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

1	翁毅敏，蔡松旺，廖洪映，等. 胸腔镜辅助与常规开胸肺叶切除治疗肺癌的疗效对比[J]. 中山大学学报（医学科学版），2009，30(s1):165-166.
2	解雅英，于建设，吴莉. 目标导向液体治疗临床新进展[J/CD]. 中华临床医师杂志（电子版），2012，6(7):1828-1829.
3	Scheeren TW, Wiesenack C, Gerlach H, et al. Goal-directed intraoperative fluid therapy guided by stroke volume and its variation in high-risk surgical patients: a prospective randomized multicentre study[J]. J Clin Monit Comput, 2013, 27 (3): 225-233.
4	Aya HD, Cecconi M, Hamilton M, et al. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis[J]. Br J Anaesth, 2013, 110 (4): 510-517.
5	Rhodes A, Cecconi M, Hamilton M, et al. Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study[J]. Intensive Care Med, 2010, 36 (8): 1327-1332.
6	Cecconi M, Corredor C, Arulkumaran N, et al. Clinical review: goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups[J]. Crit Care, 2013, 17 (2): 209.
7	Luo J, Xue J, Liu J, et al. Goal-directed fluid restriction during brain surgery: a prospective randomized controlled trial[J]. Ann Intensive Care, 2017, 7 (1): 16.
8	Yuan J, Sun Y, Pan C, et al. Goal-directed fluid the-rapy for reducing risk of surgical site infections following abdominal surgery-a systematic review and meta-analysis of randomized controlled trials[J]. Int J Surg, 2017 (39): 74-87.
9	Rollins KE, Lobo DN. Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a meta-analysis of randomized controlled trials[J]. Ann Surg, 2016, 263 (3): 465-476.
10	Shoemaker WC, Appel PL, Kram HB, et al. Pros-pective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients[J]. Chest, 1988, 94 (6): 1176-1186.
11	Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock[J]. N Engl J Med, 2001, 345 (19): 1368-1377.
12	刘晓文. 老年腹部外科手术的危险因素与防治对策[J]. 国际医药卫生导报，2005，11(4):7-9.
13	向东明，夏志洁，肖东，等. 老年患者腹部手术后再次转入外科ICU的危险因素分析[J/CD]. 中华临床医师杂志（电子版），2011，5(5):1487-1489.
14	Bundgaard-Nielsen M, Secher NH, Kehlet H. 'Liberal' vs. 'restrictive' perioperative fluid therapy-a critical assessment of the evidence [J]. Acta Anaesthesiol Scand, 2009, 53 (7): 843-851.
15	Lobo SM, Salgado PF, Castillo VG, et al. Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients[J]. Crit Care Med, 2000, 28 (10): 3396-3404.
16	Bellomo R, Raman J, Ronco C. Intensive care unit management of the critically ill patient with fluid overload after open heart surgery[J]. Cardiology, 2001, 96 (3-4): 169-176.
17	赵国良，周银燕，彭沛华，等. 目标导向液体治疗对胃肠道肿瘤手术老年患者术后康复的影响[J]. 中华麻醉学杂志，2015，35(4):453-456.
18	Marik PE, Cavallazzi R. Does the central venous pre-ssure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense[J]. Crit Care Med, 2013, 41 (7): 1774-1781.
19	Swan HJ, Ganz W, Forrester J, et al. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter[J]. N Engl J Med, 1970, 283 (9): 447-451.
20	Connors AF Jr, McCaffree DR, Gray BA. Evaluation of right-heart catheterization in the critically ill patient without acute myocardial infarction[J]. N Engl J Med, 1983, 308 (5): 263-267.
21	Peyton PJ, Chong SW. Minimally invasive measurement of cardiac output during surgery and critical care: a meta-analysis of accuracy and precision[J]. Anesthesiology, 2010, 113 (5): 1220-1235.
22	姚萍，吴允孚，曾元英，等. 彩色多普勒超声心动图、Swan-Ganz导管和脉波指示剂连续心排血量监测仪血流动力学检测的同步比较研究[J/CD]. 中华危重症医学杂志（电子版），2010，3(2):99-103.
23	Rudziński PN, Henzel J, Dzielińska Z, et al. Pul-monary artery rupture as a complication of Swan-Ganz catheter application. Diagnosis and endovascular treatment: a single centre's experience[J]. Postepy Kardiol Interwencyjnej, 2016, 12 (2): 135-139.
24	费云捷，张洪熹，张大维，等. Swan-Ganz流向导管的并发症分析[J]. 上海医学，1993，16(5):281-282.
25	Mcgee WT, Horswell JL, Calderon J, et al. Validation of a continuous, arterial pressure-based cardiac output measurement: a multicenter, prospective clinical trial[J]. Crit Care, 2007, 11 (5): R105.
26	Wang P, Wang HW, Zhong TD. Effect of stroke vol-ume variability-guided intraoperative fluid restriction on gastrointestinal functional recovery[J]. Hepatogastroenterology, 2012, 59 (120): 2457-2460.
27	Benes J, Chytra I, Altmann P, et al. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study[J]. Crit Care, 2010, 14 (3): R118.
28	Forget P, Lois F, de Kock M. Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management[J]. Anesth Analg, 2010, 111 (4): 910-914.
29	Venn R, Steele A, Richardson P, et al. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures[J]. Br J Anaesth, 2002, 88 (1): 65-71.
30	Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery[J]. Anesthesiology, 2002, 97 (4): 820-826.
31	Portari PEP, Diogo IP, Ravanini G, et al. Protocol of restricted perioperative fluid therapy reduces surgical morbidity after major abdominal surgery[J]. AClin Nutr ESPEN, 2016 (12): e53.

