去甲肾上腺素与去氧肾上腺素对SVV导向液体治疗下老年结直肠癌手术预后影响的研究

发布时间：2018-03-19 23:24

  本文选题：每博量变异度/SVV　切入点：液体治疗　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的每博量变异度(Stroke volume variation,SVV)是一种准确、方便的测量液体反应性和功能性的血流动力学参数。而以SVV为导向目标的液体治疗也是一种限制性液体治疗,往往不足以稳定患者的病情,尤其是老年患者。由于老年患者心血管功能下降,加之术前禁食禁饮,术前消化道准备,以及术中麻醉药的心血管抑制作用等原因,更易引起术中血流动力学波动,大大增加围术期风险。相关文献研究表明在老年患者限制性输液引起低血压时,预防性给予小剂量去甲肾上腺素,能有效的增加组织氧供,减少术后并发症的发生,且无明显胃肠道微循环及氧耗的不良影响。鉴于去氧肾上腺素在临床上相对于去甲肾上腺素更为常用,本课题拟在SVV导向液体治疗基础上进行前瞻性、单中心、随机、双盲对照研究,观察去甲肾上腺素与去氧肾上腺素对结(直)肠癌根治术患者的预后对比,评价两种升压药物对患者的安全性,并找到一个可行的围手术期液体治疗优化方案。方法本课题研究对象为择期行结(直)肠癌根治术患者。采用随机数字表法将患者随机分为去甲肾上腺素(5μg/ml)组和去氧肾上腺素(100μg/ml)组,每组各20例。患者入室后在局麻下行桡动脉穿刺置管测压,并连接FloTrac/Vigileo监测系统监测SVV、心指数(Cardiac index,CI)、心输出量(Cardiac output,CO)等指标,局麻下行中心静脉穿刺,连接静脉通路并监测中心静脉压(Central venous pressure,CVP)。术中液体背景输注速度5ml/kg.h,根据SVV调控液体输注速度及种类。若血压低于基础值的20%,则泵入去甲肾上腺素或去氧肾上腺素。两种血管活性药的背景输入量为5ml/h。主要观察指标为:术后肾功、ICU入住时间、ICU机械通气时间、住院花费、术后第一天急性生理和慢性健康评估II(APACHE II)评分、排气时间、住院天数、术后并发症、28天患者再入院率及死亡率。次要观察指标:分别在入室平稳后、动脉穿刺后、麻醉诱导前、插管即刻、插管后3min、手术开始、手术结束及手术开始后每隔30min记录病人基本情况(Bp、HR、SpO2、ABP、CO、SVV、CI、SV、CVP、Bis、ETCO2、T)、术中血管活性药物使用量(ml)、多巴酚丁胺是否使用及使用量、术中尿量、利尿药使用量、晶体入量、胶体入量、及术中输注其他液体入量、术中失血量、麻醉时间。结果术中在SVV导向的液体治疗下,去甲肾上腺素与去氧肾上腺素对结(直)肠癌根治术患者的术中观察指标及术后预后观察指标均无统计学差异。两组术中Bp、HR、SpO2、ABP、CO、SVV、CI、SV、CVP、Bis、ETCO2、T、术中血管活性药物使用量(ml)、多巴酚丁胺是否使用及使用量、术中尿量、利尿药使用量、晶体入量、胶体入量、及术中输注其他液体入量、术中失血量、麻醉时间均无统计学差异(P0.05)。两组在术后肾功、ICU入住时间、ICU机械通气时间、住院花费、排气时间、住院天数、术后并发症、28天患者再入院率及死亡率均无统计学差异(P0.05)。去氧肾上腺素组术后APACHE II评分较去甲肾上腺素组更低一些,两组有统计学差异(P=0.048)。这与去氧肾上腺素组在ICU机械通气时间相关,去氧肾上腺组的ICU通气时间平均为2.8 h,而去甲肾上腺素组的ICU通气时间平均为4.9 h,所以去氧肾上腺素组加速了ICU拔管时间,而在术后并发症及组织氧合方面无明显差异,所以去氧肾上腺素也是一种良好的,可以用于术中的血管活性药。结论术中在SVV导向的液体治疗下,去甲肾上腺素与去氧肾上腺素对结(直)肠癌根治术患者的术后预后影响基本相同。在无心功能障碍的患者术中应用去氧肾上腺素也是一种良好的选择,在预后上与去甲肾上腺素相比无明显差异。
[Abstract]:Objective stroke volume uariability (Stroke volume, variation, SVV) is a kind of accurate measurement of liquid reaction and functional hemodynamic parameters conveniently. The liquid treatment with SVV as the orientation is also a kind of restrictive fluid therapy, is often not enough to stabilize the patient's condition, especially in elderly patients. Due to the decline in cardiovascular the function of elderly patients with preoperative fasting, gastrointestinal preparation before surgery, and intraoperative anesthetic inhibition of cardiovascular and other reasons, more likely to cause hemodynamic fluctuations during operation, greatly increased perioperative risk. Relevant literature research shows that in the elderly patients with restrictive transfusion induced hypotension, giving small doses of preventive norepinephrine can effectively increase oxygen supply, reduce the incidence of postoperative complications, and no obvious adverse effects on gastrointestinal tract microcirculation and oxygen consumption. In view of phenylephrine in clinical factors Compared with norepinephrine is more commonly used in this study were prospectively, based on SVV directed fluid therapy on a single center, randomized, double-blind study, observation of norepinephrine and phenylephrine on node (straight) comparison of prognosis for patients with colorectal cancer radical, evaluation of two kinds of drugs to boost patient safety, and to find a feasible perioperative fluid therapy optimization. Methods the research objects as nodes (straight) undergoing resection of colorectal cancer patients. According to the random number table method were randomly divided into norepinephrine (5 g/ml) group and phenylephrine (100 g/ml) group, 20 cases in each group. Patients under local anesthesia for radial artery puncture manometry, and FloTrac/Vigileo connection monitoring system SVV, cardiac index (Cardiac index, CI), cardiac output (Cardiac, output, CO) and other indicators, local anesthesia for central venous puncture, venous connection Access and monitoring central venous pressure (Central venous, pressure, CVP). The liquid background infusion rate during 5ml/kg.h, according to the SVV regulation of the liquid infusion rate and type. If the blood pressure lower than the baseline value of 20%, while pumping norepinephrine or phenylephrine. Background input two kinds of vasoactive drugs as the main observation index 5ml/h. as the renal function after operation, ICU ICU check-in time, mechanical ventilation time, hospitalization costs, the first day of II evaluation of acute physiology and chronic health after surgery (APACHE II) score, exhaust time, hospitalization time, postoperative complications, 28 days the patient readmission rate and mortality. Secondary outcome measures: in the stationary burglary after arterial puncture, before anesthesia induction, intubation and 3min after intubation, surgery, surgery and after surgery began to end every 30min record the basic situation of patients (Bp, HR, SpO2, ABP, CO, SVV, CI, SV, CVP, Bis, ETCO2, T), intraoperative vasoactive 鑽�鐗╀娇鐢ㄩ嚕�

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