目标导向液体治疗在腹腔镜肝脏切除的应用研究

发布时间：2018-07-02 20:06

本文选题：目标导向 + 液体治疗　；参考：《浙江大学》2014年博士论文

【摘要】：第一部分目标导向液体治疗在腹腔镜肝脏切除中的临床对比研究研究目的通过对目标导向液体治疗和常规液体治疗在腹腔镜肝脏切除中的前瞻性临床对比研究,评价目标导向液体治疗在腹腔镜肝脏切除中的应用价值。研究方法本研究采用病例对照研究方法,选取2012年1月至2013年7月期间在某医院微创中心行腹腔镜肝脏切除手术患者47例,以电脑软件随机分组法纳入目标导向组(GDT)23例,根据Flotrac/vigileo系统监测维持心指数2.5～4L/minxm2且每搏变异度13%；常规治疗组(CVP)24例,维持中心静脉压5-12mmHg且平均动脉压65-90mmHg。所有病例都由同一治疗组固定成员完成手术操作,均采用相同的全身麻醉方案,比较两组患者的手术时间、气腹时间、切肝时间、补液总量、出血量、术中尿量、输血量、有创动脉血压、心率及血气监测结果术中指标,术后气管导管拔除时间、肛门排气时间、进食时间、下床活动时间、术后3天内的镇痛情况、有无并发症、术后住院日及住院费用、术后7天内生命体征和腹腔引流量等临床指标,以及血常规、肝肾功能和凝血功能的实验室指标。结果3例因术中中转开腹排除本研究,最终完成研究共44例,其中GDT组21例,CVP组23例。两组在年龄、性别、体重指数、ASA分级、Child分级、疾病种类以及术式上无统计学差异(P0.05)。两组比较,在二氧化碳气腹时间、手术时间、切肝时间、出血量、术中尿量、输注晶体液总量以及术中输注红细胞比例上无统计学差异(P0.05),但GDT组术中输注胶体液总量少于CVP组(P0.05),具有统计学差异。术中两组之间的动脉平均压、心率、指脉搏氧饱和度、呼气末二氧化碳无统计学差异(P0.05),切肝期间GDT组的PH值高于CVP组(P0.05),建立气腹并头高位时GDT组BE值高于CVP组(P0.05),二氧化碳气腹过程中GDT组的动脉氧分压高于CVP组(P0.05)。两组病人的Hb、Hct、Lac无统计学差异(P0.05)。术后GDT组气管导管拔除明显早于CVP组(P0.01),GDT组肛门排气早于CVP组(P0.05),GDT组住院费用较少(P0.05),具有统计学差异。但两组在进食时间、离床活动时间、术后住院日及并发症发生率没有统计学差异(P0.05)。术后第三天起GDT组腹腔引I流量少于于CVP组(P0.05),术后5天和术后7天则显著低于CVP组(P0.01)。但日平均最高体温、心率和镇痛情况两组之间无统计学差异(P0.05)。术后3天时GDT组WBC低于CVP组,术后5天GDT组的Hb高于CVP组(P0.05)。术后5天CVP组的APTT长于GDT组,术后7天GDT组纤维蛋白原高于CVP组,具有统计学差异(P0.05)。术后3天、5天、7天GDT组的ALT低于CVP组(P0.05),术后5天GDT组的AST也低于CVP组(P0.05)。其余实验室指标两组之间无统计学差异(P0.05)。结论与常规液体治疗相比,腹腔镜肝脏切除病人在目标导向液体治疗下需要输注的胶体液更少,组织微循环及氧供更好,肝功能和凝血影响更小,炎症反应更轻,肠道功能恢复更早,在短期临床预后中具有优势,还能明显减少住院费用。第二部分目标导向液体治疗对腹腔镜肝脏切除患者应激反应的影响研究目的比较目标导向液体治疗和常规液体治疗对腹腔镜肝脏切除患者应激反应的影响。研究方法将2012年1月至2013年7月在某医院微创中心行腹腔镜肝脏切除术的最终入选患者44例,具体分组情况、麻醉及手术过程详见第一部分。比较两组患者手术前后外周静脉血中白细胞总数及中性粒细胞百分数以及IL-6、IL-10、 TNF-α等细胞因子和HSP70、SAA和CRP等急性反应蛋白的变化,并比较两组可的松、胰岛素、血糖及胰岛素抵抗指数(HI)的差异以及术后7天内SIRS发生的情况。结果术前两组之间可的松、胰岛素、血糖和HI无统计学差异(P0.05)。术后3小时和12小时GDT组的可的松水平显著低于CVP组(P0.01)。