本文選題：目標(biāo)導(dǎo)向液體治療　切入點(diǎn)：老年腰椎手術(shù)　出處：《北京協(xié)和醫(yī)學(xué)院》2016年博士論文　論文類(lèi)型：學(xué)位論文

【摘要】：目的：恰當(dāng)?shù)囊后w管理能夠改善患者術(shù)后重要器官灌注,減少術(shù)后并發(fā)癥,縮短住院時(shí)間。目標(biāo)導(dǎo)向液體治療(Goal-Directed Therapy)用于圍術(shù)期液體管理,通過(guò)監(jiān)測(cè)血流動(dòng)力學(xué)指標(biāo)判斷患者對(duì)液體的需求,根據(jù)患者不斷變化的需求進(jìn)行補(bǔ)液,指導(dǎo)術(shù)中液體治療及血管活性藥物的應(yīng)用,提高心輸出量,增加組織器官灌注和氧供,達(dá)到維持有效的組織灌注與細(xì)胞氧和。本文旨在觀(guān)察以每搏量變異率(Stroke Volume Variation)為目標(biāo)導(dǎo)向的液體治療管理策略,在老年(年齡大于55歲)腰椎手術(shù)患者中,對(duì)老年患者的血流動(dòng)力學(xué)、圍術(shù)期乳酸、組織灌注、術(shù)中用液以及預(yù)后的影響。方法：本研究為前瞻隊(duì)列對(duì)照研究,選取201 5年12月至2016年5月間66例老年骨科腰椎手術(shù)患者,通過(guò)隨機(jī)分組,將其分為目標(biāo)導(dǎo)向液體治療組即實(shí)驗(yàn)組(G組)和對(duì)照組(C組),實(shí)驗(yàn)組入室后進(jìn)行橈動(dòng)脈穿刺,在LIDCO監(jiān)護(hù)儀的監(jiān)測(cè)及指導(dǎo)下,以每搏輸出量變異(SVV)和收縮壓(SBP)為目標(biāo),根據(jù)GDT方案對(duì)患者進(jìn)行容量管理,而對(duì)照組則根據(jù)麻醉醫(yī)師的經(jīng)驗(yàn),按照現(xiàn)有麻醉操作標(biāo)準(zhǔn)常規(guī)補(bǔ)液方法進(jìn)行液體管理。選取術(shù)中用液情況及血?dú)馊樗嶂底鳛橹饕Y(jié)局指標(biāo),分別在術(shù)前24h(T0),麻醉誘導(dǎo)后(T1),腰椎減壓前(T2),腰椎減壓完成后(T3),手術(shù)結(jié)束即刻(T4),出恢復(fù)室即刻(T5),術(shù)后24h(T6)七個(gè)時(shí)間點(diǎn)采集動(dòng)脈血?dú)獠⒂涗浫樗釘?shù)值,評(píng)估患者灌注情況。選取術(shù)后并發(fā)癥、術(shù)后功能恢復(fù)及住院時(shí)長(zhǎng)為次要結(jié)局指標(biāo)。收集數(shù)據(jù)后用使用SPSS 22.0進(jìn)行統(tǒng)計(jì)分析。結(jié)果：(1)本實(shí)驗(yàn)根據(jù)入選標(biāo)準(zhǔn)共納入66例老年腰椎手術(shù)患者(實(shí)驗(yàn)組33人,對(duì)照組33人),這兩組患者的年齡、性別組成、體重指數(shù)、既往史及術(shù)前檢查方面無(wú)顯著差異。(2)術(shù)中乳酸與PH的變化：實(shí)驗(yàn)組乳酸術(shù)中維持平穩(wěn),對(duì)照組術(shù)中乳酸呈持續(xù)升高,在T5時(shí)間點(diǎn)其乳酸值顯著高于實(shí)驗(yàn)組,對(duì)照組在T5、T6高乳酸血癥的發(fā)生率也顯著高于實(shí)驗(yàn)組。兩組術(shù)中PH均呈持續(xù)降低狀態(tài),術(shù)后第一天恢復(fù)至基線(xiàn)水平,組間無(wú)差異。(3)術(shù)中血流動(dòng)力學(xué)變化：實(shí)驗(yàn)組和對(duì)照組在T1-T4這四個(gè)時(shí)間點(diǎn)的MAP和HR數(shù)值并無(wú)統(tǒng)計(jì)學(xué)差異,但實(shí)驗(yàn)組的四個(gè)時(shí)間點(diǎn)的SVV是明顯低于對(duì)照組的,另外實(shí)驗(yàn)組在T4的CO也是顯著高于對(duì)照組的。(4)術(shù)中用液、用藥的變化和差異：實(shí)驗(yàn)組晶體液用液量和總液體量是顯著高于對(duì)照組,對(duì)比兩組用藥情況,兩組使用麻黃堿和苯腎的人數(shù)并無(wú)差異,但實(shí)驗(yàn)組麻黃堿的人均使用量是顯著低于對(duì)照組的,差異有統(tǒng)計(jì)學(xué)意義。(5)術(shù)后恢復(fù)情況及并發(fā)癥發(fā)生率：實(shí)驗(yàn)組與對(duì)照組在術(shù)后出血量、進(jìn)流食、半流食、排氣、排便、總住院時(shí)長(zhǎng)上并無(wú)統(tǒng)計(jì)學(xué)差異,但對(duì)照組共有13人通過(guò)藥物輔助排氣、排便,顯著高于實(shí)驗(yàn)組的3人,實(shí)驗(yàn)組并發(fā)癥的發(fā)生概率也顯著低于對(duì)照組,組間差異有統(tǒng)計(jì)學(xué)意義。結(jié)論：(1) 本研究結(jié)果顯示目標(biāo)導(dǎo)向液體治療組患者術(shù)中液體用量明顯高于對(duì)照組,乳酸水平明顯降低,提示目標(biāo)導(dǎo)向液體治療對(duì)改善老年腰椎手術(shù)患者的灌注有一定積極作用。(2)本研究結(jié)果顯示目標(biāo)導(dǎo)向液體治療可以有效改善老年腰椎手術(shù)患者術(shù)后胃腸功能恢復(fù)情況,加快患者術(shù)后康復(fù),減少患者術(shù)后并發(fā)癥的發(fā)生,改善預(yù)后。
[Abstract]:Objective: fluid management properly can improve the postoperative perfusion of vital organs, reduce postoperative complications, shorten the hospitalization time. Goal-directed fluid therapy (Goal-Directed Therapy) for perioperative fluid therapy, patients demand for liquid by monitoring the hemodynamic parameters, the replacement of patients according to the changing needs of application, operation guide liquid treatment and vasoactive drugs, improve cardiac output, increase organ perfusion and oxygen supply, to maintain effective tissue perfusion and oxygen. The purpose of this paper is to observe and to stroke volume variation (Stroke Volume Variation) liquid treatment management strategies for goal oriented, in the elderly (aged over 55) in patients with lumbar in the operation, on the hemodynamics of elderly patients, perioperative lactic acid, tissue perfusion, fluid and prognosis during operation. Methods: This study was a prospective cohort control The research, from December 2015 to May 2016 66 cases of elderly patients in Department of orthopedics, through a randomized, divided into goal-directed fluid therapy groups: experimental group (G group) and control group (C group), experimental group A after radial artery puncture, LIDCO monitor monitoring and guidance, to each stroke volume variation (SVV) and