文章摘要
不同水平脉压差变异率指导肺切除术中液体管理的随机对照研究
A randomized controlled analysis of fluid management in pneumonectomy based on different levels of pulse pressure variation
投稿时间：2019-01-08  
DOI：10.3969/j.issn.1000-0399.2019.08.003
中文关键词: 胸腔镜  目标导向液体治疗  脉压差变异率  术后肺部并发症
英文关键词: Thoracoscopy  Goal-directed fluid therapy  Pulse pressure variation rate  Postoperative pulmonary complications
基金项目:安徽省科技攻关项目（项目编号：1704a0802165）
作者单位E-mail
樊迪 230001 合肥 安徽医科大学第二附属医院麻醉与围术期医学科  
刘晓芬 230001 合肥 安徽医科大学第二附属医院麻醉与围术期医学科  
李云 230001 合肥 安徽医科大学第二附属医院麻醉与围术期医学科  
张野 230001 合肥 安徽医科大学第二附属医院麻醉与围术期医学科 zhangye_hassan@sina.com 
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中文摘要:
      目的 评价以不同阈值脉压差变异率（PPV）为目标导向液体治疗（GDFT）对胸腔镜肺切除患者术后早期康复的影响。方法 选择2017年8月至2018年11月在安徽医科大学第二附属医院择期行胸腔镜肺实质切除患者171例，采用随机数字表法分为标准血流动力学管理组（C组）57例、低PPV组（G1组）57例及高PPV组（G2组）57例。C组根据中心静脉压（CVP）、心率（HR）、尿量指导输液；G1组以低PPV（3%≤PPV≤6%）为目标指导输液；G2组以高PPV （10%≤PPV≤13%）为目标指导输液。比较3组患者各时间点血流动力学、液体出入量、术后1周肺部并发症（PPCs）、术后肺功能、住院时间等差异。结果 3组患者HR在不同时间点有随时间变化的趋势，时间效应有统计学意义（P<0.05），分组效应及交互效应无统计学意义（P>0.05）。3组患者的平均动脉压（MAP）在不同时间点有随时间及分组变化的趋势，时间效应及分组效应有统计学意义（P<0.05），交互效应无统计学意义（P>0.05），G1组、G2组术中各时间点MAP值较C组更稳定。3组患者的乳酸值（Lac）在不同时间点有随时间及分组变化的趋势，时间效应、分组效应及交互效应有统计学意义（P<0.05），G1组术中各时间点Lac值更稳定，优于C组、G2组。3组患者的氧合指数（PaO2/FiO2）在不同时间点有随时间及分组变化的趋势，时间效应及分组效应有统计学意义（P<0.05），交互效应无统计学意义（P>0.05），G1组、G2组术中各时间点PaO2/FiO2值更稳定，优于C组。3组患者的动脉血二氧化碳分压（PaCO2）在不同时间点有随分组变化的趋势，分组效应有统计学意义（P<0.05），时间效应及交互效应无统计学意义（P>0.05），G1组、G2组术中各时间点PaCO2更稳定，优于C组。C组、G1组、G2组患者术后1周术后肺部并发症（PPCs）发生率分别为35.09%、14.04%和28.07%，3组患者PPCs发生率的差异有统计学意义（χ2=6.855，P=0.032）。C组、G1组、G2组住院时间分别为（14.56±5.52）d、（11.42±3.83）d、（12.91±3.77）d，G1组患者住院时间与C组、G2组患者相比明显缩短（P<0.05）。结论 胸腔镜下肺切除术中运用GDFT时，以低PPV为目标的液体输注方案为好，能够改善氧合，降低PPCs发生率、缩短住院时间，有利于预后。
英文摘要:
      Objective To evaluate the effect of different threshold pulse pressure variation-based goal-directed fluid therapies on early postoperative rehabilitation of patients with thoracoscopic pneumectomy.Methods A total of 171 patients admitted to the Second Hospital of Anhui Medical University between August 2017 and November 2018 were recruited in this study and randomly divided into three groups (n=57):conventional therapy group (group C), in which patients received fluid therapy according to heart rate, mean arterial pressure, urine output, low PPV-based goal-directed fluid group (group G1), in which patients received fluid therapy to keep PPV between 3% and 6%, and high PPV-based goal-directed fluid group (group G2), in which patients received fluid therapy to keep PPV between 10% and 13%. Hemodynamic index, liquid balance, postoperative pulmonary complications of three groups were compared a week after operation, pulmonary function was compared 1 day, 3 days and 7 days after operation, and length of postoperative hospital stay was also recorded.Results The HR of patients in three groups showed a trend of changing with time at different time points, and the time effect was statistically significant (P<0.05), while the group effect and interaction effect had no statistical significance (P>0.05). MAP of patients in three groups showed a tendency to change with time and group at different time points, and the time effect and group effect had statistical significance (P<0.05), while the interaction effect had no statistical significance (P>0.05). MAP value at each time point in group G1 and group G2 was more stable than that in group C. Lac of patients in three groups showed a tendency to change with time and group at different time points, and the time effect, group effect and interaction effect all had statistical significance (P<0.05). PaO2/FiO2 of patients in three groups showed a tendency to change with time and group at different time points, and the time effect and group effect had statistical significance (P<0.05), while the interaction effect was not statistically significant (P>0.05). PaCO2 of patients in three groups showed a tendency to change with the group at different time points, and the group effect was statistically significant (P<0.05), while the time effect and interaction effect were not statistically significant (P>0.05). PaCO2 value at each time point in group G1 and group G2 was more stable than that in group C. The incidence of PPCs in groups C, G1, G2 was 35.09%, 14.04%, 28.07%, respectively. There was statistical significance among three groups in the incidence of PPCs (χ=6.855, P=0.032). The length of hospital stay in groups C, G1, G2 was (14.56±5.52)days, (11.42±3.83) days, (12.91±3.77) days, respectively. The length of hospital stay of group G1 was significantly shorter than that of group C and group G2 (P<0.05).Conclusions During GDFT for thoracoscopic pneumectomy, fluid boluses targeting lower PPV are beneficial than the other two groups, which can improve oxygenation, reduce the incidence of postoperative pulmonary complications, and shorten the time of hospitalization in patients undergoing thoracoscopic pulmonary parenchyma resection.
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