基于PiCCO的目标导向容量管理在非停跳冠状动脉搭桥术围手术期的应用  

Application of PiCCO-guided goal-directed volume management in off-pump coronary artery bypass surgery during perioperative period

作　　者：张双银[1] 华玉芳[1] 韩芳霞 张荣智[1] 王迎斌[1] 杨小华[1] 赵启明[2] Zhang Shuangyin;Hua Yufang;Han Fangxia;Zhang Rongzhi;Wang Yingbin;Yang Xiaohua;Zhao Qiming(Department of Anesthesiology,Lanzhou University Second Hospital,Lanzhou 730030,China;Department of CICU,Lanzhou University Second Hospital,Lanzhou 730030,China)

机构地区：[1]兰州大学第二医院麻醉科,730030 [2]兰州大学第二医院CICU,730030

出　　处：《中国医师进修杂志》2020年第7期577-581,共5页Chinese Journal of Postgraduates of Medicine

基　　金：甘肃省自然科学基金(1606RJZA115)。

摘　　要：目的观察以心脏指数(CI)、胸腔内血容量指数(ITBVI)、血管外肺水指数(EVLWI)为目标导向的容量管理策略对非停跳冠状动脉搭桥术患者转归的影响。方法选取兰州大学第二医院2017年1月至2018年12月非停跳冠状动脉搭桥术患者40例,美国麻醉医师协会(ASA)分级2~3级。将其按随机数字表法分为研究组和对照组,每组各20例。对照组监测中心静脉压(CVP)指导补液。研究组进行中心静脉置管+股动脉置管+PiCCO模块连接,应用PiCCO监测血流动力学指标,测定CVP、心脏指数(CI)、ITBVI、EVLWI,准确评估患者容量状况,以CI 3.0~5.0 L/(min·m2),ITBVI 800~1000 ml/m^2,EVLWI 3.0~7.0 ml/kg为参考值进行目标导向液体治疗。术中根据CI、ITBVI、EVLWI动态变化调整补液,监测患者心率(HR)、平均动脉压(MAP)、尿量、中心静脉血氧饱和度(ScvO2)、乳酸、肾功能等指标。记录两组患者呼吸机辅助通气时间、ICU停留时间、住院时间、急性肺水肿发生率、急性肾功能不全发生率及术后30 d病死率。结果研究组患者组织灌注改善,尿量明显增加(P<0.05),中心静脉血氧饱和度明显增加(P<0.05),血乳酸浓度明显降低(P<0.05),急性肺水肿、急性肾功能不全发生率明显低于对照组(5.0%比15.0%、5.0%比10.0%)(P<0.05),病死率低于对照组(5.0%比15.0%)(P<0.05)。ICU停留时间与住院时间均低于对照组(P<0.01)。结论以CI、ITBVI、EVLWI为目标导向液体治疗能有效优化非停跳冠状动脉搭桥术患者的心脏前负荷,提高心输出量,保证微循环灌注,维持机体氧供需平衡,降低并发症发生率与病死率,降低ICU停留时间与住院时间。Objective To evaluate the influence of goal-directed volume management based on cardiac output index(CI),intrathoracic blood volume index(ITBVI)and extravascular lung water index(EVLWI)in patients undergoing off-pump coronary artery bypass surgery.Methods Forty patients(ASA 2 to 3 grade)undergoing off-pump coronary artery bypass surgery in Lanzhou University Second Hospital from January 2017 to December 2018 were selected.The patients were divided into 2 groups by random digits table method with 20 cases in each group:study group(goal-directed fluid therapy treatment with CI,ITBVI and EVLWI)and control group(conventional fluid therapy).The control group was given central venous pressure(CVP)monitoring rehydration,and the study group was given PiCCO hemodynamic monitoring indicators.The CVP,CI,ITBVI and EVLWI for fluid management were measured.Accurate assessment of volume status of patients was done.The study group received goal-directed fluid therapy based on CVP,CI,ITBVI and EVLWI,with the goal of CI in the 3.0 to 5.0 L/(min·m2)range,ITBVI in the 800 to 1000 ml/m2 range and EVLWI in the 3.0 to 7.0 ml/kg range.The heart rate,mean arterial pressure(MAP),urine volume,central venous oxygen saturation(ScvO2),lactic acid and renal function were monitored.The ventilator withdrawal time,hospitalization in ICU,length of stay,incidence of acute pulmonary edema,incidence of acute renal failure,mortality of 30 d after surgery were recorded and compared between the two groups.Results Tissue perfusion and urine volume of the study group was significantly improved compared with that of control group(P<0.05).ScvO2 of the study group was higher than that of the routine group(P<0.05).The concentration of lactic acid of the study group was lower than that of the routine group(P<0.05).The incidences of acute pulmonary edema,acute renal insufficiency and mortality of the study group were lower than those of the routine group(5.0%vs.15.0%,5.0%vs.10.0%and 5.0%vs.15.0%),and there were statistical differences(P<0.05).The length of sta

关 键 词：冠状动脉旁路移植术 非体外循环 心指数 胸腔内血容量指数 血管外肺水指数 目标导向液体治疗 

分 类 号：R654.2[医药卫生—外科学]