[1]	李刘庆, 陈小翔, 吕成余. 全腹腔镜与腹腔镜辅助远端胃癌根治术治疗进展期胃癌的近中期随访比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 23-26.
[2]	刘世君, 马杰, 师鲁静. 胃癌完整系膜切除术+标准D2根治术治疗进展期胃癌的近中期随访研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 27-30.
[3]	李华志, 曹广, 刘殿刚, 张雅静. 不同入路下行肝切除术治疗原发性肝细胞癌的临床对比[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 52-55.
[4]	常小伟, 蔡瑜, 赵志勇, 张伟. 高强度聚焦超声消融术联合肝动脉化疗栓塞术治疗原发性肝细胞癌的效果及安全性分析[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 56-59.
[5]	王露, 周丽君. 全腹腔镜下远端胃大部切除不同吻合方式对胃癌患者胃功能恢复、并发症发生率的影响[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 92-95.
[6]	康婵娟, 张海涛, 翟静洁. 胰管支架置入术治疗急性胆源性胰腺炎的效果及对患者肝功能、炎症因子水平的影响[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 667-670.
[7]	付成旺, 杨大刚, 王榕, 李福堂. 营养与炎症指标在可切除胰腺癌中的研究进展[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 704-708.
[8]	许杰, 李亚俊, 冯义文. SOX新辅助化疗后腹腔镜胃癌D2根治术与常规根治术治疗进展期胃癌的近期随访比较[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 647-650.
[9]	曾繁利, 齐秩凯, 杨贺庆. 两种经Glisson蒂鞘解剖路径肝切除术治疗原发性肝癌的肿瘤学疗效及风险比对[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(05): 525-527.
[10]	王维花, 王楠, 乔庆, 罗红. 完全腹腔镜右半结肠癌切除术两种腔内消化道重建方案对比研究[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(05): 574-577.
[11]	丁荷蓓, 王珣, 陈为国. 七氟烷吸入麻醉与异丙酚静脉麻醉在儿童腹股沟斜疝手术中的应用比较[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(05): 570-574.
[12]	罗柳平, 吴萌萌, 陈欣磊, 林科灿. 胰腺全系膜切除在胰头癌根治术中的应用价值[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(05): 651-656.
[13]	韩青雷, 丛赟, 李佳隆, 邵英梅. 术前减黄方式对壶腹周围癌胰十二指肠切除术后并发症的影响[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(05): 665-669.
[14]	王守森, 傅世龙, 鲜亮, 林珑. 深入理解控制性减压技术对创伤性颅脑损伤术中脑膨出的预防机制与效果[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(05): 257-262.
[15]	谢浩文, 丁建英, 刘小霞, 冯毅, 姚婧. 椎旁神经阻滞对微创胃切除肥胖患者术中血流、术后应激及康复质量的影响[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 569-573.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

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

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

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