Observation of Achieving Controlled Low Central Venous Pressure with Goal-directed Fluid Therapy Combined with Milrinone in Laparoscopic Hepatic Lobectomy
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摘要:
目的 探讨目标导向液体治疗联合米力农在腹腔镜肝叶切除术中实现控制性低中心静脉压（controlled low central venous pressure，CLCVP）的效果。 方法 选取2021 年08月至2023 年11 月昆明市第一人民医院行腹腔镜肝叶切除手术患者60 例为研究对象，采用随机数字表法将其均分为2 组，即对照组、实验组各30 例。对照组采用严格控制液体治疗（输注3 mL/kg晶胶比为1∶1的液体），根据患情使用泵注Nitroglycerin实现CLCVP；实验组则采用以SVV 1%～9%为目标进行液体治疗（输注 20 mL/kg晶胶比为1∶1的液体），并联合使用米力农实现CLCVP。记录2 组手术视野满意率、出血量、血压变化、尿量和中心静脉压以及住院时间指标。 结果 实验组手术医生术中视野满意率高于对照组，差异有统计学意义（P < 0.05）；实验组术中总出血量、平均出血量均低于对照组，手术时间短于对照组，差异有统计学意义（P < 0.05）；2 组在术前平均动脉压方面比较，差异无统计学意义（P > 0.05）；实验组在术中、术后平均动脉压均高于对照组，差异有统计学意义（P < 0.05）；2 组在术中尿量方面比较，差异无统计学意义（P > 0.05），但术后尿量实验组高于对照组，术中平均CVP值低于对照组，差异有统计学意义（P < 0.05）；实验组总住院时间、平均住院时间均短于对照组，差异有统计学意义（P < 0.05）。 结论 在腹腔镜肝叶切除手术中，采用目标导向液体治疗联合米力农实现控制性低中心静脉压（CLCVP）的方法，相较于传统严格液体控制，显著减少术中出血，维持循环稳定，缩短手术与住院时间，提高手术医生视野满意率。 -
关键词:
- 腔镜肝叶切除术 /
- 目标导向液体治疗 /
- 米力农 /
- 控制性低中心静脉压技术
Abstract:Objective To investigate the effect of goal-directed fluid therapy combined with milrinone in achieving controlled low central venous pressure （CLCVP） in laparoscopic hepatic lobectomy. Methods Sixty patients undergoing laparoscopic hepatectomy at the First People’ s Hospital of Kunming City from August 2021 to November 2023 were selected as the study subjects. They were randomLy divided into two groups, with 30 cases in each group: the control group and the experimental group. The control group received strict fluid therapy （infusion of crystalloid at a ratio of 1∶1 at 3 mL/kg） and Nitroglycerin infusion to achieve CLCVP based on the patient’ s condition. The experimental group received fluid therapy targeting SVV 1%～9% （infusion of crystalloid at a ratio of 1∶1 at 20 mL/kg） and milrinone was used in combination to achieve CLCVP. Surgical field satisfaction, blood loss, blood pressure changes, urine output, central venous pressure, and length of hospital stay were recorded for both groups. Results The intraoperative surgical field satisfaction of the experimental group was higher than that of the control group, with statistically significant differences （P < 0.05）; the total intraoperative blood loss and average blood loss in the experimental group were lower than those in the control group, and the surgical time was shorter than that of the control group, with statistically significant differences （P < 0.05）. There was no statistically significant difference in preoperative mean arterial pressure between the two groups （P > 0.05）. The experimental group had higher mean arterial pressure both intraoperatively and postoperatively than the control group, with statistically significant differences （P < 0.05）. There was no statistically significant difference