目标容量填充对沙滩椅位下骨科肩关节镜手术患者血流动力学的影响

目的评价FloTrac/Vigileo系统监测常规容量填充和目标靶控容量填充对沙滩椅位(beach chair position,BCP)下骨科肩关节镜手术患者血流动力学的影响。方法选择择期行肩部关节镜手术患者30例,男17例,女13例,年龄18~65岁,体重49~68kg,ASAⅠ或Ⅱ级,随机分为两组:常规容量填充组(R组)和FloTrac/Vigileo指导下目标靶控容量填充组(S组),每组15例。R组麻醉诱导后30 min内予以10 ml/kg羟乙基淀粉130/0.4快速静滴行容量填充;S组使用FloTrac/Vigileo系统监测MAP、每搏变异度(SVV)、每搏输出量指数(SVI)和心脏指数(CI),当SVV13%时,5min内静注3 ml/kg羟乙基淀粉130/0.4氯化钠注射液后观察各项指标变化,当SVV13%,观察CI变化(1)CI2.5L·min-1·m-2时,给予多巴胺0.5~1μg·kg-1 min-1,至CI2.5L·min-1·m-2;(2)若CI2.5L·min-1·m-2,不予处理,观察SVV、MAP、CI的变化。记录麻醉诱导前(T1)、诱导后3min(T2)、BCP时(T3)、BCP后5 min(T4)、30 min(T5)以及手术结束平卧位(T6)的MAP、HR、CI、SVI、SVV;记录两组患者麻醉期间血管活性药物的用量、术中用于容量填充的胶体液用量、胶体液总量以及液体总量;记录患者不良反应的发生情况。结果与T1时比较,T3~T5时两组MAP、CI、SVI明显降低(P0.05);与T2时比较,T3~T5时R组SVV明显升高(P0.05)。T3~T5时S组MAP、CI、SVI明显高于R组,而SVV明显低于R组(P0.05)。S组术中用于容量填充的胶体液用量、胶体液总量以及液体总量明显多于R组(P0.05),两组晶体液总量差异无统计学意义。S组术中麻黄碱、多巴胺用量、尿量明显少于R组,低血压发生率明显低于R组(P0.05)。结论以MAP、CI、SVV为目标靶控容量填充模式较传统容量填充可更为安全有效稳定BCP引起的血流动力学波动。

Effect of goal-directed fluid management on hemodynamics in patients with orthopaedic arthroscopic shoulder surgery in beach chair position

Objective To evaluate the effect of conventional or goal-directed fluid management on hemodynamics in patients undergoing orthopaedic arthroscopic shoulder surgery in beach chair po-sition.Methods Thirty healthy adult patients,male 1 7 cases,female 13 cases,aged 18-65 years, weight 49-68 kg,ASA Ⅰor Ⅱ,undergoing elective arthroscopic shoulder surgery,were enrolled.Pa-tients were randomly assigned to the group R(Routine group,n = 1 5 )and the group S(SVV/CI/MAP-directed,n =1 5).All patients received 10 ml/kg of hydroxyethyl starch rapidly in group R;while in group S,if SVV > 13%,patients would receive 3 ml/kg of hydroxyethyl starch in 5 min, then the changes of each index were observed;if SVV <13% and CI< 2.5 L·min-1 ·m-2 ,given dopamine 0.5~1 μg·kg-1 ·min-1 ,until CI>2.5 L·min-1 ·m-2 .At 5 min after anesthesia induc-tion,patients were placed in a 60° upright position.The hemodynamic changes were monitored by FloTrac/Vigileo system.Heart rate (HR),mean artery pressure(MAP),cardiac index(CI),stroke volume variation(SVV),stroke volume index (SVI),were recorded on pre-induction (T1 ),post-induc-tion (T2 ),immediately after in beach chair position (T3 ),5 min after in beach chair position(T4 ),30 min after in beach chair position(T5 ),and at the end of surgery(T6 ).The duration of surgery,crys-talloid requirements,colloid requirements,urinary output,the dose of vasoactive drugs and the inci-dence of hypotension were recorded.Results Compared with T1 ,MAP,CI and SVI at T3-T5 point (after in BCP to the end of the surgery)were higher in both group(P <0.05 ).Compared with T2 , SVV in group R at T3-T5 were significantly increased (P <0.05),while SVV in group S only at T3 was slightly increased (P <0.05).Compared with group R,MAP,CI and SVI at T3-T5 were signif-icantly higher respectively,while SVV were higher at T3-T5 in group R (P <0.05).Compared with group R,the colloid requirements and total requirements in group S were significantly increased(P <0.05).Compared with group R,the doses of dopamine and ephedrine,the urinary output,the inci-dence of hypotension in group S were significantly reduced(P <0.05).Conclusion SVV/CI/MAP-di-rected fluid management is safer,more effective and renders much more stable hemodynamic than the routine fluid management.