术后12小时、术后1天、3天GDT组的血糖和胰岛素水平均低于CVP组(P0.05)。术后3天内GDT组HI低于CVP组(P0.05),其中术后12小时和术后3天两个时间点有显著统计学差异(P0.01)。术后1天发生SIRS比例最高,GDT组发生率(42.86%)低于CVP组发生率(73.91%),两组之间存在统计学差异(P0.05),其余时间点两组之间随无统计学差异。术前两组之间各细胞因子和急性反应蛋白均无统计学差异(P0.05)。术后12小时、术后1天、3天GDT组IL-6水平低于CVP组(P0.05),术后5天、7天GDT组IL-6水平明显低于CVP组(P0.01)。GDT组与CVP组之间进行比较,除了术后5天这个时间点之外,术后所有其他时间点GDT组的IL-10水平均高于CVP组(P0.05)。术后12小时、术后1天、3天、7天GDT组的TNF-α水平低于CVP组(P0.05)。GDT组术后12小时、术后1天、术后3天的HSP70水平低于CVP组(P0.05),术后3天内各时间点GDT组的SAA水平均低于CVP组(P0.05),术后12小时和术后1天GDT组的CRP水平低于CVP组(P0.05)。结论与常规液体治疗相比,腹腔镜肝脏切除病人采用GDT液体治疗能降低应激相关激素的水平和胰岛素抵抗程度,也能在一定程度上降低术后炎性细胞因子和急性期反应蛋白水平,降低术后SIRS发生率,表明GDT液体治疗有助于减轻术后机体的炎症应激反应程度,加快机体从应激状态中恢复。第三部分目标导向液体治疗对腹腔镜肝脏切除患者免疫功能的影响研究目的比较目标导向液体治疗和常规液体治疗对腹腔镜肝脏切除患者免疫功能的影响。研究方法将2012年1月至2013年7月在某医院微创中心行腹腔镜肝脏切除的最终入选患者44例,具体分组情况、麻醉及手术过程详见第一部分。比较术后1、3、5、7天两组患者外周静脉血T淋巴细胞CD3、CD4、CD8以及单核细胞CD14、HLA-DR表达水平、NK细胞比例以及IgA、IgM、IgG、C3及C4水平。结果GDT组与CVP组比较各时间点CD3+T淋巴细胞表达无统计学差异(P0.05)。GDT组与CVP组之间比较,术前CD4+T淋巴细胞表达、CD4+/CD8+T淋巴细胞比例以及NK细胞比例均无统计学差异。术后各时间点GDT组CD4+T淋巴细胞表达以及CD4+/CD8+T淋巴细胞比例均高于CVP组(P0.05)。术后5天、7天GDT组的NK淋巴细胞比例高于CVP组(P0.05),术后3天、5天、7天GDT组的单核细胞CD14+/HLA-DR+表达均高于CVP组(P0.05)。GDT组与CVP组相比,术前外周血IgA、IgG/IgG/C3、C4两组之间均无统计学差异(P0.05)。GDT组在术后3天IgA的表达高于CVP组(P0.05),术后1天及术后3天GDT组的IgM和IgG表达均高于CVP组(P0.05),术后1天GDT组的C4水平高于CVP组(P0.05)。结论腹腔镜肝脏切除病人术后早期表现为轻度免疫抑制状态,术后早期GDT组免疫细胞比例和免疫球蛋白水平总体上高于CVP组,免疫球蛋白消耗更少,提示GDT组细胞免疫功能恢复比CVP组更快更早,对体液免疫功能的影响更少,GDT液体治疗策略较传统液体治疗策略对术后免疫功能具有更好的保护作用。
[Abstract]:Part one
Clinical comparative study of target directed fluid therapy in laparoscopic hepatectomy
Objective to evaluate the value of objective guided liquid therapy in laparoscopic hepatectomy through prospective clinical comparative study of target oriented liquid therapy and conventional liquid therapy in laparoscopic hepatectomy.
