术中不同补液疗法对脊柱手术患者术后谵妄的影响

摘要：目的　探讨术中不同补液疗法对脊柱手术患者术后谵妄（POD）的影响。方法　择期行脊柱手术的中老年（≥50岁）患者195例，以随机数字表法分为限制性输液组（RF组）97例和目标导向液体治疗组（GDT组）98例。RF组：麻醉诱导时输注乳酸钠林格注射液5 mL/kg，麻醉诱导后以5 mL/（kg·h）的流率持续输注，直至手术结束。GDT组：麻醉诱导时输注乳酸钠林格注射液5 mL/kg，麻醉诱导后根据无创血压监测系统（CNAP）中的脉压变异率（PPV）调整输液速度维持9%≤PPV≤13%。记录术中输液量、输血量、尿量、出血量、血管活性药物用量，分别记录2组患者麻醉诱导前（T0）、麻醉诱导后5 min（T1）、手术开始时（T2）、术中30 min（T3）、术中60 min（T4）、术中90 min（T5）、术中120 min（T6）、手术结束时（T7）和拔管后5 min（T8）的有创平均动脉压（MAP）、心率（HR）、心脏指数（CI）、脑氧饱和度（rSO2）以及T2、T7的血乳酸（LAC）值，术后3 d连续记录患者疼痛视觉模拟评分（VAS）、中文修订版谵妄诊断量表（CAM-CR）评分。结果　与RF组比较，GDT组MAP和rSO2在T5~T8时均明显升高，CI在T6~T8时明显升高，而HR在T6~T8明显降低（P＜0.05）。与RF组比较，GDT组术中使用麻黄素较少［（1.5± 0.5） mg vs. （4.7 ± 5.8） mg, t=3.309, P＜0.05］，术中输液总量较多［（1 826.1±608.5） mL vs. （1 345.4±548.7）mL，t=5.791，P＜0.05］、术中尿量较多［（470.9±296.8）mL vs. （380.8±228.1）mL，t=2.326，P＜0.05］。GDT组患者POD发生率低于RF组（4.1% vs. 12.4%，χ2=4.448，P＜0.05）。结论　目标导向输液可以稳定脊柱手术患者围术期血流动力学，改善组织灌注，降低POD的发生率。

The effect of different intraoperative fluid therapy on postoperative delirium in patients undergoing spinal surgery

Abstract: Objective　To investigate the effect of different intraoperative fluid therapy on postoperative delirium (POD) in patients undergoing spinal surgery. Methods　A total of 195 patients of middle- and elderly-aged (≥ 50 years old) scheduled for elective spinal surgery were included and randomly divided into two groups by using a random number table: restrictive fluid therapy group (group RF, n=97) and goal-directed fluid therapy group (group GDT, n=98). In group RF , a bolus of lactated Ringer's solution was firstly administered at 5 mL/kg during the induction of anesthesia, then at 5 mL/(kg×h) until the end of surgery. For patients in the GDT group, in addition to the initial administration of lactated Ringer's solution at 5 mL/kg, the following fluid therapy was adjusted by using CNAP noninvasive blood pressure monitoring system to maintain 9%≤PPV≤13%. The volume of fluid infusion, blood transfusion volume and urine volume, blood loss, as well as the usage of vasoactive agents were all recorded during the entire operation. The mean arterial pressure (MAP), heart rate (HR), cardiac index (CI) and regional cerebral oxygenation index (rSO2) were recorded at different time points, including before anesthesia induction (T0), 5 minutes after anesthesia induction (T1), when the operation began (T2), and at different time points (30 minutes, 60 minutes, 90 minutes and 120 minutes) during operation (T3-T6), at the end of operation (T7), at 5 minutes after operation (T8). Arterial blood samples were collected to test lactic (LAC) value at T2 and T7. The Visual Analogue pain score (VAS ) and the Method-Chinese revision(CAM-CR) score were recorded three days after the operation. Results　Compared with group RF, MAP and rSO2 were increased at T5-T8 in group GDT, while CI and HR were increasedat T6-T8 in group GDT (P＜0.05). Meanwhile, compared with group RF, less usage of ephedrine (1.5± 0.5) mg vs. (4.7 ± 5.8) mg, t=3.309, P＜0.05], more intraoperative fluid infusion volume (1826.1 ± 608.5) mL vs. (1345.4 ± 548.7) mL, t=5.791, P＜0.05] and more intraoperative urine volume (470.9 ± 296.8) mL vs. (380.8 ± 228.1) mL, t=2.326, P＜0.05] were observed in the group GDT. POD incidence rate was lower in group GDT than that in group RF (4.1% vs. 12.4%, χ2=4.448, P＜0.05). Conclusion　The goal-directed fluid therapy can stabilize the perioperative hemodynamics, improve tissue perfusion and reduce the incidence of POD following spinal surgery.