【作者】 何燕；

【导师】 孙建宏； 张建友；

【作者基本信息】 扬州大学 ， 临床医学硕士（专业学位）， 2021， 硕士

【摘要】 目的本研究旨在通过以SVV为目标进行围术期液体导向治疗,观察腹腔镜下胃癌根治术患者肠道屏障功能的变化及术后康复质量等情况,探讨其在胃癌手术患者中的应用价值,为以后的临床应用提供参考依据。方法选择将于择期全身麻醉下行腹腔镜胃癌根治术的患者60例随机分为2组:G组为观察组(n=30),采用SVV指导下的目标导向液体治疗(Goal-directed Fluid Therapy,GDFT);C组为对照组(n=30),采用传统液体治疗方法。麻醉采用静吸复合全麻,以快速诱导方案进行气管插管,控制呼吸,以丙泊酚、瑞芬太尼、苯磺顺阿曲库铵、盐酸右美托咪定、七氟烷维持麻醉。记录手术时间、术中输液总量、晶胶体液量、出血量、尿量、丙泊酚、舒芬太尼、瑞芬太尼、苯磺顺阿曲库铵及血管活性药物使用情况;记录麻醉前(To)、手术开始时(T1)、气腹后5min(T2)、气腹后30min(T3)、手术2h(T4)、手术结束时(T5)、出 PACU 时(T6)的 MAP、HR、SVV、CO、CI。分别于麻醉前(t0)、手术结束时(t1)、术后1d(t2)、术后3d(t3)测定血浆肠脂肪酸结合蛋白(Intestinal Fatty Acid Binding Protein,I-FABP)、D-乳酸浓度、动脉血乳酸(Lactic Acid,Lac)浓度。术后随访患者,记录术后首次排气时间、术后住院天数、术后心血管并发症,肺部并发症及肾功能损害等发生情况。分别于术前1 d(QoR40-Pre)、术后1 d(QoR40-POD1)、术后3d(QoR40-POD3)由不知情的麻醉医师采用QoR-40量表对患者恢复情况进行分项评估。结果(1)两组患者一般资料(性别、年龄、ASA分级、BMI、手术时长)比较,差异均无统计学意义(P>0.05)。(2)主要结果:两组患者各时间点D-乳酸、I-FABP水平的比较①组间比较,t0时,两组D-乳酸、I-FABP水平差异无统计学意义(f>0.05);t1～t3时,C组D-乳酸、I-FABP水平显著高于G组(P<0.01)。②组内比较,两组D-乳酸、I-FABP水平均先上升后下降;与to时相比,t1～t3时,两组D-乳酸、I-FABP水平均显著升高CP<0.01);与t1时相比,t2～t3时,C组D-乳酸水平、G组I-FABP水平显著升高(P<0.05);t2时,C组I-FABP水平、G组D-乳酸水平较t1时显著升高(P<0.01)。与t2时比较,t3时两组D-乳酸、I-FABP水平均显著下降(P<0.01)。(3)次要结果:术后并发症及预后指标的比较两组术后肺部并发症、心血管并发症、肾功能损害的发生率差异无统计学意义(P>0.05)。与C组相比,G组术后首次排气时间、术后住院天数显著缩短(P<0.01)。(4)次要结果:两组患者各时间点QoR-40量表评分的比较组间比较,两组QoR40-Pre评分差异无统计学意义(f>0.05);术后1天及术后3天,G组QoR-40量表评分显著较C组高(P<0.01)。组内比较,两组患者QoR40-POD1评分均较QoR40-Pre显著降低(P<0.01),QoR40-POD3评分较QoR40-POD1显著增加(P<0.01),但仍显著低于QoR40-Pre评分(P<0.01)。(5)两组患者各时间点动脉血乳酸浓度的比较t0、t2和t3时,两组动脉血乳酸浓度差异无统计学意义(P>0.05);t,时,G组动脉血乳酸浓度显著低于C组(P<0.05)。(6)两组患者麻醉药物及出入量等的比较与C组相比,G组晶体输液量、胶体输液量、总输液量显著减少(P<0.05)。两组患者术中麻醉药物用量、术中出血量、尿量、输血情况、血管活性药物使用情况差异无统计学意义(f>0.05)。(7)两组患者血流动力学指标的比较①T0～T6时,两组MAP、HR差异无统计学意义(P>0.05)。②T5时,G组SVV较C组显著降低(P<0.05)。③与T0时比较,T1～T3时,两组SVV均显著升高(P<0.01);T4～T5时,两组SW均显著下降(P<0.01)。④T5～T6时,G组CI、CO较C组显著升高(P<0.05)。⑤C组T1～T6时的CI和CO均较To时显著下降(P<0.01)。G组T1～T4时的CI和CO均较T0时显著下降(P<0.01)。结论SVV指导下的目标导向液体治疗在腹腔镜胃癌根治术中,可为患者提供个性化、精准化的液体治疗策略,在输注较少的适量液体时,仍能维持良好的血流动力学状态,较高的心输出量及心指数,保证了组织器官灌注,保护了胃癌切除术患者肠道屏障功能,避免输液过度,促进患者术后快速康复。更多还原