In this study, a case control study was used to select 47 cases of laparoscopic hepatectomy from January 2012 to July 2013 in a minimally invasive center of a hospital, and 23 cases were included in the target group (GDT) by the computer software random grouping method. The cardiac index was monitored by the Flotrac/vigileo system, and the cardiac index was 2.5 to 4L/minxm2 and each stroke diversity was 1. 3%, 24 cases in the routine treatment group (CVP), maintaining central venous pressure of 5-12mmHg and average arterial pressure in all cases were performed by the same group of fixed members. The same general anesthesia scheme was used to compare the operation time, pneumoperitoneum time, liver cutting time, total amount of fluid, amount of bleeding, urine volume, blood transfusion in the two groups. Arterial blood pressure, heart rate and blood gas monitoring results, postoperative endotracheal tube extraction time, anus exhaust time, feeding time, ambulation time, 3 days of postoperative analgesia, postoperative hospitalization days and hospitalization expenses, clinical indicators of life body and abdominal volume within 7 days after operation, blood routine and liver and kidney work. Laboratory indicators of energy and coagulation function.
Results 3 cases were excluded because of the operation during the operation, and 44 cases were completed, including 21 cases in group GDT and 23 cases in group CVP. The two groups were in age, sex, body mass index, ASA classification, Child classification, disease types, and no statistical difference (P0.05). The two groups were compared in groups of carbon dioxide pneumoperitoneum, operation time, liver cutting time, bleeding volume, and operation. There was no significant difference in the amount of urine, the amount of the infusion of crystal liquid and the proportion of the infusion of red blood cells (P0.05), but the total amount of the infusion colloid in the group GDT was less than that of the CVP group (P0.05), with statistical difference. The mean arterial pressure, heart rate, pulse oxygen saturation, and no statistical difference between the two groups during the operation were not statistically different (P0.05), and the GDT group during the liver resection period The pH value of the GDT group was higher than that of the CVP group (P0.05), and the BE value of group GDT was higher than that of group CVP (P0.05). The arterial oxygen partial pressure in group GDT in the process of carbon dioxide pneumoperitoneum was higher than that of group CVP (P0.05). There was no statistical difference between the two groups of patients' Hb, Hct, and the extraction of the tracheal conduit was earlier than that of the group. 5), in group GDT, the cost of hospitalization was less (P0.05), but there was statistical difference. But there was no statistical difference between the two groups at the time of feeding, the time of leaving the bed, the days of hospitalization and the incidence of complications (P0.05). The I flow rate in the GDT group was less than that of the CVP group (P0.05) on the third day of the operation, and the average day after the operation was lower than that of the CVP group (P0.01), but the average day was the highest. There was no statistical difference between the two groups of body temperature, heart rate and analgesia (P0.05). At the 3 day after operation, the WBC in group GDT was lower than that in group CVP, and the Hb in group GDT was higher than that in group CVP (P0.05) on the 5 day after operation. The APTT of group CVP in group CVP was longer than that in the GDT group, and the fibrinogen in the GDT group was higher than that of the group at the 7 day after the operation. The 3 days, 5 days and 7 days after the operation were lower than those of the group. 05) the AST of group GDT was also lower than that of group CVP (P0.05) on the 5 day after operation. There was no significant difference in the other laboratory indexes between the two groups (P0.05).
Conclusion compared with conventional liquid therapy, patients undergoing laparoscopic hepatectomy need less infusion of colloid fluid, better tissue microcirculation and oxygen supply, less liver function and coagulation, lighter effects of liver function, lower inflammatory response, early intestinal function recovery, advantages in short-term clinical prognosis and significantly reduced hospitalization costs.
The second part
Effect of target directed fluid therapy on stress response in patients undergoing laparoscopic liver resection
Objective to compare the effects of target directed fluid therapy and conventional fluid therapy on stress response in patients undergoing laparoscopic liver resection.
Methods 44 patients were selected from January 2012 to July 2013 in a hospital minimally invasive Center for laparoscopic hepatectomy. The specific grouping situation, anesthesia and operation process were detailed in the first part. Compared the total number of white blood cells and neutrophils in peripheral venous blood of the two groups before and after operation, and the details of IL-6, IL-10, TNF- A and so on. The changes of cytokine and acute reaction proteins such as HSP70, SAA and CRP, and the difference between two groups of cortisone, insulin, blood glucose and insulin resistance index (HI) and the occurrence of SIRS within 7 days after the operation were compared.
