去甲肾上腺素与去氧肾上腺素在SVV导向液体治疗下老年结直肠癌手术对组织氧供和血流动力学稳定的研究

发布时间：2018-03-10 20:18

  本文选题：老年人　切入点：SVV　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的液体管理是危重患者复苏的基石,尤其是老年患者的液体管理,一直是困扰麻醉医生和外科医生的棘手问题。若开放液体管理,会引起组织水肿、肠道梗阻、肺部并发症等一系列不良后果,且延长ICU和住院时间;反之,若限制液体入量,则又会引起血压降低导致组织低灌注、全身炎症反应综合征以及继发多器官功能障碍;因此,液体超负荷或者过度限制液体入量,对患者都是有害的。近年来,研究者们发现了一种新的治疗方法,即通过优化心脏前、后负荷以及心肌收缩力来实现血流动力学平稳,达到机体氧供需平衡状态,因此提出了目标导向液体治疗(Goal directed fluid therapy,GDFT)。GDFT是根据患者的年龄、体重、性别、疾病特点、患者全身情况等指标,制定的个体化补液方案,常用的监测指标为肺动脉导管和超声等,由于其高创伤性、高花费等原因限制了使用,而每搏量变异度(Stroke volume variation,SVV)是一种便捷、准确的测量容量反应性的血流动力学参数,具有较高的灵敏度和特异性。随着全球人口老龄化,老年患者的手术量呈几何倍数增长,而老年患者由于自身心血管系统功能的衰退、术前肠道准备、麻醉药物的心血管抑制作用等原因,术中极易发生血流动力学波动,影响组织器官灌注及氧供,甚至危及生命。然而老年患者在麻醉诱导期间发生的低血压,通常主要是因为麻醉状态下其外周血管阻力降低使得血管扩张导致,基于前人研究一般给予去甲肾上腺素来纠正,然而去氧肾上腺素也是一种选择性a-受体激动剂,且可以反射性降低心率以及心输出量,减少心脏做功。鉴于在svv导向液体治疗中去甲肾上腺素与去氧肾上腺素的对比鲜有研究,因此我们设计了本课题。拟选用择期行结直肠癌根治术的老年患者,在svv导向液体治疗下,观察去甲肾上腺素与去氧肾上腺素对老年患者血流动力学的维持以及组织氧合情况。方法我们收集了40位,asa分级为ii~iii的行结直肠癌手术的老年患者资料。患者被随机分为2组:去甲肾上腺素组(组1;n=20)和去氧肾上腺素组(组2;n=20)。两组患者在术中均接受背景输注量为5ml/kg/h的晶体液(乳酸林格液),当svv9%(由flotrac/vigileo3.0仪器监测)时,则额外给予200ml胶体液(羟乙基淀粉130/0.4;6%),观察5min后重复给予液体负荷量,直至svv9%;若svv在9-13%之间,给予8m/kg/h的晶体液(乳酸林格液)。在麻醉诱导开始时,血管活性药(去甲肾上腺素或去氧肾上腺素)以5ml/h的背景速度输注,以维持收缩压90mmhg或map65mmhg。若血压下降超过20%基础值或ci2.5l/min/m2时,则给予多巴酚丁胺。所有患者均接受中心静脉穿刺置管及桡动脉穿刺置管,并监测ecg,map,cvp,脉搏氧,体温,呼末二氧化碳和脑电双频指数。两组患者均接受标准的麻醉诱导,分别在入室穿动脉后,诱导即刻,诱导后3min时,手术开始和手术结束时记录血流动力学参数:hr,spo2,cvp,bp,svv,sv,ci,co,尿量,bis,t,etco2,abg,vbg,crt。结果我们发现随着手术的进行,两组患者的hr和map呈下降趋势。在手术结束时去氧肾上腺素组hr(65.45±10.25)低于去甲肾上腺素组(69.4±10.9)患者(p=0.751);而在手术结束时sv,ci和co值增加,去氧组明显减低。术中晶体液的入量,去氧肾上腺素组(1682.5±837ml)明显低于去甲肾上腺素组(2143.5±1014ml),p=0.125。同样的,胶体液的入量比较,去氧肾上腺素组(488.5±153ml)也低于去甲肾上腺素组(713±529ml),p=0.082。术中血管活性药的使用量,去氧肾上腺素组(18.87±20.68ml)比去甲肾上腺素组(38.35±40.9ml)略低,但P=0.065,两组相比无明显统计学差异。术中失血量,麻醉持续时间和CRT值,两组相比均无统计学差异。结论在行结直肠癌根治术的老年患者中,去氧肾上腺素与去甲肾上腺素同样安全,二者均可以维持老年患者的血流动力学平稳以及组织氧供需平衡。在无严重心血管疾病的老年患者中,去氧肾上腺素也是一种不错的选择。
[Abstract]:The purpose of fluid management is the cornerstone of resuscitation in critically ill patients, especially elderly patients with liquid management, has been a thorny problem to doctors and surgeons anesthesia problems. If the open fluid management, causes tissue edema, intestinal obstruction, pulmonary complications and a series of adverse consequences, and prolong ICU and hospitalization time; on the contrary, if the restriction of fluid intake it will lead to lower blood pressure, leading to tissue hypoperfusion, systemic inflammatory response syndrome and multiple organ dysfunction secondary; therefore, fluid overload or excessive fluid restriction, is harmful to the patients. In recent years, the researchers found a new treatment method, namely by optimizing the heart before and after load and myocardial contractility to achieve stable hemodynamics, reach the balance of supply and demand of oxygen, therefore proposed the goal-directed fluid therapy (Goal directed fluid therapy, GDFT) is