经食管超声心动描计术引导下目标导向液体治疗在肺叶切除术中的应用

Application of goal-directed fluid therapy directed by transesophageal echocardiography in patients undergoing lobectomy

摘要:

目的 观察胸腔镜下左肺下叶切除术中应用经食管超声心动描记术（TEE）监测对改善患者血流动力学的临床效应及预后。方法 择期行胸腔镜下左肺下叶切除术患者40例。随机分为限制性输液组（C组，n?= 20）和TEE引导液体输入组（E组，n?=20）。E组在TEE监测下的管理目标：左室射血时间（LVET）控制在350～400?ms、每搏量（SV）上升<10%。记录两组患者诱导即刻（T1）、切皮（T2）、单肺通气（T3）、关胸（T4）、术毕（T5）时的血流动力学变化，T1和T5时间点氧输送指数（DO2I）、氧消耗指数（VO2I）、乳酸（Lac）及液体量、尿量、失血量及术中使用血管活性药物情况。结果 E组输液量和尿量均高于C组（P?<0.05）；E组麻黄素和去氧肾上腺素用量均少于C组（P?<0.05）。两组患者不同时间点平均动脉压（MAP）、心率（HR）有差异（P?<0.05）；组间比较HR有差异，E组HR低于C组（P?<0.05），相对血流动力学更加稳定。在T5时E组DO2I、VO2I高于C组，Lac低于C组（P?<0.05）。E组T5时DO2I、VO2I高于T1时，Lac低于T1时（P?<0.05）；C组T5时VO2I高于T1时，Lac低于T1时（P?<0.05）。结论 TEE引导下的目标导向液体治疗肺叶切除术的患者可以获得较满意的容量状态，有助于改善患者的术后转归，减少术后并发症发生率。

Abstract:

Objective To observe the clinical effect and prognosis of transesophageal echocardiography (TEE) in improving the hemodynamics of patients under thoracoscopic lobectomy. Methods Fifty patients underwent thoracoscopic left lower lobectomy were randomly divided into the fluid restriction group (C group, n?=?20) and TEE group (E group, n?=?20). C group used restrictive fluid infusion; Group E used TEE to guide the fluid input. The management objective was to control the left ventricular ejection time (LVET) at 350 to 400 ms and the stroke volume (Stroke volume, SV) increased by < 10% under TEE. The hemodynamic changes, T1 and T5 time points DO2I, VO2I, Lac and fluid volume, urine volume, blood loss and intraoperative use of vasoactive drugs at immediate induction time (T1), cut time (T2), single lung ventilation time (T3), chest closing time (T4), and surgery finishing time (T5) were recorded. Results Infusion volume and urine volume in group E were higher than those in group C (P?< 0.05). The dosage of Ephedrine and Deoxyepinephrine in group E was lower than that in group C (P?< 0.05). There were differences in MAP and HR between the two groups at time points of T2-T5 (P?< 0.05). There were differences in HR between groups ,HR in group E was lower than that in group C (P < 0.05), and the relative hemodynamics was more stable. At T5 time point, DO2I and VO2I in group E were higher than those in group C, and Lac was lower than those in group C (P?< 0.05). DO2I and VO2I at T5 time point in group E were higher than those at T1 time point, and Lac was lower than those at T1 time point (P?< 0.05). In group C, VO2I at T5 time point was higher than that at T1 time point, and Lac was lower than that at T1 time point (P?< 0.05). Conclusions TEE-guided target-directed fluid therapy can achieve a satisfactory volume status in patients undergoing lobectomy, which can improve the patient's postoperative outcome and reduce the incidence of postoperative complications.