions during induction period on gastric mucosa perfusion in laparoscopic colorectal surgery

作　　者：邓云新[1] 金珏[1] 金善良[1] 于布为[1] 

机构地区：[1]上海交通大学医学院附属瑞金医院麻醉科,200025

出　　处：《上海医学》2009年第1期23-28,共6页Shanghai Medical Journal

基　　金：上海市自然科学基金资助课题(03ZR14046)

摘　　要：目的应用胃黏膜张力计评估以不同溶液行高容量填充对腹腔镜结直肠手术中胃黏膜灌注的影响。方法择期行腹腔镜下结直肠手术患者36例,随机均分为乳酸林格液(RL)组、琥珀酰明胶注射液(Gel)组和高渗氯化钠羟乙基淀粉40注射液(HS)组,在全身麻醉诱导期行高容量填充。比较基础时(T1)、扩容结束时(T2)、气腹后5min(T3)、气腹后15min(T4)、气腹后30min(T5)、气腹后60min(T6)及结束气腹后5min(T7)、15min(T8)、25min(T9)时各组间的动脉血血气分析、无创血流动力学、胃黏膜张力计测定值和中心静脉压(CVP)。此外,3组患者均按年龄分为两个亚组,A亚组年龄<65岁,B亚组年龄≥65岁。结果3组间的基本情况、手术情况、麻醉诱导前的各项数据的差异均无统计学意义(P值均>0.05)。T2时间点后,3组的红细胞压积(Hct)均下降,以Gel组的下降程度较为明显且维持时间较长。3组胃黏膜-血二氧化碳分压差(Pg-aCO2)在T2时间点后开始下降,T5时间点后回升,但始终未超过基础值。3组间Pg-aCO2、胃黏膜二氧化碳(PgCO2)、胃黏膜pH值(pHi)和黏膜-呼气末二氧化碳分压(Pg-etCO2)的差异均无统计学意义(P值均>0.05)。HS组T2～T9时间点血Na+均显著高于T1时间点及RL、Gel组(P值均<0.01)。RL组和Gel组的血浆碳酸氢根(HCO3-)自T2时间点开始持续上升,直至T7时间点后下降,此现象在HS组不明显。RL组和Gel组中,B亚组血压波动较A亚组明显。结论腹腔镜下行结直肠癌手术对患者的循环状况有一定程度的影响。麻醉诱导期行高容量填充可改善胃黏膜灌注的情况,不同溶液均可在早期达到良好的效果。HS在这类手术中可维持更为平稳的血流动力学效果,但在输注后即刻有一过性的轻度高钠血症,对术前已有高钠血症者应慎用。Objective To compare the effects of lactated Ringer＇ s, gelatin and hypertonic saline hydroxyethyl starch 40 solutions on hemodynamics and gastric mucosa perfusion in patients undergoing elective laparoscopic colorectal surgery. Methods Thirty-six patients undergoing elective laparoscopic colorectal surgery were randomly divided into three groups （n = 12 each）; group RL （lactated Ringer＇s solution, RL）, group Gel （succinylated gelatin injection, Gel） and group HS （Hypertonic saline hydroxyethyl starch 40, HS）. Hypervolemic fluid filling （HFF） was initiated with the induction of general anesthesia. The artery blood gas analysis, noninvasive hemodynamics, gastric tonometry and central venous pressure （CVP） were measured and recorded at baseline （T1）, after HFF （T2）, 5 min （T3）, 15 min （T4）, 30 min （T5）, 60 min （T6） after CO2 pneumoperitoneum, 5 min （T7）, 15 min （T8）, and 25 min （T9） after the end of pneumoperitoneum. Results The clinical characteristics of patients, duration of the operation and parameters at T1 were similar among the 3 groups. Hematocrit （Hct） was decreased at T2 in all groups and the decrease was more significant and prolonged in group Gel than in other groups （all P〈0. 05）. Grastric intramucosal CO2-arterial CO2 （Pg-aCO2） was decreased at T2 in all groups and began to increase at T5 and remained at a lower level compared with that at the baseline. The gastric tonometric values among groups were similar. In group HS, serum Na^＋ was significantly increased at T2 and then gradually normalized before T8. The plasma HCO3ˉ was significantly increased between T2 and T7 in group RL and Gel, but not in group HS. In group RL and Gel, pHa and pHi were lower in older patients than at the baseline level. Pg-aCO2 remained unchanged in the three groups, Conclusion The circulatory condition is partially impacted during the operation of laparoscopic colorectal surgery. All fluids used in the study are effective in improving gastric

关 键 词：高容量液体填充 内脏灌注 胃黏膜张力计 高渗氯化钠羟乙基淀粉40 

分 类 号：R614[医药卫生—麻醉学]