in urine output between the two groups intraoperatively （P > 0.05）, but postoperatively, the urine output in the experimental group was higher than that in the control group. The average CVP value was lower in the experimental group than in the control group, with statistically significant differences （P < 0.05）. The total length of hospital stay and average length of hospital stay were shorter in the experimental group than in the control group, with statistically significant differences （P < 0.05）. Conclusion In laparoscopic liver resection surgery, the use of goal-directed fluid therapy combined with milrinone to achieve controlled low central venous pressure （CLCVP） significantly reduces intraoperative bleeding, maintains hemodynamic stability, shortens surgical and hospital stay, and improves surgeon’ s satisfaction with surgical field compared to the traditional strict fluid control method. -
表 1 2组一般资料比较[（$\bar x \pm s $）/n（%）]
Table 1. Comparison of general data between the two groups[（$\bar x \pm s $）/n（%）]
组别 n 性别 平均年龄（岁） 疾病类型 切除部位 男 女 肝血管瘤 肝内胆管结石 肝占位性病变 左半肝 肝左外侧 对照组 30 18（60.00） 12（40.00） 42.5±12.2 14（46.67） 11（36.67） 5（16.67） 22（73.33） 8（26.67） 实验组 30 20（66.67） 10（33.33） 40.7±14.4 12（40.00） 11（36.67） 7（23.33） 21（70.00） 9（30.00） t/χ2 − 0.327 0.633 1.163 0.064 P − 0.567 0.530 0.559 0.800 
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表 2 2组外科医生对术中视野满意率情况比较[n（%）]
Table 2. Comparison of surgeons' satisfaction rates with intraoperative surgical fields between the two groups[n（%）]
组别 n 优 良 中 差 术中视野满意率 对照组 30 5（16.67） 15（50.00） 9（30.00） 1（3.33） 20（66.67） 实验组 30 23（76.67） 5（16.67） 2（6.67） 0（0.00） 28（93.33） χ2 − − − − − 6.269 P − − − − − 0.012* *P < 0.05。
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表 3 2组总出血量、平均出血量及手术时间对比（$\bar x \pm s $）
Table 3. Comparison of total blood loss，average blood loss，and operation time between the two groups （$\bar x \pm s $）
组别 n 术中总出血量（mL） 平均出血量（mL） 手术时间（min） 对照组 30 690.26±110.32 667.25±102.55 142.03±75 实验组 30 346.19±52.66 289.61±46.52 104.14±51 t − 8.801 17.722 2.631 P − 0.001* 0.001* 0.010* *P < 0.05。
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表 4 2组不同时间点MAP值情况比较（$\bar x \pm s $）
Table 4. Comparison of MAP values at different time points between the two groups （$\bar x \pm s $）
组别 n 术前（mmHg） 术中（mmHg） 术后（mmHg） 对照组 30 95.81±11.20 70.50±10.09 77.52±9.67 实验组 30 94.30±10.24 78.63±10.28 84.61±9.55 F − 0.004 62.031 49.634 P − 0.952 0.001* 0.001* *P < 0.05。
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表 5 2组术中平均CVP值、术中及术后尿量变化情况比较（$\bar x \pm s $）
Table 5. Comparison of average intraoperative CVP values and changes in intraoperative and postoperative urine volume between the two groups （$\bar x \pm s $）
