目标导向液体治疗联合甲氧明对创伤性脑损伤患者围术期的影响

目的评估目标导向液体治疗(GDFT)联合甲氧明对创伤性脑损伤(TBI)手术患者围术期的影响。方法选择2019年1—12月收治的24 h内入院的TBI手术患者60例,男42例,女18例,年龄18~64岁,BMI<28 kg/m²,ASAⅡ—Ⅳ级。采用随机数字表法分为两组:GDFT联合甲氧明组(GM组)和GDFT组(G组),每组30例。两组均以每搏量变异度(SVV)为目标导向进行补液。GM组于麻醉诱导后持续泵注甲氧明1.5~4.0μg·kg^-1·min^-1至术毕;G组泵注等容量生理盐水。记录晶体输注量、胶体输注量、总输液量、红细胞输注量、血浆输注量、总输血量、尿量和出血量。记录麻醉诱导后(T₀)、切开硬脑膜时(T₁)、切开硬脑膜后1 h(T₂)、术毕(T₃)、术后12 h(T₄)的HR和MAP。记录术中去甲肾上腺素使用例数。T₀—T₄时采集桡动脉及颈内静脉球部血样行血气分析,记录颈内静脉球部血氧饱和度(SjvO₂)和颈内静脉乳酸(jvLac)浓度,计算动静脉血氧含量差(Da-jvO₂)及脑氧摄取率(C_ERO₂)。T₀—T₄时采集颈内静脉球部血样,采用ELISA法检测血清S100β蛋白和神经元特异性烯醇化酶(NSE)浓度。分别于术前、术后1、3、5、7 d评估格拉斯哥昏迷量表(GCS)评分。出院前采用格拉斯哥预后评分(GOS)评估术后早期生存质量。记录住院时间以及术后切口及颅内感染、脑积水、脑梗死、脑脊液漏、心肌梗死、肺炎等并发症的发生情况。结果与G组比较,GM组晶体输注量、胶体输注量、总输液量明显减少;T₁—T₃时MAP明显升高;术中去甲肾上腺素使用率明显降低;T₁—T₄时SjvO₂明显升高,Da-jvO₂、C_ERO₂明显降低;T₃时jvLac浓度明显降低;T₄时S100β蛋白、NSE浓度明显降低;术后3、5、7 d GCS评分明显升高(P<0.05)。两组红细胞输注量、血浆输注量、总输血量、尿量、出血量、不同时点HR、出院前GOS评分、住院时间以及术后并发症发生率差异无统计学意义。结论目标导向液体治疗联合甲氧明用于创伤性脑损伤手术患者,可以优化临床输液方案,稳定血流动力学以及改善脑组织氧供需平衡,从而改善患者预后。

Effects of goal-directed fluid therapy combined with methoxymine on perioperative period of patients with traumatic brain injury

Objective To evaluate the effects of goal-directed fluid therapy(GDFT)combined with methoxymine on perioperative period of patients with traumatic brain injury(TBI).Methods Sixty TBI patients admitted from January 2019 to December 2019,42 males and 18 females,aged 18-64 years,BMI<28 kg/m²,ASA physical statusⅡ-Ⅳ,were divided randomly into two groups:GDFT combined with methoxymine group(group GM)and methoxymine group(group G),30 patients in each group.Fluid replacement was guided by stroke volume variation(SVV)in all patients.After anesthesia induction,methoxymine was continuously pumped at a speed of 1.5-4.0μg·kg^-1·min^-1 until the end of operation in group GM.The same amount of normal saline was given in group G.The volume of crystalloid,colloid and total transfusion,erythrocyte,plasma and total blood transfusion,urine and blood loss were recorded.The intraoperative consumption of norepinephrine was recorded.Five time-points were set as flowing:after anesthesia induction(T₀),the dural mater opening(T₁),1 hour after the dural mater opening(T₂),end of the surgery(T₃)and 12 hours after surgery(T₄).Heart rate(HR)and mean arterial pressure(MAP)were recorded at T₀-T₄.Blood samples were collected from the radial artery and internal jugular vein bulb during T₀-T₄ for blood gas analysis.The concentration of internal jugular venous bulb oxygen saturation(SjvO₂)and jugular venous lactate(jvLac)were recorded.The difference of arterial and jugular bulb venous oxygen content(Da-jvO₂)and cerebral extraction rate of oxygen(C_ERO₂)were calculated.Blood samples were collected from the internal jugular venous bulb at T₀-T₄.The concentrations of biochemical indicators of neuron injury including S100βprotein,and neuron-specific enolase(NSE)were detected by enzyme-linked immunosorbent assay(ELISA).Glasgow coma scale(GCS)were recorded before surgery,and 1,3,5,and 7 days after operation.Glasgow outcome scale(GOS)and the length of hospital stay was evaluated.Postoperative incision,intracranial infection,hydrocephalus,cerebral infarction,cerebrospinal fluid leakage,myocardial infarction,pneumonia and other complications were recorded.Results Compared with group G,the volume of crystalloid,colloid and total transfusion were decreased,the consumption of norepinephrine was decreased,MAP at T₁-T₃ and the SjvO₂ at T₁-T₄ were increased,the Da-jvO₂ and the C_ERO₂ at T₁-T₄ were decreased,and jvLac at T₃ was decreased,and the level of S100βprotein and NSE at T₄ were decreased,and the GCS 3,5,and 7 days after surgery were increased in group GM(P<0.05).There were no significant differences in erythrocyte infusion volume,plasma infusion volume,total blood transfusion volume,urine volume,blood loss,HR at different time points,GOS score before discharge,length of hospital stay and incidence of postoperative complications between the two groups.Conclusion GDFT combined with methoxamine can optimize fluid strategy,stabilize hemodynamics,improve cerebral oxygen metabolism and outcome of TBI patients.