TEE指导GDFT联合小剂量去甲肾上腺素用于老年腹腔镜结直肠癌手术的临床观察

目的观察经食管超声心动图（transesophageal echocardiography，TEE）指导的术中目标导向液体治疗（goal-directed fluid therapy，GDFT）联合小剂量去甲肾上腺素对老年腹腔镜结直肠手术病人的术中循环管理和术后恢复的影响。方法60岁以上择期行乙状结肠或直肠癌根治术的病人50例，ASA分级Ⅰ~Ⅱ级，随机分为2组，每组25例，观察组为TEE指导下GDFT联合小剂量去甲肾上腺素组（N组），对照组为常规液体治疗组（C组）。N组麻醉后根据TEE监测降主动脉的纠正血流时间和每搏输出量调整液体和去甲肾上腺素用量。C组按照传统方法补液。比较2组病人麻醉诱导前（T₀）、气管插管前（T₁）、建立人工气腹后即刻（T₂）、肿物切除（T₃）、停止气腹后（T₄）、拔管后（T₅）的平均动脉压（MAP）、心率（HR）、中心静脉压（CVP）。术后记录晶体/胶体比例及总量、尿量、天门冬氨酸氨基转移酶（AST）、丙氨酸氨基转移酶（ALT）、血浆尿素氮（BUN）及肌酐（Cr）水平，术后恢复期不良反应和并发症发生情况。结果N组术中尿量、平衡液输注量明显少于C组（P < 0.01和P < 0.05），聚明胶肽输注量多于C组（P < 0.05）；2组HR、MAP在T₁、T₂时间点均较麻醉诱导前T₀降低（P < 0.05~P < 0.01），CVP在T₁时间点较T₀增高（P < 0.01）。与C组比较，N组HR在T₄、T₅时间点升高（P < 0.01），CVP在T₃、T₄、T₅时间点降低（P < 0.01）；与术前比较，术后N组的ALT水平上升（P < 0.01），AST和BUN水平下降（P < 0.01），术后C组的ALT、AST、BUN、Cr水平差异均无统计学意义（P>0.05）；N组不良反应发生率16.0%与C组不良反应发生率28.0%差异无统计学意义（P>0.05），N组并发症发生率8.0%明显低于C组并发症发生率32.0%（P < 0.05）。结论TEE指导GDFT联合小剂量去甲肾上腺素用于腹腔镜结直肠手术病人术后恢复有优势。

Value of GDFT guided by TEE combined with small dose of norepinephrine in the application of laparoscopic colorectal cancer surgery in elderly patients

ObjectiveTo observe the effects of goal-directed fluid therapy(GDFT) guided by transesophageal echocardiography(TEE) combined with small dose of norepinephrine on intraoperative circulation management and postoperative recovery in elderly patients treated with laparoscopic colorectal surgery.MethodsFifty patients over 60 years scheduled by radical resection of colorectal cancer, ASA grade Ⅰto Ⅱ, were randomly divided into the observation group and control group(25 cases each group).The observation group was treated with GDFT guided by TEE combined with small doses of norepinephrine, and the control group was treated with conventional liquid.The amounts of liquid and norepinephrine in observation group after anesthesia were adjusted according to the blood flow time corrected(FTc) and stroke volume(SV) of the descending aorta monitored by TEE, and the control group was treated with the traditional method fluid infusion.The mean artery pressure(MAP), heart rate(HR) and central venous pressure(CVP) between two groups were compared before anesthesia induction(T₀) and tracheal intubation(T₁), at the time of establishing artificial pneumoperitoneum(T₂), after resecting tumor(T₃), after stopping pneumoperitoneum(T₄) and after extubation(T₅).The crystal/gel ratio and total amount, urine volume, levels of aspertate aminotransferase(AST), alanine aminotransferase(ALT), blood urea nitrogen(BUN) and creatinine(Cr), and incidence rates of adverse reaction and complications during postoperative recovery were recorded in two groups.ResultsThe amounts of intraoperative urine and balance solution infusion in observation group were significantly less than those in control group(P < 0.01 and P < 0.05), and the amount of polygelatin peptide infusion in observation group was significantly more than that in control group(P < 0.05).The HR and MAP in two groups at T₁ and T₂ decreased compared with at T₀(P < 0.05 to P < 0.01), and the CVP in two groups at T₁ increased compared with at T₀(P < 0.01).Compared with the control group, the HR in observation group increased at T₄ and T₅(P < 0.01), and the CVP in observation group decreased at T₃, T₄ and T₅(P < 0.01).Compared with before operation, the ALT level increased, and the levels of AST and BUN decreased in observation group after operation(P < 0.01).The differences of the levels of ALT, AST, BUN and Cr in control group were not statistically significantly between before and after operation(P>0.05).There was no statistical significance in the incidence rate of adverse reaction between observation group(16.0%) and contorl group(28.0%), and the incidence rate of complications in observation group(8.0%) was significantly lower than that in control group(32.0%)(P < 0.05).ConclusionsThe GDFT guided by TEE combined with small dose of norepinephrine has advantages in the postoperative recovery of patients treated with laparoscopic colorectal surgery.