以CI、ITBVI、EVLWI为目标导向液体治疗在老年患者重大手术中的应用研究

摘要

目的：观察以心指数（CI）、胸腔内血容量指数（ITBVI）、血管外肺水指数（EVLWI）为目标导向的液体管理策略对老年重大手术后转归的影响。方法选取急诊行重大手术的老年患者40例，ASA评分3～4级。将其随机分为研究组和对照组，每组各20例。对照组监测CVP（中央静脉压）指导补液。研究组进行中心静脉置管＋股动脉置管＋PiCCO模块连接，应用PICCO监测血流动力学指标，测定CVP、CI、ITBVI、EVLWI，准确评估患者容量状况，以CI 3．0～5．0 L／min／m2， ITBVI 800～1000 mL／m2，EV－LWI 3．0～7．0 mL／kg为参考值，进行目标导向液体治疗。术中根据CI、ITBVI、EVLWI动态变化调整补液，监测患者心率（ HR）、平均动脉压（ MAP）、尿量、中心静脉血氧饱和度（ ScvO2）、乳酸、肾功能等指标。观察患者术后休克改善情况及呼吸机撤除时间，以及急性肺水肿发生率、急性肾功能不全发生率、死亡率变化。结果研究组患者组织灌注改善，休克改善明显好转，尿量明显增加（P＜0．05），中心静脉血氧饱和度明显增加（P＜0．05），血乳酸浓度明显降低（P＜0．05），急性肺水肿、急性肾功能不全发生率明显低于对照组（ P＜0．05），死亡率低于对照组（ P＜0．05）。结论以CI、ITBVI、EVLWI为目标导向液体治疗，能有效优化老年重大手术患者的心脏前负荷，提高心输出量，保证微循环灌注，维持机体氧供需平衡，减少并发症发生，降低死亡率。%Objective To evaluate the influence of goal -directed fluid management based on CI ,ITBVI and EVLWI in geriatric pa-tients undergoing major operation .Methods 40 patients (ASA 3~4) undergoing major operation were included and randomly divided into two groups:goal-directed fluid therapy treatment with CI, ITBVI and EVLWI(group S)and conventional fluid therapy(group R).The routine group was given CVP monitoring rehydration ,and the study group was given PICCO hemodynamic monitoring indicators .CVP, CI, ITBVI and EVLWI for fluid management were measured; accurate assessment of volume status of patients was done .The study group re-ceived goal-directed fluid therapy based on CVP , CI, ITBVI and EVLWI, with the goal of CI in the 3.0~5.0 L/min/m2 range,ITBVI in the 800~1000 mL/m2 range and EVLWI in the 3.0~7.0 mL/kg range.Heart rate (HR), mean arterial pressure (MAP), urine volume, central venous oxygen saturation (ScvO2), lactic acid, renal function and so on were monitored.Postoperative shock improvement and vent-ilator withdrawal time , as well as the incidence of acute pulmonary edema , acute renal failure incidence , mortality between the two groups were observed and compared .Results Tissue perfusion and shock of the study group were significantly improved than that of control group,and urine volume increased (P<0.05).ScvO2 of the study group were higher than that of the routine group (P<0.05).The con-centration of lactic acid of the study group was lower than that of the routine group (P<0.05).The incidence of acute pulmonary edema , acute renal insufficiency and mortality of the study group were lower than that of the routine group (P<0.05).Conclusion Goal-direct-ed fluid therapy based on CI , ITBVI and EVLWI optimizes the cardiac preload effectively in geriatric patients undergoing major operation , improves cardiac output , guarantees the perfusion of microcirculation as well as maintaines the oxygen delivery -consumption balance , re-duces complications , and reduces the mortality rate .