胸部恶性肿瘤根治术后患者目标导向液体治疗的价值研究

doi:10.3877/cma.j.issn.1674-6880.2017.03.008

目的

探讨目标导向液体治疗（GDFT）在胸部恶性肿瘤根治术后患者的应用价值。

方法

收集100例择期全身麻醉下行胸部恶性肿瘤根治术的患者分为对照组和GDFT组，每组各50例。对照组患者术后常规补液治疗，GDFT组患者进行个体化目标导向滴定式补液治疗。比较两组患者入ICU时（T1）、术后8 h（T2）及24 h（T3）的心率、平均动脉压（MAP）、中心静脉压（CVP）、心脏指数及每搏输出量（SV）。同时，记录所有患者术后低血容量、肺水肿、代谢性酸中毒的发生情况、ICU住院时间及总住院时间。

结果

两组患者心率指标各时间点比较，差异无统计学意义（F = 0.335，P = 0.564），而MAP、CVP、心脏指数及SV水平各时间点间的比较，差异均有统计学意义（F = 7.905，P = 0.006；F = 76.563，P < 0.001；F = 378.906，P < 0.001；F = 267.969，P < 0.001），且在T2、T3时GDFT组MAP[（80 ± 9）mmHg vs.（68 ± 10）mmHg，（85 ± 11）mmHg vs.（76 ± 9）mmHg]、CVP[（7.9 ± 2.8）cmH₂O vs.（4.6 ± 2.2）cmH₂O，（8.3 ± 3.0）cmH₂O vs.（5.7 ± 2.9）cmH₂O]、心脏指数[（2.9 ± 0.4）L·min^-1·m^-2 vs.（2.2 ± 0.3）L·min^-1·m^-2，（3.1 ± 0.3）L·min^-1·m^-2 vs.（2.4 ± 0.3）L·min^-1·m^-2]及SV[（53 ± 11）mL vs.（49 ± 9）mL，（61 ± 10）mL vs.（48 ± 10）mL]水平均显著高于对照组（P均< 0.05）。同时，与对照组相比，GDFT组患者术后低血容量发生率[17/50 vs. 8/50，χ² = 5.869，P = 0.015]较低，ICU住院时间[（4.9 ± 2.7）vs.（2.9 ± 1.8）d，t = 4.137，P < 0.001]及总住院时间[（22 ± 4）d vs.（17 ± 5）d，t = 4.660，P < 0.001]明显缩短。

结论

胸部恶性肿瘤根治术后患者行GDFT方法的血流动力学参数显著优于常规补液的方法，同时可减少患者ICU住院时间，有助于患者的术后恢复。

关键词: 目标导向液体治疗, 胸部肿瘤, 血流动力学, 手术后并发症

Objective

To investigate the value of goal-directed fluid therapy (GDFT) after radical surgery in patients with thoracic malignant neoplasms.

Methods

Totally 100 patients with malignant neoplasms underwent thoracic surgery were randomly divided to the control group and GDFT group, 50 patients in each group. Patients in the control group received routine fluid therapies, and patients in the GDFT group were given individually GDFT. The heart rates, mean arterial pressure (MAP), central venous pressure (CVP), cardiac index and stroke volume (SV) were detected at ICU (T1), 8 h (T2), 24 h (T3) after surgery. The incidence rates of hypovolemia, pulmonary edema and metabolic acidosis after surgery, length of ICU and hospital stay were recorded and compared between the two groups.

Results

The heart rates in the two groups showed no significant differences (F = 0.335, P = 0.564), and the MAP, CVP, cardiac index and SV all showed significant differences between the two groups (F = 7.905, P = 0.006; F = 76.563, P < 0.001; F = 378.906, P < 0.001; F = 267.969, P < 0.001), and MAP [(80 ± 9) mmHg vs. (68 ± 10) mmHg, (85 ± 11) mmHg vs. (76 ± 9) mmHg], CVP [(7.9 ± 2.8) cmH₂O vs. (4.6 ± 2.2) cmH₂O, (8.3 ± 3.0) cmH₂O vs. (5.7 ± 2.9) cmH₂O], cardiac index [(2.9 ± 0.4) L·min^-1·m^-2 vs. (2.2 ± 0.3) L·min^-1·m^-2, (3.1 ± 0.3) L·min^-1·m^-2 vs. (2.4 ± 0.3) L·min^-1·m^-2] and SV [(53 ± 11) mL vs. (49 ± 9) mL, (61 ± 10) mL vs. (48 ± 10) mL] in the GDFT group at T2, T3 were much higher than those in the control group (all P < 0.05). Compared with the control group, the incidence rates of hypovolemia were much lower [17/50 vs. 8/50, χ² = 5.869, P = 0.015], the length of ICU [(4.9 ± 2.7) d vs. (2.9 ± 1.8) d, t = 4.137, P < 0.001] and hospital stay [(22 ± 4) d vs. (17 ± 5) d, t = 4.660, P < 0.001] were much shorter in the GDFT group.

Conclusion

GDFT could significantly improve hemodynamic parameters and reduce the length of hospital stay, and be helpful to postoperative recovery of patients with thoracic malignant neoplasms.

