目标导向血流动力学管理策略对老年合并脆弱心脏功能腹部手术患者转归的影响  

Effect of goal-directed haemodynamic management on the postoperative outcome in elderly patients with fragile cardiac function undergoing Aabdominal. surgery

作　　者：郑立山[1] 顾尔伟[1] 彭晓慧[1] 张雷[1] 曹袁媛[1] 

机构地区：[1]安徽医科大学第一附属医院麻醉科,合肥230032

出　　处：《中华医学杂志》2016年第43期3464-3469,共6页National Medical Journal of China

基　　金：安徽省科技攻关计划项目（1301042204）

摘　　要：目的观察以每搏量变异度（SVV）、心脏指数（CI）、平均动脉血压（MAP）为目标导向的血流动力学管理策略对老年合并脆弱心脏功能行腹部胃肠手术患者术后转归的影响。方法选择2015年10月至2016年5月安徽医科大学第一附属医院住院的老年合并脆弱心脏功能拟行择期胃肠手术患者90例，年龄65-90岁，美国麻醉医师协会（ASA）分级Ⅱ或Ⅲ级，纽约心脏病协会（NYHA）心功能分级Ⅱ或Ⅲ级，随机分为经验麻醉组（E组，n=45）和目标导向血流动力学管理组（G组，n=45）。G组连接Vigileo传感器监测CI和SVV，术中依据SVV（≤12%）、CI（≥2.5 L·min^-1·m^-2）、MAP（维持在基础值±20%）来调整前负荷输注液体、给予正性肌力药和正性压力药；E组依据麻醉医生经验判断输注液体及给予血管活性药物。两组均应用多模式麻醉管理：脑电双频指数（BIS）监测麻醉镇静深度、靶控输注（TCI）异丙酚、肺保护性通气、维护核心体温，双侧腹横肌平面阻滞为基础的多模式镇痛。记录术前、术毕、术后24 h两组患者N-末端B-型利钠肽前体（NT-proBNP）、肌钙蛋白T（cTnT）的值；术后住院期间心肌梗死/心绞痛、心力衰竭、严重心律失常等心血管严重并发症及脑梗死、肾衰竭、其他相关并发症发生情况；患者出院后电话随访上述并发症至术后30 d。结果E组术中晶体、胶体、液体输注总量分别为（1 110.20±332.00）、（536.65±72.25）、（1 677.20±424.44） ml，G组术中晶体、胶体、液体总量分别为（708.72±240.85）、（414.41±74.31）、（878.51±199.13） ml，与E组比较，G组术中液体输注减少，差异均有统计学意义（t=6.057、2.701、9.742，均P〈0.05）；术后24 h血乳酸值较小，E组为（1.11±0.43） mmol/L，G组为（0.89±0.31） mmol/L，差异有统计学意义（t=-2.848，P〈0.05）；术后24 h动脉血氧分压（PaO2）较高，E组ObjectiveTo investigate the effect of goal-directed haemodynamic management based on stroke volume variation （SVV）, cardiac index （CI） and mean arterial blood pressure （MAP） on the postoperative outcome in elderly patients with fragile cardiac function undergoing gastrointestinal surgery.MethodsNinety patients with fragile cardiac function, aged 65-90 years old, ASAⅡ or Ⅲ, NYHA Ⅱor Ⅲ, scheduled for abdominal surgery were enrolled in this study.The patients were randomly assigned to two groups： Experience anesthesia group （group E, n=45） and goal-directed hemodynamic management group （G group, n=45）. After anesthesia induction, in group G, the SVV and CI were monitored by Vigileo and according SVV （≤12%）, CI （≥2.5 L·min^-1·m^-2） and MAP （maintain the base value of ±20%） to adjust the preloaded infusion fluid and give positive inotropic drugs and positive pressure drugs; in group E, fluid and vasoactive agent were used according to the experience of anesthesiologist.Multi-mode monitoring anesthesia management using BIS, TCI of propofol, low-tidal-volume lung protective ventilation management strategy, body temperature protection, and postoperative multimodal analgesia techniques was performed in the two groups.Values of N-terminal pro-B-type natriuretic peptide （NT-proBNP） and cardiac troponin T （cTnT） were recorded before operation, at the end of operation, and postoperative 24 h. The incidence of myocardial infarction/angina, heart failure, arrhythmia and cerebral infarction, renal failure, length of hospitalization, and complications in 30-days after surgery were recorded by telephone follow-up.ResultsCrystal, colloid, total liquid of group E were （1 110.20±332.00）, （536.65±72.25）, （1 677.20±424.44） ml and these of group G were （708.72±240.85）, （414.41±74.31）, （878.51±199.13） ml, respectively.Compared with group E, the fluid infusion were reduced in group G （t=6.057, 2.701, 9.742, all P〈0.05）. The lactic acid value of 24

关 键 词：血流动力学 病例管理 老年人 心脏功能试验 利钠肽 B型 肌钙蛋 白T 手术后并发症 

分 类 号：R614[医药卫生—麻醉学]