【Abstract】 PurposeThe study was carried out to observe the changes in intestinal barrier function and postoperative recovery quality of patients undergoing laparoscopic radical resection of gastric cancer,which was treated with perioperative fluid therapy guided by SVV,and to explore its application value in patients undergoing gastric cancer surgery,in order to provide clinical evidence.MethodsSixty patients who underwent elective laparoscopic radical resection of gastric cancer were randomly divided into 2 groups:Group G(observation group,n=30)was treated with Goal-directed Fluid Therapy guided by SVV and Group C(control group,n=30)with conventional fluid therapy.All patients used rapid induction of anesthesia to endotracheal intubation and control respiratory.Anesthesia was maintained with intravenous infusion of propofol、remifentanil、cisatracurium besilste and dexmedetomidine and inhalation of sevoflurane.Length of surgery,total volume of fluid infused,volume of crystalloid and colloid fluid infused,bleeding volume,urine volume,doses of propofol、sufentanil、remifentanil、cisatracurium besilste and the use of vasoactive drugs were recorded.The values of MAP、HR、SVV、CO and CI were recorded before anesthesia(T0),at the beginning of surgery(T1),5 minutes after pneumoperitoneum(T2),30 minutes after pneumoperitoneum(T3),2 hours after surgery(T4),at the end of surgery(T5)and at the exit of PACU(T6).Levels of I-FABP、D-lactic and arterial Lac were recorded before anesthesia(t0),at the end of surgery(t1),1 day(t2)and 3 day(t3)after surgery.The patients were followed up after surgery,and exhaust time,postoperative hospital stay time,postoperative cardiovascular complications,pulmonary complications and renal function impairment were recorded.QOR-40 scale was used to evaluate the recovery of patients by anesthesiologists who did not know the grouping at 1 day before surgery(QOR40-pre),1 day after surgery(QOR40-POD1),and 3 days after surgery(QOR40-POD3).Results(1)There were no significant differences in the demographic data(sex、age、ASA、BMI and duration of surgery)between the two groups(P>0.05).(2)Primary outcome:The comparison of the levels of D-lactic and I-FABP in two groups① The levels of D-lactic and I-FABP were no significant differences in two groups at t0(P>0.05),but the levels of D-lactic and I-FABP were significantly higher in Group C than in Group G at t1～t3(P<0.01).② Compared with t0,the levels of D-lactic and I-FABP were significantly higher at t1～t3 in two groups(P<0.01);the level of I-FABP in Group C and the level of D-lactic in Group G were significantly higher at t2(P<0.01).Compared with t2,the levels of D-lactic and I-FABP were significantly lower in two groups at t3(P<0.01).(3)Secondary outcome:There were no significant differences in the incidence of postoperative pulmonary complications,cardiovascular complications and renal function impairment(P>0.05).The exhaust time and postoperative hospital stay time were significantly shorter in Group G than in Group C(P<0.01).(4)Secondary outcome:There was no significant difference in the score of QoR40-Pre between two groups(P>0.05).The score of QoR40-POD1 and QoR40-POD3 were significantly higher in Group G than in Group C(P<0.01).The score of QoR40-POD1 was significantly lower than the score of QoR40-Pre in two groups(P<0.01).The score of QoR40-POD3 was higher than the score of QoR40-POD1(P<0.01),but lower than the score of QoR40-Pre(P<0.01).(5)There was no significant difference in the value of arterial Lac at t0、t2 和 t3 between two groups(P>0.05).The value of arterial Lac was significantly lower in Group G than in Group C at t1(P<0.05).(6)The volume of crystalloid and colloid fluid and total volume of fluid infused were significantly lower in Group G than in Group C(P<0.05).The required doses of anesthestics,bleeding volume,urine volume,incidence of blood transfusion and vasoactive drugs were no significant differences(P>0.05).(7)The comparison of hemodynamic indicators in two groups①At T0～T6,MAP and HR were no significant differences in two groups(P>0.05).②At T5,SVV was significantly lower in Group G than in Group C(P<0.05).③Compared with T0,SVV was significantly higher at T1～T3(P<0.01)and significantly lower at T4-T5 in two groups(P<0.01).④ At T5 and T6,CI and CO were significantly higher in Group G than in Group C(P<0.05).⑤Compared with T0,CI and CO were significantly lower at T1～T6 in Group C(P<0.01);CI and CO were significantly lower at T1～T4 in Group G(P<0.01).ConclusionsGoal-directed Fluid Therapy under the guidance of SVV can provide personalized and accurate fluid therapy strategies for patients undergoing laparoscopic radical resection of gastric cancer.It can maintain hemodynamic status,high cardiac output and index by less appropriate amount of fluid,which ensures tissue and organ perfusion,protects intestinal barrier function,avoids excessive infusion and promotes rapid postoperative recovery.更多还原