围术期目标导向液体治疗

围术期液体管理一直是围术期处理争论最多的问题之一.最近的研究显示围术期目标导向液体治疗有助于减少围术期并发症,如术后恶心呕吐;加快胃肠功能恢复;缩短住院日.现就围术期目标导向液体治疗的实施方案、监测指标和监护仪的选择及对术后转归的影响作一综述.     

目标导向治疗引领血流动力学监测的发展

随着危重及老年患者数量的不断增加,同时麻醉医师对手术患者术后转归的关注不断加强,目标导向治疗正在推动临床麻醉实践的不断发展。对于不同手术的患者,基于术后转归的要求,所制定的导向目标也有所不同。基于导向目标的不同,所选择的血流动力学监测技术会存在差异。因此,针对当前常见的危重患者和高危手术患者,如何通过确定导向目标,选择合适的血流动力学监测指标,从而达到在导向目标出现异常时,准确分析影响这些目标的血流动力学参数,并作出准确诊断以及处理,对于麻醉医师来说十分重要。     

围手术期目标导向液体治疗对凝血功能的影响

目标导向液体治疗(goal directed fluid therapy, GDFT)作为一种优化的围手术期液体治疗管理方案, 能够改善围手术期凝血功能, 但其机制尚未完全明确。文章综述了常规液体治疗时液体类型、血液稀释和多糖包被(endothelial glycocalyx, EG)损伤导致凝血功能紊乱, 以及GDFT通过减少术中出血和EG脱落等改善围手术期患者凝血功能的研究进展, 为临床医师在围手术期容量管理中选择合理的液体治疗方案提供参考, 减少术后并发症, 加速患者康复。     

心脏病患者围术期的液体治疗

心脏病患者施行心脏或非心脏手术,围术期合理的液体治疗是维持心血管功能和血液动力学稳定的重要手段,但是实践过程的难度较高,常易发生血容量过多或不足而导致心血管功能、组织血流灌注或氧供需平衡的变化。因此,本文就心脏病患者围术期血容量变化的特点、液体治疗的监测、液体种类的选择以及如何合理实施围术期液体治疗进行讨论,为临床上心脏病患者实施液体治疗提供参考。     

每搏量变异度监测的研究进展与评价

背景每搏量变异度(stroke volume variation,Svv)是一项重要的功能性血液动力学指标,用于监测机械通气患者的容量状态及预测机体对液体治疗的反应性,具有敏感、准确、安全等特点.目的综述SVV的适应证、影响因素及研究进展.内容SVV由心肺的相互作用产生,可通过动脉压力波形分析技术进行连续监测,主要适用于机械通气的围手术期及休克患者.SVV与容量变化的相关性优于静态血液动力学指标,但也受多种因素的影响.趋向近年来,SVV与目标导向治疗相结合,拥有广阔的应用前景.     

肾移植围手术期目标导向性液体治疗进展

<正>同种异体肾移植是治疗终末期肾病最理想的手段,与血液透析治疗相比,肾移植能为终末期肾病患者提供更高的生存率和生活质量[1-2]。近年来,肾移植相关并发症和死亡率明显降低,这主要得益于围手术期管理,尤其是围手术期的液体治疗管理。既往常采用传统的监测指标来指导液体治疗,效果不佳,以功能性血流动力学参数指导液体治疗的目标导向性液体治疗(goal-directed fluid therapy,GDFT)显示出其优势。本文就GDFT的研究进展作一综述。     

加强肝移植围手术期的液体治疗

肝移植是治疗终末期肝病最有效的手段,患者术后1年生存率高达90％,5年生存率亦可达80％。然而,肝移植手术创伤大、出血量多,对全身血流动力学影响明显;同时终末期肝病患者存在特殊的病理生理学特征,术后避免过量输注液体和尽早实现适当的负平衡是降低术后并发症发生率和死亡率的重要措施。围手术期容量管理的基本原则是根据终末期肝病患者术前容量状态及手术过程的出入量情况,以血流动力学监测指标指导液体治疗。     

