Application of Goal-directed Fluid Therapy Combined with Low-dose Methoxamine in Combined Radical Thoracoabdominal Surgery for Esophageal Carcinoma
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摘要:
目的 在预防性静脉泵注小剂量甲氧明1.0～2.5 μg/（kg·min）的背景下，比较目标导向液体治疗（goal-directed fluid therapy，GDFT）和限制性液体治疗两种液体管理方案对胸腹联合腔镜食管癌根治术患者的影响，旨在为这类患者提供更为优化的液体管理。 方法 择期拟行胸腹联合腔镜食管癌根治术患者36例，按随机数字表法分成目标导向液体治疗组（G组）和限制性液体治疗组（R组）。G组患者以SVV值8%~10%，CI > 2.5 L/（min·m2）为目标进行导向液体管理；R组采用限制性输液方案；监测并记录麻醉诱导前（T0）、麻醉诱导后（T1）、双肺通气15 min（T2）、单肺通气15 min（T3）、肺复张后双肺通气15 min（T4）、手术完成（T5）各时间点患者的HR、MAP、SVV、CO、CI、SV；记录术中输液量、晶体量、胶体量、尿量、失血量以及甲氧明用量及术后早期并发症的发生。 结果 在T4、T5时间点，G组患者的HR低于R组，差异有统计学意义（P < 0.05）。G组患者的MAP、SVV、CO、CI、SV均高于R组患者，差异有统计学意义（P < 0.05）。在液体出入量方面，G组的总液体量少于R组，其中以晶体液减少为主，差异有统计学意义（P < 0.05），而G组的胶体液多于R组，差异有统计学意义（P < 0.05）；R组患者术中的尿量明显多于G组，差异有统计学意义（P < 0.05）。在并发症方面，G组患者在术后恶心呕吐、咳嗽咳痰的发生率低于R组，两组疼痛并发症发生率差异有统计学意义（P < 0.05）。 结论 GDFT联合小剂量甲氧明更适合胸腹联合腔镜食管癌根治术患者的液体管理。 Abstract:Objective To compare the effects of two fluid management regimens, goal-directed fluid therapy（GDFT）and restrictive fluid therapy, on patients undergoing thoracoabdominal combined endoscopic esophagectomy for esophageal cancer in the context of prophylactic intravenous pump infusion of low-dose methoxamine 1.0～2.5 μg/（kg·min）, in order to provide more optimal fluid management for such patients. Methods Thirty-six patients were scheduled to undergo thoracoabdominal combined with laparoscopic radical esophagectomy foresophageal cancer were divided into goal-directed liquid therapy group（Group G）and restrictive liquid therapy group（Group R）according to random number table method. Group G patients were managed with SVV value of 8%～10%, CI > 2.5 L/（min·m2）as the target. The restrictive infusion regimen was used in group R. HR, MAP, SVV, CO, CI and SV were monitored and recorded before anesthesia induction（T0）, after anesthesia induction（T1）, two lung ventilation for 15 min（T2）, one lung ventilation for 15 min（T3）, two lung ventilation for 15 min（T4）after lung recruitment and operation completion（T5）; intraoperative infusion volume, crystalloid volume, colloid volume, urine volume, blood loss, the usage of methoxamine and the occurrence of early postoperative complications were recorded. Results At the time points of T4 and T5, the HR of group G was lower than that of group R, and the difference was statistically significant（P < 0.05）. The MAP, SVV, CO, CI and SV of group G were higher than those of group R, and the difference was statistically significant（P < 0.05）. In terms of fluid intake and output, the total fluid volume in group G was less than that in group R, in which the decrease of crystalloid fluid was the main factor, and the difference was statistically significant（P < 0.05）, while the colloidal fluid volume in group G was more than that in group R, the difference was statistically significant（P < 0.05）; the intraoperative urine volume in group R was significantly more than that in group G, and the difference was statistically significant（P < 0.05）. In terms of complications, the incidence of postoperative nausea and vomiting, cough and expectoration in group G was lower than that in group R. The difference of the pain complications was statistically significant（P < 0.05）. Conclusion GDFT combined with low-dose methoxamine is more suitable for fluid management in patients undergoing thoracoabdominal combined laparoscopic esophagectomy for esophageal cancer. -
