活体肝移植术患者术中每搏量变异度变化及临床意义

目的探讨成人活体部分肝移植术患者术中每搏量变异度(SVV)的变化规律及意义。方法对32例患者于静吸复合全麻下行部分肝移植术。分别于切皮前即刻(T0)、无肝期5 min(T1)、30 min(T2)、新肝期5 min(T3)、30 min(T4)和术毕(T5)记录SVV、心排血量(CO)、心脏指数(CI)、HR、MAP、CVP、肺动脉毛细血管楔压(PC-WP)和混合静脉血氧饱和度(S_VO2)。结果与T0时比较:SVV于T1～2升高,T3～4降低,T5时恢复至切皮前水平;CO和CI于T1～4降低,T5时升高;HR于T1～5时升高;MAP于T1～4降低,T5时恢复至切皮前水平;CVP和PCWP于T1～2降低,T3时升高,T4时恢复至切皮前水平;S_VO2于T1～2降低,T3～5时升高(P<0.05或P<0.01)。结论 SVV于无肝期时升高,新肝期时降低,术毕时恢复至切皮前水平。提示活体肝移植术无肝期时血容量不足,此期机体对液体治疗的反应性较好,需积极补液治疗;而新肝期时机体对液体负荷的反应效果下降,应避免过多补液。     

每搏量变异度在预测液体治疗反应性中的应用

<正>对于大多数血流动力学不稳定的危重症患者,通过补液提高心脏前负荷,从而增加心输出量,改善组织灌注,是临床重要的抢救措施之一。然而在过去几年的研究中显示,重症监护病房(ICU)中仅有50%的患者可以从补液治疗中获益,即对液体复苏治疗有反应性。因此能够在液体复苏治疗之前,准确评估出对液体复苏有反应的患者,避免补液可能带来的风险,如肺水肿等,是至关重要的。临床上判断患者循     

每搏量变异度监测在脓毒血症休克行机械通气患者血容量复苏中的应用

目的探讨每搏量变异度(SVV)监测在脓毒血症休克行机械通气患者血容量复苏中的应用。方法脓毒血症休克行机械通气患者71例,分为SVV、中心静脉压(CVP)组,分别用经外周动脉波形分析(FloTrac-Vigileo)系统监测SVV和传统CVP监测来指导血容量复苏,比较6 h后两组中心静脉氧饱和度(ScvO2)、MAP、24 h后血乳酸水平及急性生理和慢性健康状况评估(APACHEⅡ)评分情况。结果 6 h后SVV组与CVP组ScvO2、MAP相近(P均>0.05),24 h后SVV组血乳酸水平及APACHEⅡ评分明显低于CVP组(P均<0.05)。结论 SVV监测能更好地指导脓毒血症休克行机械通气患者的血容量复苏,效果优于传统CVP监测。     

每搏量变异率在老年胸科手术患者中的应用

目的观察每搏量变异率(SVV)在老年胸科手术患者单肺通气前后的变化。方法择期行胸腔镜辅助下肺癌根治术老年组和中年组患者,每组12例。术中使用Vigileo系统监测血流动力学,观察患者在麻醉后、单肺通气(OLV)30 min、OLV结束恢复TLV即刻、恢复双肺通气30 min后的心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、心输血量(CO)、每搏量(SV)、SVV及计算值外周血管阻力(SVR)的变化。结果与麻醉后比较,两组患者的HR、MAP、CO、SV比较无统计学差异(P>0.05),但老年组患者CVP升高(P<0.05)、SVV和SVR在OLV 30 min和恢复双肺通气30 min后升高(P<0.05)。结论 SVV在OLV开始和结束时反映瞬间血容量变化,可作为胸科麻醉中老年患者的有效监测指标。     

