脉搏灌注变异指数在腹腔镜胃肠手术患者围术期液体管理中的应用价值

目的 探讨脉搏灌注变异指数(PVI)在腹腔镜胃肠手术患者围术期液体管理中的应用价值。方法 前瞻性研究。纳入2019年9月—2020年9月蚌埠医学院第一附属医院择期行腹腔镜胃肠手术的60例患者的临床资料,男39例、女21例,年龄60~70岁,美国麻醉医师协会(ASA)Ⅱ~Ⅲ级。采用随机数字表法分为两组:观察组30例,在PVI指导下补液;对照组30例,在中心静脉压、平均动脉压指导下补液。通过Masimo Radical-7和SedLine连续监测患者PVI、灌注指数(PI)、患者状态指数(PSI),术中PSI保持25~50。观察指标:(1)比较两组患者的基线资料;(2)围术期观察指标,包括术中晶体输入量、胶体输入量、输液总量、尿量,以及拔管时间、麻醉后监测治疗室(PACU)时间、警觉/镇静(OAA/S)评分、排气时间、住院时间;(3)血流动力学及容量指标,包括患者入室6 min(T0)、插管后6 min(T1)、切皮时(T2)、胃肠吻合后(T3)、拔管后6 min(T4)的心率、平均动脉压、PVI、PI、中心静脉压;(4)炎症细胞因子及动脉血乳酸指标,包括患者术前、术后第1天和第3天血浆中C反应蛋白、内毒素、降钙素原及乳酸。结果 (1)两组患者基线资料比较差异均无统计学意义(P值均＞0.05)。(2)两组患者拔管时间、PACU时间、OAA/S评分、住院时间差异均无统计学意义(P值均＞0.05),对照组术中晶体输液量、术中输液总量、术中尿量、排气时间均高于观察组,术中胶体输液量低于观察组,差异均有统计学意义(P值均＜0.05)。(3)两组间不同时间点心率、平均动脉压、PVI比较,差异均无统计学意义(P值均＞0.05);对照组的中心静脉压和PVI均高于观察组,前者在T2、T4时组间比较差异有统计学意义,后者在T1、T4时组间比较差异有统计学意义(P值均＜0.05)。组内不同时间点比较:两组患者的PI、对照组心率、观察组平均动脉压,差异均无统计学意义(P值均＞0.05);与T0时比较,观察组心率T1~T3逐渐降低、T4时升高,对照组平均动脉压T1时降低、T2~T4时逐渐升高,两组中心静脉压T1时降低、T2~T4时逐渐升高,两组PVI T1~T4逐渐降低,差异均有统计学意义(P值均＜0.05)。(4)两组患者内毒素、C反应蛋白、乳酸在术后第1、3天均高于术前,且术后对照组均高于观察组,差异均有统计学意义(P值均＜0.05)。结论 PVI监测应用于腹腔镜胃肠手术中能较好地指导液体管理,维持合适的循环容量和组织氧供需平衡,抑制机体炎症反应,对机体快速康复起到一定的积极作用。

Application value of pleth variability index in the peri-operative liquid control of patients undergoing laparoscopic gastrointestinal surgery

Objective This study aimed to evaluate the application value of pleth variability index (PVI) in the peri-operative liquid control of patients undergoing laparoscopic gastrointestinal surgery.Methods This prospective study was conducted from September 2019 to September 2020. Sixty patients (39 males and 21 females, aged 60-70 years old, Grade Ⅱ-Ⅲ of American Society of Anesthesiologists) were enrolled in the First Affiliated Hospital of Bengbu Medical College for laparoscopic gastrointestinal surgery. Random-number table method was used to divide the patients into two groups. The observation group (30 cases) received fluid rehydration under the guidance of PVI, while the control group (30 cases) received fluid supplementation under the guidance of central venous pressure and mean arterial pressure. Patient PVI, perfusion index (PI), and patient status index (PSI) were continuously monitored using Masimo Radical-7 and SedLine, and PSI was maintained between 25 and 50 intra-operatively. The outcome measures were as follows: (1) The baseline data of the two groups were compared. (2) Peri-operative observation indicators, including intraoperative crystal input, colloidal input, total infusion volume, urine volume, extubation time, post-anesthesia care unit(PACU) time, observer's assessment of alertness/sedation (OAA/S) score, exhaust time, and length of hospital stay were observed ;(3) Hemodynamics and volume indexes, including heart rate, mean arterial pressure, PVI, PI, and central venous pressure of patients were observed at 6 min after admission (T0), 6 min after intubation (T1), skin incision (T2), gastrointestinal anastomosis (T3), and 6 min after extubation (T4). (4) Inflammatory cytokines and arterial blood lactic acid indices, including C-reactive protein, endotoxin, procalcitonin, and lactic acid in plasma were observed before and at 1 and 3 days after surgery.Results (1) No significant difference was observed in the baseline data between the two groups (all P values＞0.05). (2) No statistically significant differences were observed in extubation time, PACU time, OAA/S score, and length of hospital stay between the two groups (all P values＞0.05). The crystal fluid volume, total infusion volume, urine volume, and exhaust time in the control group were significantly higher than those in the observation group, while the colloidal fluid volume was significantly lower than that in the observation group (all P values＜0.05). (3) No significant differences were observed in the heart rate, mean arterial pressure, and perfusion index between the two groups at different time (all P values＞0.05). The variation index of central venous pressure and pulse perfusion in the control group were higher than those in the observation group, the differences of the former at T2 and T4 and that of the latter at T1 and T4 were statistically significant (all P values＜0.05). Based on the comparison at different time points with each groups, no significant difference was observed in the perfusion index and heart rate of the control group and the average arterial pressure of the observation group (all P values＞0.05). Compared with T0 at each time point, the heart rate of observation group at T1-T3 gradually decreased but increased at T4. In the control group, the mean arterial pressure decreased at T1 and increased gradually at T2-T4. The central venous pressure in two groups decreased at T1 and gradually increased at T2-T4. The PVI at T1-T4 of two groups decreased gradually(all P values＜0.05). (4) The endotoxin, C-reactive protein, and lactic acid in two groups were higher than those before surgery 1 and 3 days after surgery, and the values from the control group were significantly higher than those from the observation group; the differences were statistically significant (all P values＜0.05).Conclusions The application of PVI monitoring in laparoscopic gastrointestinal surgery can effectively guide fluid management, maintain appropriate circulation capacity and balance of tissue oxygen supply and demand, inhibit the inflammatory response of the body, and play a positive role in the rapid recovery of the body.