表 1 两组患者一般资料比较（
$\bar x \pm s$ ）Table 1. Comparison of general information between two groups（
$\bar x \pm s$ ）项目 G组 R组 t P 例数（n） 18 18 − − 年龄（岁） 53.67 ± 5.96 54.21 ± 4.86 0.2928 0.7682 性别（男/女） 17/1 17/1 − − 体重（kg） 56.8 ± 4.25 57.07 ± 4.15 0.1928 0.8482 身高（m） 1.64 ± 0.05 1.63 ± 0.06 0.5432 0.5905 体重指数（kg/m2） 20.82 ± 1.32 21.01 ± 1.56 0.3945 0.4957 
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表 2 两组患者术中血流动力学参数比较（
$\bar x \pm s$ ）Table 2. Comparison of intraoperative hemodynamic parameters between two groups（
$\bar x \pm s$ ）项目 分组 T0 T1 T2 T3 T4 T5 HR（次/min） R组 75.87 ± 8.11 73.07 ± 7.02 67.40 ± 4.33 75.27 ± 6.84 81.13 ± 6.68 89.33 ± 6.13 G组 75.27 ± 9.19 70.67 ± 6.55 65.00 ± 4.59 72.93 ± 9.55 71.27 ± 6.88* 81.07 ± 6.75* MAP（mmHg） R组 84.27 ± 7.93 70.73 ± 5.40 76.20 ± 6.43 75.80 ± 5.41 72.47 ± 3.83 78.33 ± 7.96 G组 86.00 ± 8.78 72.53 ± 6.28 78.13 ± 7.48 77.67 ± 5.80 80.13 ± 4.53* 85.67 ± 10.86* SVV（%） R组 8.13 ± 1.31 12.2 ± 1.42 11.80 ± 2.26 8.93 ± 1.48 5.13 ± 1.15 4.67 ± 1.70 G组 8.20 ± 1.28 12.07 ± 1.61 11.13 ± 2.19 8.47 ± 2.73 8.60 ± 2.12* 8.47 ± 1.93* CO（L/min） R组 6.07 ± 1.19 5.95 ± 1.03 6.18 ± 1.01 5.71 ± 0.79 5.66 ± 0.78 5.77 ± 0.83 G组 6.13 ± 1.29 5.52 ± 1.08 5.76 ± 0.91 5.85 ± 0.75 6.62 ± 1.23* 6.74 ± 1.12* CI（L/min.m2） R组 3.85 ± 0.62 3.58 ± 0.54 3.79 ± 0.60 3.65 ± 0.61 3.60 ± 0.53 3.78 ± 0.59 G组 3.72 ± 0.66 3.49 ± 0.59 3.70 ± 0.66 3.71 ± 0.44 4.33 ± 0.63* 4.35 ± 0.61* SV（mL） R组 82.87 ± 10.38 75.93 ± 8.74 85.27 ± 9.08 73.67 ± 5.06 73.13 ± 3.91 75.67 ± 4.60 G组 80.13 ± 14.44 74.20 ± 12.03 83.93 ± 13.11 77.60 ± 14.15 84.13 ± 17.43* 86.73 ± 11.32* 与R组比较，*P < 0.05。
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表 3 两组患者术中液体出入量、甲氧明用量比较（
$\bar x \pm s$ ）Table 3. Comparison of intraoperative fluid volume and total methoxyphen usage between two groups（
$\bar x \pm s$ ）项目 G组 R组 t P 晶体量（mL） 1993 ± 327.71* 2917 ± 352.29 8.148 < 0.0001 胶体量（mL） 2150 ± 238.20* 1957 ± 225.54 2.496 0.017 总液体量（mL） 4083 ± 506.03* 4823 ± 526.74 4.302 < 0.0001 失血量（mL） 363.3 ± 49.89 356.7 ± 49.90 0.424 0.674 尿量（mL） 906.7 ± 223.51* 1173 ± 229.40 3.544 0.001 甲氧明（mg） 46.67 ± 8.56 48.93 ± 8.43 0.798 0.430 与R组比较，*P < 0.05。
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表 4 两组患者术后并发症的比较[n （%）]
Table 4. Comparison of postoperative complications between two groups[n （%）]
项目 G组 R组 F P 恶心呕吐 2（11.11） 6（33.33） 1.444 0.229 咳嗽咳痰 3（16.67） 8（44.44） 2.095 0.147 疼痛VAS评分 > 3分 3（16.67） 9（50.00） 4.500 0.034 吻合口瘘 2（11.11） 3（16.67） 0.232 0.630 肺部感染 3（16.67） 4（22.22） 0.177 0.673 肺不张 1（5.55） 2（11.11） 0.363 0.546 肺水肿 0（0） 0（0） − − 呼吸衰竭 0（0） 0（0） − − 窦性心动过速 1（5.55） 2（11.11） 0.363 0.546 房颤 0（0） 1（5.55） 1.029 0.310 心功能不全 0（0） 0（0） − − 肾功能不全 0（0） 0（0） − −
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