目标导向液体治疗对老年患者腰椎手术预后的影响

发布时间：2018-03-06 13:14

本文选题：目标导向液体治疗　切入点：老年腰椎手术　出处：《北京协和医学院》2016年博士论文　论文类型：学位论文

【摘要】：目的：恰当的液体管理能够改善患者术后重要器官灌注,减少术后并发症,缩短住院时间。目标导向液体治疗(Goal-Directed Therapy)用于围术期液体管理,通过监测血流动力学指标判断患者对液体的需求,根据患者不断变化的需求进行补液,指导术中液体治疗及血管活性药物的应用,提高心输出量,增加组织器官灌注和氧供,达到维持有效的组织灌注与细胞氧和。本文旨在观察以每搏量变异率(Stroke Volume Variation)为目标导向的液体治疗管理策略,在老年(年龄大于55岁)腰椎手术患者中,对老年患者的血流动力学、围术期乳酸、组织灌注、术中用液以及预后的影响。方法：本研究为前瞻队列对照研究,选取201 5年12月至2016年5月间66例老年骨科腰椎手术患者,通过随机分组,将其分为目标导向液体治疗组即实验组(G组)和对照组(C组),实验组入室后进行桡动脉穿刺,在LIDCO监护仪的监测及指导下,以每搏输出量变异(SVV)和收缩压(SBP)为目标,根据GDT方案对患者进行容量管理,而对照组则根据麻醉医师的经验,按照现有麻醉操作标准常规补液方法进行液体管理。选取术中用液情况及血气乳酸值作为主要结局指标,分别在术前24h(T0),麻醉诱导后(T1),腰椎减压前(T2),腰椎减压完成后(T3),手术结束即刻(T4),出恢复室即刻(T5),术后24h(T6)七个时间点采集动脉血气并记录乳酸数值,评估患者灌注情况。选取术后并发症、术后功能恢复及住院时长为次要结局指标。收集数据后用使用SPSS 22.0进行统计分析。结果：(1)本实验根据入选标准共纳入66例老年腰椎手术患者(实验组33人,对照组33人),这两组患者的年龄、性别组成、体重指数、既往史及术前检查方面无显著差异。(2)术中乳酸与PH的变化：实验组乳酸术中维持平稳,对照组术中乳酸呈持续升高,在T5时间点其乳酸值显著高于实验组,对照组在T5、T6高乳酸血症的发生率也显著高于实验组。两组术中PH均呈持续降低状态,术后第一天恢复至基线水平,组间无差异。(3)术中血流动力学变化：实验组和对照组在T1-T4这四个时间点的MAP和HR数值并无统计学差异,但实验组的四个时间点的SVV是明显低于对照组的,另外实验组在T4的CO也是显著高于对照组的。(4)术中用液、用药的变化和差异：实验组晶体液用液量和总液体量是显著高于对照组,对比两组用药情况,两组使用麻黄碱和苯肾的人数并无差异,但实验组麻黄碱的人均使用量是显著低于对照组的,差异有统计学意义。(5)术后恢复情况及并发症发生率：实验组与对照组在术后出血量、进流食、半流食、排气、排便、总住院时长上并无统计学差异,但对照组共有13人通过药物辅助排气、排便,显著高于实验组的3人,实验组并发症的发生概率也显著低于对照组,组间差异有统计学意义。结论：(1) 本研究结果显示目标导向液体治疗组患者术中液体用量明显高于对照组,乳酸水平明显降低,提示目标导向液体治疗对改善老年腰椎手术患者的灌注有一定积极作用。(2)本研究结果显示目标导向液体治疗可以有效改善老年腰椎手术患者术后胃肠功能恢复情况,加快患者术后康复,减少患者术后并发症的发生,改善预后。
[Abstract]:Objective: fluid management properly can improve the postoperative perfusion of vital organs, reduce postoperative complications, shorten the hospitalization time. Goal-directed fluid therapy (Goal-Directed Therapy) for perioperative fluid therapy, patients demand for liquid by monitoring the hemodynamic parameters, the replacement of patients according to the changing needs of application, operation guide liquid treatment and vasoactive drugs, improve cardiac output, increase organ perfusion and oxygen supply, to maintain effective tissue perfusion and oxygen. The purpose of this paper is to observe and to stroke volume variation (Stroke Volume Variation) liquid treatment management strategies for goal oriented, in the elderly (aged over 55) in patients with lumbar in the operation, on the hemodynamics of elderly patients, perioperative lactic acid, tissue perfusion, fluid and prognosis during operation. Methods: This study was a prospective cohort control The research, from December 2015 to May 2016 66 cases of elderly patients in Department of orthopedics, through a randomized, divided into goal-directed fluid therapy groups: experimental group (G group) and control group (C group), experimental group A after radial artery puncture, LIDCO monitor monitoring and guidance, to each stroke volume variation (SVV) and systolic blood pressure (SBP) as the goal, according to the GDT scheme of volume management of patients and the control group according to the experience of the anesthesiologist, fluid management was in accordance with the existing standard anesthesia operation method. Selected with conventional rehydration solution and blood lactic acid of value as the primary outcome measure in operation 24h (T0), after induction of anesthesia (T1), (T2), lumbar decompression and anterior lumbar decompression after (T3), at the end of surgery (T4), a recovery room immediately after 24h (T5), (T6) seven time point collection of arterial blood gas and lactate recorded numerical evaluation of patients irrigation Note. The postoperative complications, postoperative recovery and hospitalization time as secondary outcomes. After collecting data with 22 use SPSS for statistical analysis. Results: (1) the experiment according to the inclusion criteria included a total of 66 cases of senile lumbar surgery patients (33 in experimental group and control group of 33 people), two groups of patients with age, sex, body mass index, there was no significant difference between history and preoperative examination. (2) and the change of lactic acid during PH: the experimental group of lactic acid in the patients in the control group remained stable, lactic acid increased, the lactic acid value at T5 time point was significantly higher than the experimental group and the control group in T5, T6 hyperlactacidemia were also significantly higher than the experimental group. Two groups of patients in PH were decreased, the first postoperative day return to baseline level, no significant difference between groups. (3) the hemodynamic changes during operation: the experimental group and the control group in the four T1-T4 time point MAP and HR There was no significant difference between the values, but the four time points in the experimental group SVV was significantly lower than the control group, the experimental group in T4 CO was significantly higher than the control group. (4) using liquid in operation, change and difference of medication: the experimental group with the liquid crystal fluid volume and total liquid volume was significantly higher in the control group, compared two groups of medication, two groups of the number of the use of ephedrine and benzene kidney had no difference, but the per capita amount of ephedrine in experimental group is significantly lower than the control group, the difference was statistically significant. (5) postoperative recovery and complication rate of experimental group and the control group in the amount of bleeding, after eating, semi liquid diet, exhaust, defecation, total hospitalization duration was not statistically significant, but the control group a total of 13 people through the drug auxiliary exhaust, defecation, significantly higher than 3 in the experimental group, the probability of occurrence of complications in the experimental group were significantly lower than the control group, there is statistical difference between the groups Significance. Conclusion: (1) the results of this study show that goal-directed fluid therapy in patients with liquid group was significantly higher than the control group, the lactic acid level decreased significantly, suggesting that goal-directed fluid therapy is helpful to improve elderly patients with lumbar spinal surgery perfusion. (2) the results of this study show that goal-directed fluid therapy can effectively improve the the elderly lumbar postoperative recovery of gastrointestinal function, accelerate the rehabilitation of patients, reduce the incidence of postoperative complications in patients, improve the prognosis.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R614

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