目标导向液体治疗联合肺复张在食管癌根治术患者的应用观察

摘要

目的:观察目标导向液体治疗联合肺复张在食管癌根治术患者血流动力学、肺功能和术后肺部并发症的影响.方法:选择2015年6月至2016年5月我院胸外科食管癌切除术的患者50例,采用随机法分为对照组(A组,n=25)和治疗组(B组,n=25).两组均以胸腔内血容量指数(ITBVI)800~1000mL/m2为目标导向的液体治疗进行补液,B组同时于单肺通气(OLV)开始前,OLV结束前,关胸前,拔管前以及任何中断通气后应用呼气末正压(PEEP)递增高法进行反复肺复张.应用脉搏指示剂连续心排血(PiCCO)监测仪记录术前(T0)、双肺通气15min(T1)、单肺通气15min(T2)、肺复张后双肺通气15min(T3)和术毕(T4)患者的平均动脉压(MAP)、心率、ITBVI.记录两组患者术前(T0)和术后第2天(T5)肺功能实验和术后肺部相关并发症发生率.结果:两组患者各时点的MAP、HR、ITBVI比较差异无统计学意义(P>0.05),治疗期间无因血流动力学不稳定而终止肺复张的患者.术前肺功能实验比较差异无统计学意(P>0.05),术后第2天治疗组的FEV1、FVC、FEV1%FVC均高于对照组差异有统计学意义(P<0.05).治疗组术后低氧血症、肺部感染和延迟拔出气管导管的发生率均低于对照组差异有统计学意义(P<0.05).结论:食管癌切除术中,使用目标导向液体治疗联合肺复张可保证患者血流动力学稳定、促进术后肺功能的恢复并且能够降低术后肺部并发症的发生.%Objective:To investigate the effect of goal-directed fluid therapy combined with lung re-cruitment maneuver on hemodynamics, pulmonary function and postoperative outcomes in patients undergoing esophagectomy. Methods:From Jun. 2015 to May 2016, fifty patients scheduled for esophagectomy were ran-domly divided into control group ( group A, n=25) and therapy group ( group B, n=25) . The operative fluid therapy in the two groups was adjusted by maintaining intrathoracic blood volume index ( ITBVI) in the normal physical range(800~1000 mL/m2). Group B was treated with lung recruitment maneuver via increasing pro-gressively the positive end expiratory pressure (PEEP) at the following time points:before the one-lung ven-tilation( OLV) , before the end of OLV and closing chest, and immediately before extubation. The heart rate ( HR) , mean artery pressure ( MAP ) and intrathoracic blood volume index ( ITBVI) were recorded with pulse indicator continuous cardiac output (PiCCO) system at the following time points:before the surgery (T0), to-tal lung ventilation for 15 min ( T1 ) , one-lung ventilation for 15 min ( T2 ) , 15 min after pulmonary re-ex-pansion ( T3 ) and the end of operation ( T4 ) . The lung function test on the pre-surgery and the 2rd postopera-tive day as well as the incidence of pulmonary complications were assessed. Results: During surgery, MAP, HR,ITBVI were comparable between two groups. No lung recruitment maneuver treatment was terminated due to hemodynamic instability. There was no significantly difference between the two groups in the lung function test before the surgery ( P>0.05) . The lung function test in the group B on the 2rd postoperative day( including FEV1, FVC and FEV1%FVC)were significantly increased compared with group A (P<0.05). In the group B, the incidences of hypoxemia and lung infection were significantly lower than those of control group on post-operative 2 days ( P<0.05) . Moreover, the time to extubation was shorter in the group B than that of control group ( P<0.05) . Conclusion:Administration of goal-directed fluid therapy combined with lung recruitment maneuver in patients undergoing esophagectomy not only guarantees hemodynamic stability but also improves lung function and reduces the incidence of pulmonary complications after the surgery.