组别 n 术中平均CVP （mmHg） 术中尿量（mL） 术后尿量（mL） 对照组 30 5.30±1.80 1283.33 ±422.12779.32±253.14 实验组 30 3.81±1.50 1268.81 ±392.411086.71 ±211.63t − 7.790 0.251 5.208 P − 0.001* 0.803 0.001* *P < 0.05。
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表 6 2组总住院时间、平均住院时间情况比较（$\bar x \pm s $，d）
Table 6. Comparison of total hospital stay and average hospital stay between the two groups（$\bar x \pm s $，d）
组别 总住院时长 平均住院时长 对照组（n=30） 149.00±5.00 10.24±4.13 实验组（n=30） 107.00±3.00 7.27±2.16 t 13.225 10.526 P 0.001* 0.001* *P < 0.05。
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[1] Wu G,Chen T,Chen Z. Effect of controlled low central venous pressure technique on postoperative hepatic insufficiency in patients undergoing a major hepatic resection[J]. Am J Transl Res,2021,13(7):8286-8293. [2] 王小梅,曹琴,成可熹,等. 不同体位控制低中心静脉压在腹腔镜肝切除术中的应用[J]. 实用医院临床杂志,2020,17(3):175-177. [3] Liu J,Cao B,Luo Y,et al. Risk factors of major bleeding detected by machine learning method in patients undergoing liver resection with controlled low central venous pressure technique[J]. Postgraduate Medical Journal,2023,99(1178):1280-1286. doi: 10.1093/postmj/qgad087 [4] 赵博,李乐,杨晨,等. 控制性低中心静脉压对老年患者腹腔镜肝叶切除术脑血管事件的影响[J]. 国际老年医学杂志,2020,41(3):154-156. [5] 郭高锋,王洋洋,容雄飞,等. 不同SVV指导术中液体治疗对腹腔镜肝叶切除术中出血及术后肾功能的影响[J]. 中华麻醉学杂志,2021,41(5):584-588. [6] Wang F,Sun D,Zhang N,et al. The efficacy and safety of controlled low central venous pressure for liver resection: A systematic review and meta-analysis[J]. Gland Surgery,2020,9(2):311-320. doi: 10.21037/gs.2020.03.07 [7] Wang F,Sun D,Zhang N,et al. The efficacy and safety of controlled low central venous pressure for liver resection: A systematic review and meta-analysis[J]. Gland Surgery,2020,9(2):31120-31320. [8] 李江斌,杜锡林,董瑞,等. 复杂肝叶切除术中控制性低中心静脉压CLCVP的有效性观察[J]. 中华普外科手术学杂志(电子版),2019,13(5):521-524. [9] Yu L,Sun H,Jin H,et al. The effect of low central venous pressure on hepatic surgical field bleeding and serum lactate in patients undergoing partial hepatectomy: A prospective randomized controlled trial[J]. BMC Surgery,2020,20(1):1-9. doi: 10.1186/s12893-019-0673-7 [10] 刘辉,李志霞,谢志伟. 中心静脉压联合每搏量变异度为目标导向的液体治疗在腹腔镜肝叶切除术中的应用[J]. 山西医药杂志,2021,50(10):1672-1674. [11] 董育硕,崔佳丽,高巨,等. 米力农控制性低中心静脉压对腹腔镜肝切除术患者术中脑血流的影响[J]. 中华麻醉学杂志,2024,44(5):553-557. [12] Pan Y X,Wang J C,Lu X Y,et al. Intention to control low central venous pressure reduced blood loss during laparoscopic hepatectomy: A double-blind randomized clinical trial[J]. Surgery,2020,167(6):933-941. doi: 10.1016/j.surg.2020.02.004 [13] 周洪彬,汪灵芝,罗晨芳,等. 米力农控制性低中心静脉压用于腹腔镜肝切除术的效果[J]. 中华麻醉学杂志,2022,42(9):1093-1097. [14] 刘秀珍,李明颖,任超楠,等. 大部肝切除术中实现控制性低中心静脉压的具体措施[J]. 中华肝胆外科杂志,2020,26(6):469-471. [15] 吕华燕,胡崇辉,蓝志坚. 控制性低中心静脉压技术对腹腔镜肝切除术患者脑氧饱和度的影响[J]. 中国内镜杂志,2022,28(4):49-54. [16] 林靖,陈良巧,周艳瑾,等. 目标导向液体治疗下控制性低中心静脉压技术在肝脏手术中应用[J]. 浙江临床医学,2022,24(11):1612-1614. [17] 梁超琴,张光英,林成新,等. 以脉压变异率为目标导向的液体治疗在开腹肝脏手术中的应用效果[J]. 广西医学,2021,43(2):155-159. -