systolic blood pressure (SBP) as the goal, according to the GDT scheme of volume management of patients and the control group according to the experience of the anesthesiologist, fluid management was in accordance with the existing standard anesthesia operation method. Selected with conventional rehydration solution and blood lactic acid of value as the primary outcome measure in operation 24h (T0), after induction of anesthesia (T1), (T2), lumbar decompression and anterior lumbar decompression after (T3), at the end of surgery (T4), a recovery room immediately after 24h (T5), (T6) seven time point collection of arterial blood gas and lactate recorded numerical evaluation of patients irrigation Note. The postoperative complications, postoperative recovery and hospitalization time as secondary outcomes. After collecting data with 22 use SPSS for statistical analysis. Results: (1) the experiment according to the inclusion criteria included a total of 66 cases of senile lumbar surgery patients (33 in experimental group and control group of 33 people), two groups of patients with age, sex, body mass index, there was no significant difference between history and preoperative examination. (2) and the change of lactic acid during PH: the experimental group of lactic acid in the patients in the control group remained stable, lactic acid increased, the lactic acid value at T5 time point was significantly higher than the experimental group and the control group in T5, T6 hyperlactacidemia were also significantly higher than the experimental group. Two groups of patients in PH were decreased, the first postoperative day return to baseline level, no significant difference between groups. (3) the hemodynamic changes during operation: the experimental group and the control group in the four T1-T4 time point MAP and HR There was no significant difference between the values, but the four time points in the experimental group SVV was significantly lower than the control group, the experimental group in T4 CO was significantly higher than the control group. (4) using liquid in operation, change and difference of medication: the experimental group with the liquid crystal fluid volume and total liquid volume was significantly higher in the control group, compared two groups of medication, two groups of the number of the use of ephedrine and benzene kidney had no difference, but the per capita amount of ephedrine in experimental group is significantly lower than the control group, the difference was statistically significant. (5) postoperative recovery and complication rate of experimental group and the control group in the amount of bleeding, after eating, semi liquid diet, exhaust, defecation, total hospitalization duration was not statistically significant, but the control group a total of 13 people through the drug auxiliary exhaust, defecation, significantly higher than 3 in the experimental group, the probability of occurrence of complications in the experimental group were significantly lower than the control group, there is statistical difference between the groups Significance. Conclusion: (1) the results of this study show that goal-directed fluid therapy in patients with liquid group was significantly higher than the control group, the lactic acid level decreased significantly, suggesting that goal-directed fluid therapy is helpful to improve elderly patients with lumbar spinal surgery perfusion. (2) the results of this study show that goal-directed fluid therapy can effectively improve the the elderly lumbar postoperative recovery of gastrointestinal function, accelerate the rehabilitation of patients, reduce the incidence of postoperative complications in patients, improve the prognosis.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類(lèi)號(hào)】：R614

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