加速康复外科理念在活体肾移植供体围术期液体管理中的应用探讨

目的结合加速康复外科的理念,探讨亲属供肾切取术围术期合理的液体管理方案。方法选取2006年1月～2011年12月在我中心施行亲属供肾切取术的124例患者,将其分为两组,A组（49例）为早期术后补液方案组（2008年1月以前）,B组（75例）为改良术后补液组（2008年1月以后）。两组术前晚均补液1 000～2000 mL,补充术中生理需要量和液体丢失量。A组术后按患者体重给予补液1 500～2 500 mL,按5%葡萄糖注射及乳酸钠林格液1：1给予,如出量过大,则适当增加液体。B组记录患者24 h出入量及每小时尿量,用输液泵控制每小时液体入量,每小时入量按上一小时尿量进行加减。尿量为100～150 mL时,入量为尿量＋50 mL;尿量为151～200 mL时,入量等于尿量;尿量为〉200 mL时,入量为尿量-50 mL;尿量为〈100 mL时,入量为100 mL/h;持续2 h尿量〈50 mL,给予速尿5 mg,静脉推注。结果 124例患者均无围术期急性肾功能衰竭;术后1周肾功能、电解质、血压、尿量均正常。术后两组分别有6例和1例出现一过性低血压（平均动脉压下降〉20 mm Hg）,OR值为10.09,95%CI为1.18～86.6;术后3 d,两组分别有12例和8例肾功能暂时未恢复正常,表现为短期肾功能延迟恢复,OR值为2.72,95%CI为1.02～7.24。结论在快速康复外科理念指导下制定个体化液体治疗方案,能获得更稳定的术后血压、肾功能等指标,并能够明显减轻医护人员工作量。

Discussion on application of fast track surgery on liquid administration in perioperative period of living donor nephrectomy

Objective To investigate the fluid management program of living donor nephrectomy in the perioperative period combined with the concept of fast track surgery.Methods 124 patients undergoing living donor nephrectomy in our center were divided to two groups：Group A included 49 patients who accepted original fluid management program before January 2008;Group B included 75 patients who accepted improved fluid management program after January 2008.Two groups were all accepted 1 000-2 000 mL liquid at the night before surgery,and intraopertive volume of daily physiological need ed and lost in operation.Group A accepted 1 500-2 500 mL liquid after operation according patient＇s weight.Sodium Lactate Ringer＇s Injection and 5% Glucose Injection were set 1：1.If amount of urinary output was more than 2 000 mL,additional liquid should be added.The amounts of injected injection per hour by infusion pump were determined by latest urinary output.Results All patients does not suffer acute renal failure.Renal function,potassium,blood pressure and uri nary output are all in normal after a week.There are six patients showed transient hypotension（arterial mean pressure decreased more than 20 mm Hg） in Group A and one in Group B,OR was 10.09,and 95%CI was 1.18-86.6.At 3 d after operation,there were 12 patients in Group A whose serum creatinines didn＇t reach normal and there were 8 patients in Group B.OR was 2.72,and 95% CI was 1.02-7.24.Conclusion Establishing personal liquid management program combined with the concept of fast track surgery could acquire more stable blood pressure,renal function etc,and could de crease the labor of doctors and nurses.