每搏量变异度监测活体肝移植手术患者血容量变化的准确性评价

目的评价每搏量变异度(SVV)监测活体肝移植手术患者血容量变化的准确性。方法择期行活体肝移植手术患者23例,麻醉诱导后行气管插管,气管插管后15 min,以0.4 mL/(kg.min)的速率静脉输注6%羟乙基淀粉8 mL/kg。于输注前即刻和输注后3 min记录MAP、HR、CVP、心脏指数(CI)和SVV,计算SVV和CI的变化率(ΔSVV和ΔCI)。以ΔCI≥15%为扩容有效标准,绘制SVV判断血容量变化的ROC曲线,计算曲线下面积(AUC)及其95%可信区间(95%CI)。结果与治疗前即刻比较,治疗结束后3 min MAP、CVP、CI升高而SVV下降(P<0.05或<0.01)。ROC曲线分析结果显示,SVV监测血容量变化的AUC为0.865(95%CI 0.685～1.000),诊断阈值为9.5%,灵敏度为84.6%,特异度为80%。结论 SVV监测活体肝移植手术患者血容量变化准确性良好,可用于指导容量治疗。     

校正左心室射血时间指导冠状动脉搭桥术围术期容量管理中的应用

目的研究校正左心室射血时间(LVETc)指导非体外循环冠状动脉搭桥术围术期容量管理的应用价值。方法纳入2016年4月至2019年4月北京电力医院收治的124例择期行非体外循环冠状动脉搭桥术患者,按围术期容量管理目标的不同分为两组,各62例,其中观察组以LVETc为容量管理目标,对照组以每搏量变异度(SVV)为容量管理目标。观察两组患者手术时间、总补液量、术中尿量、术中失血量、拔管时间,血管活性药使用情况及术后心血管不良事件发生率。分别于心包打开时及进行左前降支、钝缘支、后降支搭桥时,监测患者平均动脉压、每搏量指数、心指数、全身血管阻力及血乳酸、氧供指数、氧耗指数、血糖变化情况进行分析。结果观察组总补液量显著低于对照组(t=7.702,P <0.01),观察组全身血管阻力均显著高于对照组(t=10.878、4.955、6.178、5.800,均P <0.01),心指数在心包打开时及吻合左前降支时显著低于对照组(t=6.428、6.898,均P <0.01),氧供指数在吻合左前降支、钝缘支、后降支时均显著低于对照组(t=2.998、2.501、5.109,均P <0.05)。观察组术中维持血流动力学稳定行去氧肾上腺素治疗的患者占61.29%,明显高于对照组的27.42%,差异有统计学意义(χ2=14.410,P <0.01);观察组术中去氧肾上腺素平均用量显著高于对照组(t=8.267,P <0.01)。结论对于非体外循环冠状动脉搭桥术围术期容量治疗,与SVV相比较,LVETc指导下能有效减少输液总量,维持灌注目标,缓解组织间隙液体负荷,促进脏器及肠道功能早期恢复。     

每搏量变异指导液体复苏在老年脓毒症中的应用

目的探讨每搏量变异指导液体复苏在老年脓毒症中的临床应用价值。方法选择患者100例分为两组,各50例,对照组在中心静脉压监测下进行,观察组实施每搏量变异指导,比较两组患者治疗后心率及血压情况,治疗后心脏指数、外周血管阻力指数及肺水指数和ICU住院时间、机械通气时间及30 d内病死率。结果治疗后观察组心率慢于对照组,收缩压、舒张压、心脏指数高于对照组,外周血管阻力指数、血管外肺水指数低于对照组(P<0.05),ICU住院时间、机械通气时间显著短于对照组,30 d病死率显著低于对照组(均P<0.05)。结论在每搏量变异指导下对老年脓毒症患者进行液体复苏,能更好地维持患者循环功能稳定,降低外周循环阻力,提高组织灌注,改善患者预后。     

