目标导向液体复苏在剖宫产术中产后出血容量管理中的应用  

Application of goal-oriented fluid replacement therapy in volume management of postpartum hemorrhage during cesarean section

作　　者：于洋[1] 张龑[1] 朱曦[2] 张赐敏 童春[1] 赵扬玉[1] Yu Yang;Zhang Yan;Zhu Xi;Zhang Cimin;Tong Chun;Zhao Yangyu(Department of Obstetrics and Gynecology,Peking University Third Hospital,Beijing 100191,China;Department of Critical Care Medicine,Peking University Third Hospital,Beijing 100191,China)

机构地区：[1]北京大学第三医院妇产科,北京100191 [2]北京大学第三医院危重医学科,北京100191

出　　处：《中华危重病急救医学》2021年第3期305-310,共6页Chinese Critical Care Medicine

基　　金：北京市科技计划课题(Z171100000417047)。

摘　　要：目的使用下腔静脉直径(IVCD)及下腔静脉塌陷指数(IVC-CI)指导胎盘植入剖宫产术中发生严重产后出血患者液体治疗时对容量及凝血功能的影响。方法采用前瞻性随机对照研究方法,选择2018年12月至2019年7月在北京大学第三医院住院分娩或转诊分娩且出现严重产后出血(出血量≥1 000 mL)的60例患者作为研究对象。按补液方式不同将患者分为常规补液组和目标补液组(给予目标导向补液治疗),记录患者切皮前、胎儿娩出后、产后出血和术毕时的血流动力学、血气分析、凝血功能指标及补液总量、尿量、预后、术中血管活性药物使用率及术后不良事件发生情况,并比较两组患者上述指标的差异。结果①血流动力学:两组心率(HR)均于产后出血时达峰值,但两组间各时间点HR比较差异均无统计学意义。两组平均动脉压(MAP)均呈先降低后升高趋势,产后出血时达谷值,但目标补液组产后出血时MAP明显高于常规补液组〔mmHg(1 mmHg=0.133 kPa):75.6±10.7比69.2±8.9,P<0.05〕。目标补液组中心静脉压(CVP)在胎儿娩出时稍升高后趋于平稳,常规补液组CVP呈先升高后降低趋势,产后出血时达峰值;产后出血时目标补液组CVP明显低于常规补液组〔cmH2O(1 cmH2O=0.098 kPa):9.5±3.9比11.4±3.4,P<0.05〕。②血气分析:两组术毕时动脉血氧分压(PaO_(2))、动脉血二氧化碳分压(PaCO_(2))均较产后出血时升高,但目标补液组术毕时PaO_(2)与常规补液组比较差异无统计学意义(mmHg:189.3±100.5比240.2±126.3,P>0.05),而目标补液组PaCO_(2)明显低于常规补液组(mmHg:34.6±4.6比36.8±4.1,P<0.05)。目标补液组术毕时血乳酸(Lac)明显低于常规补液组(mmol/L:2.2±0.6比2.6±1.1,P<0.05)。③液体出入量:目标补液组总输液量、晶体液输注量、悬浮红细胞输注量均明显少于常规补液组〔总输液量(mL):3 385.9±1 144.1比4 448.3±1 194.4,晶体液输注量(mL):2 635.6±789.7比3 1Objective To observe the effect of fluid therapy on volume and coagulation function in patients with severe postpartum hemorrhage during cesarean section of placenta accreta under the guidance of inferior vena cava diameter(IVCD)and inferior vena cava collapse index(IVC-CI).Methods A prospective randomized controlled study was conducted in 60 pregnant women with severe postpartum hemorrhage(blood loss≥1000 mL)who were hospitalized for delivery or referred for delivery in the Peking University Third Hospital from December 2018 to July 2019.The patients were divided into routine fluid replacement group and goal-oriented fluid resuscitation group(goal-oriented fluid replacement therapy was given)according to the different ways of fluid replacement.The hemodynamics,blood gas analysis,coagulation function,total fluid replacement,urine volume,prognosis,intraoperative vasoactive drugs utilization rate and postoperative adverse events were recorded before skin incision,after the fetus delivered,postpartum hemorrhage and at the end of operation,and the differences of these indices between the two groups were compared.Results①Hemodynamics:the heart rate(HR)of the two groups were reached the peak during postpartum hemorrhage,but there was no significant difference in HR at each time point between the two groups.The mean arterial pressure(MAP)was decreased at first and then increased in both groups,and reached the trough at postpartum hemorrhage,but the MAP in the goal-oriented fluid resuscitation group was significantly higher than that in the routine fluid replacement group[mmHg(1 mmHg=0.133 kPa):75.6±10.7 vs.69.2±8.9,P<0.05].In the goal-oriented fluid resuscitation group,the central venous pressure(CVP)was increased slightly after the fetus delivered and then stabilized,while in the routine fluid replacement group,the CVP was increased at first and then decreased,and reached the peak in postpartum hemorrhage.During postpartum hemorrhage,CVP in the goal-oriented fluid resuscitation group was significantly lower than

关 键 词：妊娠 下腔静脉 血容量 产后出血 液体复苏 

分 类 号：R714.461[医药卫生—妇产科学]