老年人开胸手术麻醉管理进展

背景 老年患者心、肺等脏器伴有不同程度功能衰减,开胸手术时易出现呼吸、循环方面的问题,大大增加了手术、麻醉的复杂性和危险性. 目的 就老年胸科手术麻醉的新进展进行综述,以提高老年胸科手术麻醉质量. 内容 麻醉前应评估心肺系统功能状况、制定个体化麻醉方案;建议采用吸入全身麻醉或联合硬膜外阻滞;术中单肺通气时应采用保护性通气策略和肺复张技术,根据目标导向液体治疗原则管理循环;术后给予充分镇痛. 趋向 对老年胸科手术患者,完善的围手术期管理有助于改善其术后转归.     

围手术期的液体治疗进展

液体治疗是围手术期的重要治疗手段.选择正确的输液和合理的治疗策略可以著降低围手术期并发症,缩短患者住院天数,改善预后.围手术期液体治疗的历史发展是一个对“选择晶体或胶体”、“选择开放或限制补液”等有争议问题不断总结、探索、论证的前进过程.在这个过程中,广大医师对具体的围手术期治疗策略有了更深层次的认识,出现了诸如目标导向性液体治疗,早期目标导向治疗、快速通道外科等临床上有显著疗效的具体治疗策略.本文对围手术期液体治疗的进展进行综述.     

目标导向循环管理策略的临床应用进展

危重患者及高危手术的不断增多,给围术期的管理带来了巨大挑战。当机体某一系统受到损害时,整个机体便会做出相应的调整代偿;当机体某一系统失代偿时,机体便会发生损伤。围术期最重要的一项工作是预防并发现机体代偿过程中出现的问题,加强器官保护,维持“脆弱”的平衡状态,改善手术患者的预后。高危患者手术持续时间长,血管内容量变化较大,术中极易出现全身氧供需失衡。组织氧合不足的后果包括伤口和吻合口破裂、器官功能障碍和死亡[1]。对于不同的手术患者,基于术后转归的要求,所选择的血流动力学监测技术及其指标、目标值也存在差异。如何确定导向目标,准确分析影响这些目标的血流动力学参数,做出准确诊断以及处理,更好地践行目标导向循环管理的理念,是麻醉科医师的重要职责。     

围手术期液体治疗策略的研究进展

背景 采用合理的液体治疗策略对外科手术患者进行液体治疗是围手术期管理的重要内容,可以显著降低围手术期并发症发生率,缩短患者住院天数,改善预后.目的 对围手术期液体治疗策略的发展过程、近年来该领域的研究进展以及目前尚存在争议的问题进行回顾和总结,为临床液体治疗策略的选择和后续研究提供借鉴.内容 回顾了围手术期液体治疗策略...     

Carbohydrate loading and fluid management within enhanced recovery

Enhanced recovery pathways (ERP) are focused on improving perioperative patient care to reduce postoperative complications and improve outcomes. ERP includes elements of preoperative preparation, fluid management, anesthesia and analgesia, and perioperative nutrition and mobilization. Significant evidence suggests that traditional non-evidence-based perioperative nutritional and fluid management dogmas that prolong fasting and promote fluid overload should be abandoned. Carbohydrate loading has been shown to be safe in non-diabetic patients while also reducing postoperative insulin resistance. Evidence suggest that perioperative fluid overload and restriction should be avoided, and near-zero homeostasis should be the goal of perioperative fluid management. Goal-directed fluid therapy (GDFT) has shown to be safe in most patients and could be beneficial in high-risk patients.     