基于每搏量变异度的液体复苏策略对脓毒性休克患者的疗效评价

目的探讨每搏量变异度(SVV)指导下的液体复苏策略对脓毒性休克患者的疗效及预后的影响。方法将62例脓毒性休克患者随机分为SVV组和对照组,各31例。所有患者均给予脓毒性休克的常规对症治疗,SVV组和对照组分别采用SVV、中心静脉压(CVP)指导下液体复苏治疗。比较两组复苏前后血流动力学指标的变化,疗效及预后情况。结果两组患者CVP、MAP、CI、ELWI、PaO_2/FiO_2均随着时间推移出现不同程度的改善,SVV组复苏后6h、24h后MAP较对照组明显降低,ELWI、PaO_2/FiO_2显著升高(P0.05)。与对照组比较,SVV组机械通气(MV)时间、ICU住院时间均明显缩短,24h血管活性药物使用量及输液量均明显减少(P0.05)。SVV组急性心功能不全的发生率为6.45%,显著低于对照组32.26%(P0.05)。结论基于SVV的液体复苏策略较CVP更为安全有效,有助于优化液体管理,维持血流动力学稳定,改善脓毒性休克患者的预后。     

每搏量变异度在重度颅脑损伤液体管理中的应用

目的探讨每搏量变异度(SVV)在重度颅脑损伤液体管理中的作用,为临床治疗提供参考。方法选取2014年6月—2017年5月安吉县第三人民医院重症医学科及浙江大学附属第一医院EICU收住的重度颅脑损伤患者46例,采用随机数字表法分为目标组及对照组,每组23例。目标组以SVV为目标进行容量管理,对照组以中心静脉压(CVP)为目标进行容量管理。比较两组患者一般资料、血流动力学、血气分析指标、患者监测及预后指标。结果两组患者24h及72h去甲肾上腺素用量、脱离机械通气时间、ICU住院时间、呼吸机相关性肺炎发生率、导管相关性感染发生率及28d病死率比较,差异均无统计学意义(P0.05)。目标组患者24h及72h时血管外肺积水(EVLW)、输液量少于对照组,差异有统计学意义(P0.05)。结论 SVV监测为重度颅脑损伤患者液体管理提供新的思路,并且优于传统的CVP,在重度颅脑损伤患者液体复苏治疗中有较大的价值。     

每搏量变异评价顽固性感染性休克患者容量反应性

目的 评价每搏量变异(SVV)能否作为机械通气的顽固性感染性休克患者容量反应性指标.方法 对收治于北京协和医院加强医疗科的42例顽固性感染性休克患者进行容量负荷试验,比较容量负荷试验有反应者和无反应者间SVV的差异,通过受试者工作特征(ROC)曲线确定SVV判断容量反应性的阈值.结果 (1)42例患者中24例患者容量负荷试验有反应,18例患者无反应.(2)容量负荷试验前有反应者和无反应者间中心静脉压、心率、平均动脉压、全心舒张末容积指数差异无统计学意义,有反应者和无反应者间SVV差异有统计学意义(17.7±7.1比9.6±4.1,P=0.006).(3)以SVV≥12%评价顽固性感染性休克患者容量反应性,灵敏度为77%,特异度为85%.结论 SVV可作为顽固性感染性休克患者容量反应性指标.     

每搏输出量变异指数在老年脓毒症患者液体复苏中的价值

目的 在老年脓毒症患者进行液体复苏过程中,观察每搏输出量变异指数(SVV)为复苏指标时相应的功能性血流动力学参数的变化、组织灌注的改善及预后. 方法 选取30例老年脓毒症患者进行早期目标指导治疗(EGDT),在液体复苏同时予脉搏指数连续心输出量监测(PiCCO)监测,随机将患者分为研究组和标准液体复苏组(对照组).观察复苏前和6h后达标患者的中心静脉压(CVP)、全心舒张末容积指数(GEDVI)、胸腔内血容量指数(ITBVI)、血管外肺水指数(EVLWI)、心排指数(CI)、中心静脉血氧饱和度(ScvO2)和乳酸清除率、急性生理和慢性健康评分(APACHEⅡ)评分.其后观察第3天APACHEⅡ变化、需要进行连续性肾脏替代治疗(CRRT)的例数、机械通气时间、ICU住院时间及28 d病死率. 结果 两组28 d病死率差异无统计学意义(x2=0.240,P=0.624).但是在存活患者中,与对照相比较,研究组患者ICU住院时间、机械通气时间缩短(t=2.166,P=0.041;t=2.104,P=0.046),第3天APACHE Ⅱ评分降低(t=2.20,P=0.038),需要进行CRRT的例数无统计学差异.在存活患者中,研究组的CVP、ITBVI、GEDVI、CI、乳酸清除率均明显高于对照组(t=2.759,P=0.011;t=2.146,P=0.043;t=2.199,P=0.038;t=2.654,P=0.014;t=3.362,P=0.003),EVLWI和Apache Ⅱ评分差异无统计学意义. 结论 在机械通气状态下老年脓毒症患者液体复苏治疗中,以SVV作为复苏目标的液体复苏方案,较以CVP为指导的EGDT方案达到更好的复苏效果,并在一定程度上改善预后.     

