下腔静脉变异度为指导的围手术期容量管理在腹腔镜肝切除术中的临床应用

目的探讨基于下腔静脉变异度（dIVC）的围手术期容量管理在腹腔镜肝切除术中的临床研究。 方法选择2019年7月至2021年3月河北省沧州中西医结合医院行腹腔镜肝切除术的64例患者，按照随机数字表法分为以dIVC为指导（dIVC组）和以中心静脉压（CVP）为指导（CVP组）围手术期容量管理，各32例。记录两组患者麻醉前（T0）、手术开始时（T1）、手术结束时（T2）、术后6 h（T3）的平均动脉压（MAP）、血氧饱和度（SPO₂）、氧合指数、血乳酸等水平变化；记录两组患者术前及术后1、3、7 d的肝肾功能指标，包括谷丙氨酸（ALT）、谷草转氨酸（AST）、总胆红素（TBIL）、肌酐（Cr）、尿素氮（BUN）等水平变化；记录两组患者术后通气时间、苏醒时间及丙泊酚用量。 结果dIVC组在T1~T3时的MAP（t=2.427、2.872、3.826，P=0.018、0.006、<0.001）、SPO₂（t=2.454、2.129、2.661，P=0.017、0.037、0.010）及氧合指数（t=2.961、2.095、2.946，P=0.004、0.040、0.005）均高于CVP组；在T2、T3时的血乳酸水平低于CVP组，差异均有统计学意义（t=2.263、7.845，P=0.027、<0.001）。dIVC组术后3、7 d的血清ALT水平低于CVP组（t=2.766、2.991，P=0.008、0.004），术后1、3 d的AST水平低于CVP组（t=2.894、2.482，P=0.005、0.016），术后3 d的TBIL水平低于CVP组（t=2.236，P=0.029），差异均有统计学意义；两组术后1、3、7 d的Cr（t=0.560、0.259、0.098，P=0.578、0.796、0.922）和BUN（t=0.222、0.362、0.569，P=0.825、0.718、0.572）水平差异均无统计学意义。dIVC组的术中机械通气时间和苏醒时间均少于CVP组，差异有统计学意义（t=2.828、2.599，P=0.006、0.012），两组术中丙泊酚用量、手术时间及术中输血情况比较差异均无统计学意义（t=1.928、0.417、0.110，P=0.058、0.678、0.740）。 结论基于dIVC的容量管理在腹腔镜肝切除术中可维持血流动力学稳定，改善组织氧供，减少肝功能损伤。

Clinical study of perioperative volume management based on variation of inferior vena cava distensibility in laparoscopic partial hepatectomy

ObjectiveTo investigate the clinical study of perioperative volume management based on inferior vena cava distensibility (dIVC) in laparoscopic partial hepatectomy. MethodsA total of 64 patients who underwent laparoscopic hepatectomy in Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine from July 2019 to March 2021 were selected and divided into dIVC group (following vena cava variation as guideline) and CVP group (following central venous pressure as guideline) according to the random number table method, with 32 cases in each group. The changes of mean arterial pressure (MAP), blood oxygen saturation (SPO₂), oxygenation index and blood lactic acid were recorded before anesthesia (T0), at the beginning of surgery (T1), at the end of surgery (T2) and 6 h after operation (T3) in the two groups. Liver and kidney function indexes including alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), creatinine (Cr) and urea nitrogen (BUN) in both groups were recorded before and 1, 3 and 5 days after operation. Postoperative ventilation time, recovery time and dosage of propofol were recorded. ResultsMAP (t=2.427, 2.872, 3.826, P=0.018, 0.006, <0.001), SPO₂ (t=2.454, 2.129, 2.661, P=0.017, 0.037, 0.010) and oxygenation index (t=2.961, 2.095, 2.946, P=0.004, 0.040, 0.005) of dIVC group from T1 to T3 were higher than those of CVP group, with statistical significances. The blood lactic acid level of dIVC group at T2 and T3 was lower than that of CVP group, with statistical significances (t=2.263, 7.845, P=0.027, <0.001). The serum level of ALT (t=2.766, 2.991, P=0.008, 0.004) of dIVC group was lower than that of CVP group on day 3 and 7 after surgery, AST (t=2.894, 2.482, P=0.005, 0.016) of dIVC group was lower than that of CVP group on day 1 and 3 after surgery, and TBIL (t=2.236, P=0.029) level of dIVC group was lower than that of CVP group on day 3 after surgery, with statistical significances. There were no significant differences in the levels of Cr (t=0.560, 0.259, 0.098, P=0.578, 0.796, 0.922) and BUN (t=0.222, 0.362, 0.569, P=0.825, 0.718, 0.572) between the two groups after operation. The duration of intraoperative mechanical ventilation and recovery time of dIVC group were both shorter than those of CVP group, with statistically significant differences (t=2.828, 2.599, P=0.006, 0.012), while there were no statistically significant differences in intraoperative propofol dosage, operation time and intraoperative blood transfusion between the two groups (t=1.928, 0.417, 0.110, P=0.058, 0.678, 0.740). ConclusionVolume management based on variation of dIVC can maintain hemodynamic stability, improve microcirculation perfusion, improve tissue oxygen supply and reduce liver function injury.