Results cortisone, insulin, blood glucose and HI were not statistically different between the two groups (P0.05). The cortisone level in group GDT 3 hours and 12 hours after operation was significantly lower than that in group CVP (P0.01). The blood glucose and insulin levels in group GDT were lower than those in group CVP (P0.05) after 12 hours after operation, 1 days after operation, 3 days after operation. HI in group GDT was lower than CVP group (P0.05) within 3 days after operation, among which 12 were smaller after operation. There were significant statistical differences between two time points and 3 days after operation (P0.01). The proportion of SIRS in 1 days after operation was the highest, the incidence of group GDT (42.86%) was lower than that of group CVP (73.91%), there was statistical difference between the two groups (P0.05), and there was no statistical difference between the two groups of the other time points. All cytokines and acute reactive protein among the two groups before the operation were neither. Statistical difference (P0.05). The IL-6 level in group GDT was lower than that in group CVP (P0.05) 12 hours after operation, 3 days after operation, and in group GDT, 5 days after operation, and 7 days in group GDT, significantly lower than that between CVP group (P0.01).GDT group and CVP group. Except for 5 days after operation, the level of GDT group at all other time points after operation was higher than that of 12 group. 12 small after operation. At 1 days, 3 days and 7 days after operation, the level of TNF- alpha in group GDT was lower than that of group CVP (P0.05).GDT group 12 hours after operation, 1 days after operation, HSP70 level in 3 days after operation was lower than that of group CVP (P0.05). The SAA level of group GDT within 3 days after operation was lower than that of CVP group (P0.05), and 12 hours after operation and 1 days after operation were lower than that of the group.
Conclusion compared with conventional liquid therapy, GDT liquid therapy can reduce the level of stress related hormones and insulin resistance in patients with laparoscopic hepatectomy, and to some extent reduce the level of postoperative inflammatory cytokines and acute phase reaction protein, and reduce the incidence of postoperative SIRS hair growth, indicating that GDT liquid therapy helps to reduce the postoperative pathogenesis. The degree of inflammation and stress of the body accelerate the recovery of the body from stress.
The third part
Effect of target directed fluid therapy on immune function in patients undergoing laparoscopic liver resection
Objective to compare the effects of target directed fluid therapy and conventional fluid therapy on the immune function of patients undergoing laparoscopic liver resection.
Methods 44 patients undergoing laparoscopic hepatectomy from January 2012 to July 2013 were selected in a minimally invasive center of a hospital. The specific grouping, anesthesia and operation process were detailed in the first part. The T lymphocyte CD3, CD4, CD8, and monocyte CD14, HLA-DR expression level, NK cells were compared in groups of peripheral venous blood at 1,3,5,7 days after operation. Proportions and levels of IgA, IgM, IgG, C3 and C4.
Results there was no significant difference in CD3+T lymphocyte expression at each time point between group GDT and group CVP (P0.05), there was no significant difference in the expression of CD4+T lymphocyte, the proportion of CD4+/CD8+T lymphocyte and the proportion of NK cells in.GDT and CVP groups. The expression of CD4+T lymphocyte in GDT group and the proportion of CD4+/CD8+T lymphocytes at each time point after operation. The ratio of NK lymphocyte in group GDT was higher than that of group CVP (P0.05) at 5 days after operation, and the ratio of NK lymphocyte in group GDT was higher than that in group CVP (P0.05). The expression of CD14+/HLA-DR+ in group GDT was higher than that of group CVP (P0.05) 3 days, 5 days after operation (P0.05).GDT group compared with CVP group. In group CVP (P0.05), the expressions of IgM and IgG in group GDT were higher than those in group CVP (P0.05) 1 days after operation and 3 days after operation. The C4 level in GDT group was higher than that in CVP group on 1 days after operation (P0.05).
Conclusion the early postoperative manifestation of laparoscopic hepatectomy is mild immunosuppressive state. In the early post operation, the immunoglobulin level and immunoglobulin level in the early GDT group were higher than that in the CVP group, and the immunoglobulin consumption was less. It suggested that the cell immune function recovery in the GDT group was faster and earlier than the CVP group, and the immune function of the body fluid was less, GDT liquid treatment was less. Compared with the traditional fluid therapy strategy, the strategy has better protective effect on postoperative immune function.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R657.3

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