Cardiopulmonary effects of one-lung ventilation in supine patients

The cardiopulmonary effects of one-lung ventilation (OLV), with continuous positive airway pressure (CPAP, 5 cm H₂O) to the nonventilated lung, were compared to the effects of two-lung ventilation (TLV) in 12 supine patients undergoing coronary artery bypass grafting (CABG). Monitoring was performed with electrocardiography (ECG), arterial, and pulmonary artery catheters. Measurements of cardiac index (CO, heart rate (HR), systemic (MAP) and pulmonary artery pressures (PAP), pulmonary artery occlusion pressure (PAOP), mixed venous oxygen saturation (SvO₂), and arterial blood for pH, PaO₂, PaCO₂ and HCO₃- were performed with stable maintenance of anesthesia during both one- and two-lung ventilation. Mean values for CI, HR, MAP, MPAP, PVR, and S_vO₂ demonstrated no significant changes between OLV and TLV; systemic vascular resistance (SVR) and pulmonary artery occlusion pressure (PAOP) were statistically (P < 0.05) different, but of minor clinical significance. The data suggest that OLV, accompanied by CPAP (5 cm H₂0) to the nonventilated lung, produces minimal changes in cardiopulmonary measurements in supine patients.     

Breath analysis during one-lung ventilation in cancer patients

Noninvasive breath analysis may provide valuable information for cancer recognition if disease-specific volatile biomarkers could be identified. In order to compare nondiseased and diseased tissue in vivo, this study took advantage of the special circumstances of one-lung ventilation (OLV) during lung-surgery. 15 cancer patients undergoing lung resection with OLV were enrolled. From each patient, alveolar breath samples were taken separately from healthy and diseased lungs before and after tumour resection. Volatile substances were pre-concentrated by means of solid-phase microextraction, and were separated, identified and quantified by means of gas chromatography-mass spectrometry. Different classes of volatile substances could be identified according to their concentration profiles. Due to prolonged fasting and activation of lipolysis, concentrations of endogenous acetone significantly increased during surgery. Exogenous substances, such as benzene or cyclohexanone, showed typical washout exhalation kinetics. Exhaled concentrations of potentially tumour associated substances, such as butane or pentane, were different for nondiseased and diseased lungs and decreased significantly after surgery. Separate analysis of volatile substances exhaled from healthy and diseased lungs in the same patient, together with thorough consideration of substance origins and exhalation kinetics offers unique opportunities of biomarker recognition and evaluation.     

不同通气模式对慢性阻塞性肺疾病患者机械通气撤机过程的应用比较

目的观察并比较压力支持通气(Pressure support ventilation,PSV)和适应性支持通气(Adaptive support ventilation,ASV)两种通气模式对慢性阻塞性肺疾病(简称慢阻肺)患者机械通气撤机过程的影响。方法将83例慢阻肺患者随机分为两组,对照组(n=41)患者采用ASV通气模式,观察组(n=42)采用PSV通气模式;比较两组患者的临床优劣性和实用性。结果两组患者撤机前后的血气分析无显著变化(P0.05);两组患者的撤机成功率、撤机失败率、重新插管率以及撤机时间均无显著差异(P0.05);两组均未发现临床水平呼吸机相关肺损伤情况。结论 PSV和ASV在慢阻肺患者机械通气中有着较为相近的撤机成功率,临床效果无显著区别,且可以在一定程度降低呼吸负荷、保护肺组织,均能够较好地应用于临床。     