based on the.GDFT The patient's age, weight, gender, disease characteristics, the general condition of patients and other indicators, individual replacement schemes, monitoring indicators commonly used for pulmonary artery catheter and ultrasound, due to its high traumatic high cost and other reasons, restrictions on the use and stroke volume variation (Stroke volume, variation, SVV) is a a convenient measurement of volume responsiveness in hemodynamic parameters accurately, has higher sensitivity and specificity. With the global population aging, the amount of surgery in elderly patients is increasing exponentially, and because of the recession itself in elderly patients with cardiovascular function, preoperative bowel preparation, anesthetic inhibition of cardiovascular and other reasons, prone to hemodynamic fluctuation during the operation, effect of tissue perfusion and oxygen supply, and even life-threatening. However in elderly patients during the induction of anesthesia hypotension, usually mainly because of anesthesia. Vascular resistance under peripheral vascular expansion leads to decrease in the previous research, the general noradrenaline corrected based on, however, phenylephrine is a selective a- receptor agonist, and can reduce reflex heart rate and cardiac output, reduced cardiac work. Few study contrast in norepinephrine and phenylephrine in SVV oriented liquid in the treatment, so we design this topic. To select elective radical resection for colorectal cancer in elderly patients, SVV guided fluid therapy, observation of norepinephrine and phenylephrine on hemodynamics in elderly patients undergoing maintenance and tissue oxygenation. Methods we collected 40 elderly patients with ASA, data classification ii~iii for colorectal cancer surgery. The patients were randomly divided into 2 groups: norepinephrine group (group 1; n=20) and phenylephrine group (group 2; n=20 two). All patients received background infusion of 5ml/kg/h in liquid crystal operation (Ringer), when svv9% (flotrac/vigileo3.0 instrument monitoring), is additional 200ml colloid (130/0.4 hydroxyethyl starch; 6%), 5min was observed after repeated given liquid load, straight to svv9%; if SVV in 9-13% liquid crystal, giving 8m/kg/h (Ringer). At the beginning of induction of anesthesia, vasoactive drugs (norepinephrine or phenylephrine) in the background of 5ml/h speed infusion to maintain systolic blood pressure 90mmHg or map65mmhg. if the blood pressure drop over 20% basic value or ci2.5l/min/m2, were given dobutamine. All patients received center vein puncture and radial artery catheterization, and monitoring of ECG, map, CVP, oxygen pulse, body temperature, end expiratory carbon dioxide and bispectral index. Two groups were treated with standard anesthesia induction in perforating artery after burglary, 璇卞�煎嵆鍒�,璇卞�煎悾�

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