经典原位肝移植术中目标导向液体治疗对术后早期呼吸及肾功能的影响

Goal-Directed Therapy during Classical Orthotopic Liver Transplantation and Its Effect on Respiratory and Renal Functions in the Early Postoperative Period

摘要: 目的：观察基于每搏变异毒(stroke volume variation, SVV)及心指数(cardiac index, CI)的目标导向液体治疗在经典原位肝移植术的作用与价值。方法：择期选择行经典原位肝移植患者32例，按照随机数字表法分为常规组(C组)及目标导向液体治疗组(G组)。两组患者均监测心电图、动脉血氧饱和度、动脉血压及CVP。但G组同时连接高端Swan-Ganz漂浮导管及Vigilance II监测系统以监测CI及SVV。C组患者术中维持CVP 8~12 mmHg，mABP ≥ 65 mmHg。G组患者根据目标导向液体治疗原则使SVV ≤ 10%、CI ≥ 3 L/min•m2且mABP ≥ 65 mmHg。记录两组患者的一般临床资料，术中记录切皮前(T0)、无肝前期(T1)、门静脉及下腔静脉阻断30 min (T2)、门静脉及下腔静脉开放30 min (T3)、术毕(T4)时两组患者的HR、mABP、CVP，并记录手术时间、术中红细胞输入量、血浆输入量、胶体输入量、晶体输入量、出血量及尿量。同时记录术后机械通气时间、再插管发生率、术后3天总尿量、术后CRRT发生率及ICU总住院日。结果：与C组相比，G组T1~T4 CVP较低(P < 0.05)，术中胶体输入量及尿量明显减少(P < 0.05)，术后机械通气时间较短(P < 0.05)，再插管率较低(P < 0.05)。两组术中T0~T4的HR、mABP；手术时间、红细胞输入量、血浆输入量、晶体输入量、出血量；术后3天总尿量、术后CRRT发生率及ICU总住院日差异均无显著性(P > 0.05)。结论：基于SVV及CI的目标导向液体治疗可安全应用于经典原位肝移植手术，在不增加肾脏并发症基础上降低术后早期肺部并发症发生。

Abstract: Objective: To observe the effect and value of Goal-directed therapy with stroke volume variation (stroke volume variation, SVV) and cardiac index (cardiac index, CI) in classical orthotopic liver transplantation. Methods: 32 patients underwent classical orthotopic liver transplantation were randomly divided into routine group (group C) and Goal-directed therapy group (group G) according to random number table. ECG, arterial oxygen saturation, arterial blood pressure and CVP were monitored in 2 groups. However, group G was simultaneously connected with high-end Swan- Ganz floating catheter and Flotrac monitoring sensor to monitor CI and SVV. Patients in group C received fluid based on CVP (8~12 mmhg) and mABP (≥65 mmHg). Patients in group G were treated under GDFT strategy with a target of SVV ≤ 10%, CI ≥ 3 L/min•m2 and mABP ≥ 65 mmHg. General clinical data of patients in the two groups were recorded. Intraoperative HR, mABP and CVP of patients were recorded before skin resection (T0), pre-hepatic (T1), portal vein and inferior vena occlusion for 30 min (T2), portal vein and inferior vena reperfusion for 30 min (T3), and after operation (T4). Operation time, erythrocyte input, plasma input, colloid input, crystal input, blood loss and urine volume were recorded. The duration of postoperative mechanical ventilation, the incidence of rein-tubation, the total urine volume 3 days after surgery, the incidence of postoperative CRRT and the total length of stay in ICU were recorded. Results: Compared with group C, group G had lower CVP at T1~T4 (P < 0.05), less intraoperative colloid input and less urine volume during the operation (P < 0.05). Moreover, shorter postoperative mechanical ventilation time (P < 0.05) and lower reintuba-tion rate (P < 0.05) were happened in group G. While, there were no significant differences in HR and mABP of intraoperative T0~T4, Operation time, erythrocyte input, plasma input, crystal input, blood loss, total urine volume 3 days after surgery, incidence of postoperative CRRT and total length of ICU stay (P > 0.05). Conclusion: Goal-directed therapy based on SVV and CI can be safely applied in classical orthotopic liver transplantation and reduce the incidence of early postoperative pulmo-nary complications without increasing renal complications.