压力和容量控制通气在老年单肺麻醉肺保护通气策略中的比较

目的比较老年开胸手术单肺通气中压力控制通气（PCV）和容量控制通气（VCV）模式对呼吸力学和动脉血气的影响。方法46例术前肺功能不正常行开胸手术的患者,年龄均＆gt;60岁,双肺通气（TLV）期间均采用VCV模式（TLV-VCV）,单肺通气（OLV）后先采用传统方法通气（OLV-VCV1）,25 min后改为单肺保护通气（OLV-VCV2）,25 min后再改为压力控制通气（OLV-PCV）。监测气道峰压（Ppeak）、气道平台压（Pplat）、气道阻力（Raw）、动态胸肺顺应性（Cdyn）、分钟通气量（MV）等。结果与TLV-VCV比较,OLV-VCV1模式时Ppeak、Pplat、Raw升高（P〈0.01）、Cdyn降低（P〈0.01）。与OLV-VCV1比较,OLV-VCV2及OLV-PCV时Ppeak、Pplat、Raw较低,Cdyn较好（P均〈0.05）。OLV时动脉血PaO2较TLV时下降（P〈0.01）,OLV-PCV及OLV-VCV2时PaO2及PaCO2较OLV-VCV1升高（P〈0.05）。结论PCV模式控制气道压更有利于减少气道损伤,更适用于肺功能不全行开胸手术的老年患者。     

Relationship between cytokine response and temporary ventilation during one-lung ventilation in esophagectomy

BACKGROUND/AIMS: Postoperative pulmonary complications are often fatal in patients with esophageal cancer. The aim of this study was to clarify the association between cytokines and temporary ventilation during one-lung ventilation. METHODOLOGY: Serum and BALF IL-6, 8 were measured in 39 patients with esophageal cancer, and the relationship between cytokine response and temporary ventilation during one-lung ventilation in esophagectomy was examined. RESULTS: Pulmonary complications did not occur in our patients. Serum IL-6 levels were significantly increased in the high one-lung ventilation ratio and long-term one-lung ventilation groups. Serum IL-6 levels in the one or more times ventilation group during one-lung ventilation were significantly low compared to the no-ventilation group. There were no significant differences in serum IL-8 and BALF IL-6, 8 levels. CONCLUSIONS: Our results indicate that it is important to ventilate one or more times during one-lung ventilation in order to reduce postoperative pulmonary complications.     

Practice variation in respiratory therapy documentation during mechanical ventilation

STUDY OBJECTIVES: Implementation of new ventilatory strategies such as lung-protective ventilation for ARDS will require a multidisciplinary approach with considerable physician and respiratory therapy (RT) interaction. One of the key factors in this communication is complete and accurate RT documentation of ventilator settings. Few studies have explored the quality and variability of this documentation. DESIGN: Population-based cross-sectional study. SETTING: Seventeen adult hospitals in King County, WA. Participants/interventions: We compared the blank RT ICU flow sheet for each institution to the 1992 American Association for Respiratory Care (AARC) clinical practice guidelines (CPGs) for patient-ventilator system checks. We interviewed RT managers at each hospital about their practices. Finally, we reviewed selected charts of patients with acute lung injury (ALI) or ARDS from each hospital to evaluate the documentation. Measurements/results: We found substantial variability in RT documentation practices and in their extent of compliance with the AARC CPGs. Only 15 of 52 items recommended by the AARC CPGs were included on blank RT flow sheets of every hospital in our study, and only 26 of 52 items were found on charts of ALI/ARDS patients at most hospitals (ie, > or =10 of 17 hospitals). Only 10 of 17 RT department managers reported using the AARC CPGs as a basis for their documentation policies. Items necessary for the implementation of lung-protective ventilation for ALI/ARDS patients were recorded inconsistently and were not included in the AARC CPGs. Plateau pressure was found on all reviewed charts of ALI/ARDS patients at only 10 of 17 hospitals. CONCLUSIONS: Considerable variability exists in RT documentation practices. We suggest that new guidelines be developed for documenting the care of patients receiving mechanical ventilation, in light of recent data on ventilator weaning and the management of ALI/ARDS, and that their effect on practice and outcomes be evaluated.