动态血流动力学指标在梗阻性黄疸患者围术期的应用
发布时间：2018-12-27 19:24
【摘要】：容量管理是影响患者围术期并发症和病死率的关键因素之一。传统指导容量管理的指标不能准确反映容量状态。近几年研究发现，每搏量变异(SVV)、脉搏压变异(PPV)、脉搏氧饱和度波形变异(PVI)等动态血流动力学指标能够较为精准地预测机体对补液治疗的反应性，并认为这些指标指导容量管理可以改善预后。然而，SVV、PPV、PVI等在梗阻性黄疸患者判断容量状态的有效性还未见报道。 本研究主要探索动态血流动力学指标在梗阻性黄疸患者预测液体反应的能力，以及这些指标对预后的影响。 第一部分：动态血流动力学指标在梗阻性黄疸患者预测液体反应能力的比较 目的：分析和比较SVV、PPV、PVI等在梗阻性黄疸患者预测液体反应的能力。方法：35例梗阻性黄疸患者，分别于术前(麻醉诱导插管机械通气后)和术中(腹腔探查后)进行液体反应实验，在5到10min内输注250ml胶体。分别记录液体治疗前后的血流动力学指标。液体治疗后每搏量指数(SVI)增加大于10%标记为液体反应阳性。绘制受试者操作特征曲线(ROC曲线)，分析和比较SVV、PPV、PVI等预测液体反应的能力。结果：术前液体反应实验，SVV、PPV、PVI等ROC曲线下面积分别为：0.955、0.875、0.593，判断阈值(敏感度/特异度%)分别为：10%(100.0/92.3)、8%(91.7/69.2)、13%(58.3/53.8)。术中液体反应实验，SVV、PPV、PVI等ROC曲线下面积分别为：0.699、0.710、0.567，判断阈值(敏感度/特异度%)分别为：10%(45.5/85.73)、7.5%(63.6/71.4)、15%(63.6/57.1)。结论：术前，SVV和PPV都能够准确的预测液体反应而PVI预测液体反应失败；术中，除了PPV有中等的预测液体反应能力以外，SVV和PVI均不能准确的预测液体反应。 第二部分：应用PPV指导梗阻性黄疸患者围术期容量管理的研究 目的：分析PPV指导梗阻性黄疸患者围术期容量管理对预后的影响。方法：60例梗阻性黄疸患者随机分为PPV组(n=30)和对照组(n=30)，PPV组通过输注胶体维持PPV在8%以下，对照组由麻醉医生根据临床经验确定容量管理方案。比较两种容量管理方案对患者乳酸水平、术后30天并发症及死亡率、术后住院日以及ICU住院日等的影响。结果：手术过程中PPV组输注了更多的胶体(1245±350vs776±391ml，，P＜0.001)，但两组液体总出入量以及血管活性药物用量无差别。手术结束时PPV组乳酸水平低于对照组(1.45±0.63vs1.93±0.88mmol/L，P=0.024)。实验组术后并发症发病率低于对照组但未达到统计学差异(25.9%vs39.3%，P=0.291)。两组在死亡率、ICU及术后住院日等方面没有差别。结论：应用PPV指导梗阻性黄疸患者围术期容量管理有减少术后并发症的趋势。
[Abstract]:Volume management is one of the key factors affecting perioperative complications and mortality. The traditional index of capacity management can not accurately reflect the capacity state. In recent years, it has been found that dynamic hemodynamic indices such as variation of pulse pressure per stroke volume, (SVV), pulse pressure variation, (PPV), pulse oxygen saturation waveform variation, (PVI) can accurately predict the body's response to fluid resuscitation. It is suggested that these indexes can improve the prognosis. However, the effectiveness of SVV,PPV,PVI et al in judging volume status in patients with obstructive jaundice has not been reported. The purpose of this study was to explore the ability of dynamic hemodynamic indexes to predict fluid response in patients with obstructive jaundice and their influence on prognosis. Part I: comparison of dynamic hemodynamic indices in predicting fluid response in patients with obstructive jaundice objective: to analyze and compare the ability of SVV,PPV,PVI and others to predict fluid response in patients with obstructive jaundice. Methods: 35 patients with obstructive jaundice underwent fluid reaction test before operation (after anesthesia induced intubation and mechanical ventilation) and during operation (after abdominal exploration). 250ml colloid was infused in 5 to 10min. The hemodynamic indexes before and after fluid therapy were recorded. After fluid therapy, (SVI) increased by more than 10% and marked as liquid positive. The operating characteristic curve (ROC curve) was drawn to analyze and compare the ability of SVV,PPV,PVI and so on to predict liquid reaction. Results: in the preoperative fluid reaction test, the area under the ROC curve of SVV,PPV,PVI was 0.955 / 0.8750.593.The threshold value (sensitivity / specificity%) was 10% (100.0 / 92.3), respectively. 8% (91.7% 69.2), 13% (58.3% 53.8). In the intraoperative fluid reaction test, the area under the ROC curve of SVV,PPV,PVI and so on were 0.699v 0.71010 / 0.567.The threshold value (sensitivity / specificity%) were 10% (45.5 / 85.73), 7.5% (63.6 / 71.4), respectively, and the sensitivity / specificity% were 10% (45.5 / 85.73), 7.5% (63.6 / 71.4), respectively. 15% (63.6% 57.1). Conclusion: before operation, both SVV and PPV can predict the liquid reaction accurately while PVI can predict the liquid reaction failure. In addition to the moderate ability of PPV to predict the liquid reaction, SVV and PVI can not predict the liquid reaction accurately. Part two: study on perioperative volume management in patients with obstructive jaundice by PPV objective: to analyze the effect of perioperative volume management guided by PPV on the prognosis of patients with obstructive jaundice. Methods: sixty patients with obstructive jaundice were randomly divided into PPV group (n = 30) and control group (n = 30), which maintained PPV below 8% by infusion of colloid. The effects of two volume management schemes on lactic acid levels, postoperative complications and mortality, postoperative hospitalization days and ICU hospitalization days were compared. Results: more colloids were injected into PPV group during operation (1245 卤350vs776 卤391ml, P < 0.001), but there was no difference in the total volume of liquid and the dosage of vasoactive drugs between the two groups. At the end of operation, the lactate level in PPV group was lower than that in control group (1.45 卤0.88 mmol / L). The incidence of postoperative complications in the experimental group was lower than that in the control group, but there was no statistical difference (25.9 vs 39.3%, 0.291). There was no difference in mortality, ICU and postoperative hospital stay between the two groups. Conclusion: perioperative volume management for obstructive jaundice patients with PPV has a tendency to reduce postoperative complications.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R614