Secrets of anesthesia in fetoscopic surgery

Certain life-threatening congenital malformations have the opportunity to be treated with minimally invasive fetal surgery. In recent years fetoscopic surgery had a triggered interest. During the fetoscopic surgery all interventions effecting uteroplasental blood flow and eventually fetal oxygenation, may occur as complications like cardiac depression, maternal hypotension or pulmonary edema. Liaise with the increase in cardiac output and heart rate, the pregnant patient may display increased sensitivity to muscle relaxants and inhalational anesthetics. Due to incomplete myelination and synaptic activation, the fetus becomes more sensitive to volatile agents and analgesics.A goal directed therapy is necessary for both maternal and fetal well-being. According to goal directed therapy, perioperative fluid, vasopressor and inotropic agent titration is recommended to be used taking into account the systemic and pulmonary vascular hemodynamics of patients as well as the pulmonary vascular permeability and fluid content. Perioperative anesthesia management with hemodynamic monitorization, airway management and postoperative pain therapy are key features that make up the secrets of anesthesia. The patient's postoperative suffering from pain also leads to fetal and maternal stress by causing uterine contractions. Thus, appropriate treatment of postoperative pain should be provided using intravenous or epidural patient-controlled analgesia. One of the most important issues in the postoperative period is to prevent patient's premature contraction and not to trigger a premature birth.     

Is surgery the best treatment for elderly gastric cancer patients?

As the elderly population increases, the number of patients with gastric cancer has also been increasing. Elderly people have various preoperative problems such as malnutrition, high frequency of comorbidities, decreased performance status, and dementia. Furthermore, when surgery is performed, high postoperative complication rates and death from other diseases are also concerns. The goal of surgery in the elderly is that short-term outcomes are comparable to those in nonelderly, and long-term outcomes reach life expectancy. Perioperative problems in the elderly include: (1) Poor perioperative nutritional status; (2) Postoperative pneumonia; and (3) Psychological problems (dementia and postoperative delirium). Malnutrition in the elderly has been reported to be associated with increased postoperative complications and dementia, pointing out the importance of nutritional management. In addition, multidisciplinary team efforts, including perioperative respiratory rehabilitation, preoperative oral care, and early postoperative mobilization programs, are effective in preventing postoperative pneumonia. Furthermore, there are many reports on the usefulness of laparoscopic surgery for the elderly, and we considered that minimally invasive surgery would be the optimal treatment after assessing preoperative risk.     

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??Enhanced recovery after surgery in perioperative fluid management YU Wen-kui??LI Ning. Nanjing General Hospital of Nanjing Military Command of PLA??Nanjing 210002??China
Corresponding author??LI Ning??E-mail??liningnju@163.com
Abstract Enhanced recovery after surgery (ERAS) is a new concept of surgical treatment in the 21st century??which recently??has been widely applied and gained good effect. ERAS is defined as a series of optimized perioperative management to reduce the stress of patients??decrease the incidence of complications and mortality??and achieve rapid recovery. Perioperative fluid management is a important component of ERAS??which is throughout the perioperative period??with a great impact on patients’ outcome. In preoperative time??patients should avoid dehydration??shorten the time of fasting and orally administrate carbohydrate. During operation??when maintaining circulating volume??avoiding edema should also be noticed. The amount of fluid infusion should be based on the loss of fluid and the hemodynamic indexes monitored. In postoperative time??patients should be encouraged early orally feeding and stopping intravenous infusion as soon as possible??preventing disturbance of water and electrolyte and tightly controlling the level of serum glucose.     

Stroke Volume Variation as a Predictor of Intravascular Volume Depression and Possible Hypotension During the Early Postoperative Period After Esophagectomy

Background  Perioperative hypotension during esophagectomy results from hypovolemia caused by a shift of extracellular fluid from the intravascular to the extravascular compartment. Fluid management is often difficult to gauge during major surgery because there are no reliable indicators of fluid status, and some patients still experience cardiorespiratory instability. In this retrospective study, we evaluated stroke volume variation (SVV), calculated by using a new arterial pressure-based cardiac output measurement device, as a predictor for fluid responsiveness after esophageal surgery. Methods  Eighteen patients undergoing esophagectomy with extended radical lymphadenectomy were monitored by the FloTrac sensor/Vigileo monitor system during the perioperative and immediate postoperative period. Fluid responsiveness was assessed and compared with concurrent SVV and central venous pressure (CVP) values, and routine hemodynamic variables. Results  Eleven of 18 patients needed additional volume loading within the first 10 postoperative hours as a result of hypotension. The maximum SVV value of fluid resuscitated patients was >15% in all cases, whereas six of seven patients without postoperative hypotension had maximum SVV values of <15%. The correlation between SVV and the development of hypotension was statistically significant (P = 0.0012). From the linear correlation analysis of hemodynamic variables influenced by additional fluid loading, SVV was significantly correlated to cardiac output (r = 0.638; P = 0.049), whereas CVP was not (P > 0.05). Conclusion  We conclude that SVV, as displayed on the Vigileo monitor, is an accurate predictor of intravascular hypovolemia and is a useful indicator for assessing the appropriateness and timing of applying fluid for improving circulatory stability during the perioperative period after esophagectomy.     