Key words: Goal-directed fluid therapy, Thoracic neoplasms, Hemodynamics, Postoperative complications

表1 两组胸部恶性肿瘤患者术前一般资料的比较（ ± s）

组别	例数	男/女（例）	年龄（岁）	ASA分级（Ⅱ/Ⅲ）	BMI（kg/m²）	血红蛋白（g/L）	血小板计数（× 10⁹/L）	血肌酐（μmol/L）
对照组	50	26/24	57 ± 10	28/22	21.2 ± 3.2	117 ± 20	286 ± 82	66 ± 14
GDFT组	50	28/22	58 ± 9	32/18	20.8 ± 2.6	114 ± 21	260 ± 102	61 ± 15
t/χ²值	?	0.901	0.606	1.737	0.197	1.777	0.963	0.811
P值	?	0.343	0.545	0.188	0.844	0.078	0.337	0.423

表1 两组胸部恶性肿瘤患者术前一般资料的比较（ ± s）

组别	例数	男/女（例）	年龄（岁）	ASA分级（Ⅱ/Ⅲ）	BMI（kg/m²）	血红蛋白（g/L）	血小板计数（× 10⁹/L）	血肌酐（μmol/L）
对照组	50	26/24	57 ± 10	28/22	21.2 ± 3.2	117 ± 20	286 ± 82	66 ± 14
GDFT组	50	28/22	58 ± 9	32/18	20.8 ± 2.6	114 ± 21	260 ± 102	61 ± 15
t/χ²值	?	0.901	0.606	1.737	0.197	1.777	0.963	0.811
P值	?	0.343	0.545	0.188	0.844	0.078	0.337	0.423

表2 两组胸部恶性肿瘤患者手术前后各时间点血流动力学参数的比较（ ± s）

组别	例数	时点	心率（次/min）	MAP（mmHg）	CVP（cmH₂O）	心脏指数（L·min^-1·m^-2）	SV（mL）
?	?	T1	90 ± 10	84 ± 9	5.4 ± 2.1	2.8 ± 0.4	53 ± 10
对照组	50	T2	103 ± 11	68 ± 10^a	4.6 ± 2.2^a	2.2 ± 0.3^a	49 ± 9
?	?	T3	99 ± 12	76 ± 9^b	5.7 ± 2.9^b	2.4 ± 0.3^a	48 ± 10^a
?	?	T1	88 ± 11	86 ± 10	5.5 ± 2.2	2.7 ± 0.5	54 ± 9
GDFT组	50	T2	97 ± 12	80 ± 9^ac	7.9 ± 2.8^ac	2.9 ± 0.4^c	53 ± 11^d
?	?	T3	92 ± 10	85 ± 11^bc	8.3 ± 3.0^ac	3.1 ± 0.3^ac	61 ± 10^abc
F值	?	?	0.335	7.905	76.563	378.906	267.969
P值	?	?	0.564	0.006	<0.001	<0.001	<0.001

表2 两组胸部恶性肿瘤患者手术前后各时间点血流动力学参数的比较（ ± s）

组别	例数	时点	心率（次/min）	MAP（mmHg）	CVP（cmH₂O）	心脏指数（L·min^-1·m^-2）	SV（mL）
?	?	T1	90 ± 10	84 ± 9	5.4 ± 2.1	2.8 ± 0.4	53 ± 10
对照组	50	T2	103 ± 11	68 ± 10^a	4.6 ± 2.2^a	2.2 ± 0.3^a	49 ± 9
?	?	T3	99 ± 12	76 ± 9^b	5.7 ± 2.9^b	2.4 ± 0.3^a	48 ± 10^a
?	?	T1	88 ± 11	86 ± 10	5.5 ± 2.2	2.7 ± 0.5	54 ± 9
GDFT组	50	T2	97 ± 12	80 ± 9^ac	7.9 ± 2.8^ac	2.9 ± 0.4^c	53 ± 11^d
?	?	T3	92 ± 10	85 ± 11^bc	8.3 ± 3.0^ac	3.1 ± 0.3^ac	61 ± 10^abc
F值	?	?	0.335	7.905	76.563	378.906	267.969
P值	?	?	0.564	0.006	<0.001	<0.001	<0.001

表3 两组胸部恶性肿瘤患者术后并发症发生率及住院时间的比较（ ± s）

组别	例数	低血容量[例（%）]	肺水肿[例（%）]	代谢性酸中毒[例（%）]	ICU住院时间（d）	总住院时间（d）
对照组	50	17（34）	4（8）	14（28）	4.9 ± 2.7	22 ± 4
GDFT组	50	8（16）	3（6）	13（26）	2.9 ± 1.8	17 ± 5
t/χ²值	?	5.869	0.455	0.034	4.137	4.660
P值	?	0.015	0.455	0.854	<0.001	<0.001

表3 两组胸部恶性肿瘤患者术后并发症发生率及住院时间的比较（ ± s）

组别	例数	低血容量[例（%）]	肺水肿[例（%）]	代谢性酸中毒[例（%）]	ICU住院时间（d）	总住院时间（d）
对照组	50	17（34）	4（8）	14（28）	4.9 ± 2.7	22 ± 4
GDFT组	50	8（16）	3（6）	13（26）	2.9 ± 1.8	17 ± 5
t/χ²值	?	5.869	0.455	0.034	4.137	4.660
P值	?	0.015	0.455	0.854	<0.001	<0.001

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Evaluation of goal-directed fluid therapy after radical surgery in patients with thoracic malignant neoplasms

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Evaluation of goal-directed fluid therapy after radical surgery in patients with thoracic malignant neoplasms