不同容量治疗对老年肺切除术患者血流动力学和血管外肺水的影响

目的 研究不同容量治疗方法对老年肺癌患者肺切除手术的血流动力学和血管外肺水的影响.方法 择期行肺切除手术的老年肺癌患者20例,随机分为容量限制组(A组)和扩容组(B组),每组10例.A组术中持续静脉滴注5 mL·kg~(-1)·h~(-1)乳酸钠林格液,B组在麻醉开始后30 min内静脉滴注10 mL/kg乳酸林格液及10 mL/kg 6%羟乙基淀粉(万汶),以后按基础需要量+禁食丧失量+术中丢失+第三间隙损失量补液.两组术中出血量由6%羟乙基淀粉按1:1补偿.记录诱导前(T_1,基础值)、麻醉诱导后10 min(T_2)、输液30 min(T_3)、侧卧位即刻(T_4)、开胸后即刻(T_5)、肺叶切除后(T_6)、关胸时(T_7)、术毕(T_8)及术后1 d(T_9)患者的心率(HR),平均动脉压(MAP)、中心静脉压(CVP)、心指数(CI)、胸腔内血容量(ITBV)及胸内血管外肺水(EVLW).结果 两组间在T_1时间点的HR、MAP、CVP、ITBV、CI、外周血管阻力(SVR)、EVLW基础值的差异均无统计学意义(P值均>0.05).两组在T_2、T_3、T_4时间点的HR、MAP均较同组T_1时间点显著降低(P值均<0.05).两组在T_2、T_3、T_4、T_5、T_6、T_7、T_8时间点的CVP均较T_1时间点显著升高(P值均<0.05),B组在T_2、T_5时间点的CVP显著高于A组(P值均<0.05).A组在T_3、T_4、T_5、T_6、T_8时间点的ITBV值较同组T_1时间点显著降低(P值均<0.05),两组间各时间点的差异无统计学意义(P值均>0.05).A组在T_2、T_3、T_4、T_6时间点及B组在T_2、T_3时间点的CI均较同组T_1时间点显著降低(P值均<0.05),B组在T_4时间点的CI恢复至T_1时间点水平,在T_6、T_7、T_8时间点的CI显著高于A组同时间点(P值均<0.05).两组间及组内不同时间点SVR和EVLW的差异均无统计学意义(P值均>0.05).结论 对心肺功能良好的行肺叶切除手术的老年患者,限制液体输注并加用小剂量缩血管药物的治疗作用与麻醉诱导期进行扩容治疗对低血压的预防作用相当,在麻醉诱导期适当扩容治疗并不增加肺水肿的风险,且更有利于组织的灌注.

Effects of different volume therapies on hemodynamics and extravascular lung water in aged patients undergoing pulmonary lobectomy

Objective To observe the effects of different volume therapies on the hemodynamics and extravascular lung water (EVLW) in aged patients undergoing pulmonary Iobectomy. Methods Twenty aged patients with lung cancer were randomly assigned to volume restriction group (group A, n=10) or volume expansion group (group B, n=10). Ringer's solution were administrated at 5 mL ·kg~(-1)·h~(-1) in group A. In group B, 10 mL/kg Ringer's solution plus 10 mL/kg VOLUVEN was applied within 30 min after anesthesia, then infusion rate was adjusted according to the patient's basal requirement, preoperative fast, intraoperative lose and third space lose. In both groups the same volume of VOLUVEN as the bleeding was infused during operation. The heart rate (HR), mean artery pressure (MAP), central venous pressure (CVP), cardiac index (CI), intrathoracic blood volume (ITBV) and EVLW were recorded at the following 9 time points: pre-anesthesia induction (T_1),10 mins after anesthesia induction (T_2), 30min after the beginning of volume therapy (T_3), patients put in lateral position (T_4), after thoracotomy (T_5), after Iobectomy (T_6), thorax closure (T_7), after operation (T_8) and 1 day after operation (T_8). Results There was no significant difference between the two groups in all observation variables at T_1 (P>0.05). HR, MAP and CI were decreased at T_2,T_3 and T_4 compared to those at T_1 (P<0.05) in two groups, while CVP increased at T_2, T_3,T_4, T_5, T_6, T_7and T_8 (P<0.05). Compared to group A, CVP was significantly higher at T_2 and T_5 in group B (P<0.05). ITBV was markedly decreased in group A at T_3, T_4, T_5, T_6 and T_8 compared to that at T_1 (P<0. 05). CI was decreased at T_2, T_3, T_4 and T_6 in group A compared to that at T_1 (P<0. 05), while in group B only T_2 and T_3 were significantly decreased (P<0.05), and CI restored to the T_1 level at T_4. Compared to group A, CI was significantly higher at T_6, T_7and T_8 in group B (P<0. 05). Systemic vascular resistance (SVR) and EVLW had no significant difference between the two groups or within group (P > 0.05). Conclusion Volume restriction plus vasoconstrictor has the same prophylaxis effects on anesthesia induction hypotension as volume expansion. Volume expansion improves the tissue perfusion but does not increase the risk of pulmonary edema.