腹腔镜内镜微创手术治疗高龄结直肠癌患者

目的 探讨腹腔镜内镜微创手术治疗高龄结直肠癌患者的安全性、可行性以及围手术处理.方法 回顾性分析我院 2010 年 10 月～ 2012 年 12 月间 153 例采用择期腹腔镜内镜微创手术治疗的 70 岁以上高龄结直肠癌患者的临床资料.采用一套专门制定的诊治流程进行围手术期处理,并运用个体化的微创手术进行治疗,其中腹腔镜辅助结直肠手术 148 例、经肛门内镜微创手术 5 例.结果 本组 153 例均按预期完成腹腔镜或内镜微创结直肠手术,无手术死亡,手术时间平均 170 min,出血量平均 185 ml,术后住院时间平均 8.3 d.术后并发心功能不全、肺部感染、伤口并发症和尿潴留的比例分别仅为 1.3% 、3.9% 、3.3% 和 7.8%.结论 高龄患者因各种并存病增加了手术风险,围手术期应多科协作,有针对性地进行处理.腹腔镜内镜微创手术治疗高龄结直肠癌患者是安全、可行的.     

Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery

Fluid therapy is one of the most controversial topics in perioperative management. There is continuing debate with regard to the quantity and the type of fluid resuscitation during elective major surgery. However, there are increasing reports of perioperative excessive intravascular volume leading to increased postoperative morbidity and mortality. Recent evidence suggests that judicious perioperative fluid therapy improves outcome after major elective gastrointestinal surgery. The observed benefits may not be solely attributable to crystalloid restriction but also to the use of colloids instead. Some clinically useful guidelines based on the studies discussed in this review include avoidance of deep general anesthesia and elimination of preload for patients who receive epidural analgesia. A balanced approach to fluid management is recommended, with colloids administered to provide hemodynamic stability and maintain urine output of 0.5 mL x kg(-1) x h(-1) and crystalloids administered only for maintenance. In addition, blood loss may be replaced with colloid on a volume-to-volume basis. Furthermore, predetermined algorithms that suggest replacement of third space losses and losses through diuresis are unnecessary. Significant reduction in crystalloid volume can be achieved without encountering intraoperative hemodynamic instability or reduced (i.e., < 0.5 mL x kg(-1) x h(-1)) urinary output just by avoiding replacement of third space losses and preloading. Finally, there is a need for well-controlled studies in a well-defined patient population using clear criteria or end-points for perioperative fluid therapy.     

Perioperative fluid therapy

Precise physiological systems ensure normal fluid and electrolyte homeostasis in health. These mechanisms can be disrupted by illness and injury (including surgery). Disruption results in altered cellular and organ function. An understanding of this physiology is therefore crucial to provide safe and effective fluid management for these patients. Effective fluid management is required to cover the full perioperative period and there is increasing evidence to support the use of cardiac output monitoring to guide fluid therapy. The ultimate aim is to ensure preoperative, intra-operative and postoperative fluid optimisation to maximise cardiac output and oxygen delivery at the cellular level. Such ‘goal directed’ fluid therapy tailors management to individual patient physiology, associated co-morbidity and the degree of surgical insult and subsequent stress response with the aim of reducing mortality, morbidity and reducing the length of postoperative stay.