[Abstract]:Volume management is one of the key factors affecting perioperative complications and mortality. The traditional index of capacity management can not accurately reflect the capacity state. In recent years, it has been found that dynamic hemodynamic indices such as variation of pulse pressure per stroke volume, (SVV), pulse pressure variation, (PPV), pulse oxygen saturation waveform variation, (PVI) can accurately predict the body's response to fluid resuscitation. It is suggested that these indexes can improve the prognosis. However, the effectiveness of SVV,PPV,PVI et al in judging volume status in patients with obstructive jaundice has not been reported. The purpose of this study was to explore the ability of dynamic hemodynamic indexes to predict fluid response in patients with obstructive jaundice and their influence on prognosis. Part I: comparison of dynamic hemodynamic indices in predicting fluid response in patients with obstructive jaundice objective: to analyze and compare the ability of SVV,PPV,PVI and others to predict fluid response in patients with obstructive jaundice. Methods: 35 patients with obstructive jaundice underwent fluid reaction test before operation (after anesthesia induced intubation and mechanical ventilation) and during operation (after abdominal exploration). 250ml colloid was infused in 5 to 10min. The hemodynamic indexes before and after fluid therapy were recorded. After fluid therapy, (SVI) increased by more than 10% and marked as liquid positive. The operating characteristic curve (ROC curve) was drawn to analyze and compare the ability of SVV,PPV,PVI and so on to predict liquid reaction. Results: in the preoperative fluid reaction test, the area under the ROC curve of SVV,PPV,PVI was 0.955 / 0.8750.593.The threshold value (sensitivity / specificity%) was 10% (100.0 / 92.3), respectively. 8% (91.7% 69.2), 13% (58.3% 53.8). In the intraoperative fluid reaction test, the area under the ROC curve of SVV,PPV,PVI and so on were 0.699v 0.71010 / 0.567.The threshold value (sensitivity / specificity%) were 10% (45.5 / 85.73), 7.5% (63.6 / 71.4), respectively, and the sensitivity / specificity% were 10% (45.5 / 85.73), 7.5% (63.6 / 71.4), respectively. 15% (63.6% 57.1). Conclusion: before operation, both SVV and PPV can predict the liquid reaction accurately while PVI can predict the liquid reaction failure. In addition to the moderate ability of PPV to predict the liquid reaction, SVV and PVI can not predict the liquid reaction accurately. Part two: study on perioperative volume management in patients with obstructive jaundice by PPV objective: to analyze the effect of perioperative volume management guided by PPV on the prognosis of patients with obstructive jaundice. Methods: sixty patients with obstructive jaundice were randomly divided into PPV group (n = 30) and control group (n = 30), which maintained PPV below 8% by infusion of colloid. The effects of two volume management schemes on lactic acid levels, postoperative complications and mortality, postoperative hospitalization days and ICU hospitalization days were compared. Results: more colloids were injected into PPV group during operation (1245 卤350vs776 卤391ml, P < 0.001), but there was no difference in the total volume of liquid and the dosage of vasoactive drugs between the two groups. At the end of operation, the lactate level in PPV group was lower than that in control group (1.45 卤0.88 mmol / L). The incidence of postoperative complications in the experimental group was lower than that in the control group, but there was no statistical difference (25.9 vs 39.3%, 0.291). There was no difference in mortality, ICU and postoperative hospital stay between the two groups. Conclusion: perioperative volume management for obstructive jaundice patients with PPV has a tendency to reduce postoperative complications.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R614
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