控制性低中心靜脈壓在肝門(mén)膽管癌根治手術(shù)中的應(yīng)用
發(fā)布時(shí)間：2018-12-18 12:05
【摘要】：目的對(duì)比觀察控制性低中心靜脈壓在梗阻性黃疸患者行肝門(mén)膽管癌根治術(shù)中對(duì)其血流動(dòng)力學(xué)和內(nèi)環(huán)境的影響，評(píng)價(jià)控制性低中心靜脈壓技術(shù)在中、重度黃疸患者行肝葉切除手術(shù)中應(yīng)用的可行性和安全性。方法選擇解放軍總醫(yī)院2012年12月—2013年10月伴有黃疸的肝門(mén)膽管癌患者和肝功能正常行肝葉切除的患者各60例，兩類(lèi)患者按是否采用控制性低中心靜脈壓各分兩組共四組：控制性低中心靜脈壓黃疸組(A組）、非控制性低中心靜脈壓黃疸組（B組）、控制性低中心靜脈壓非黃疸組（C組）、非控制性低中心靜脈壓非黃疸組（D組），每組30例。A、C兩組從手術(shù)開(kāi)始至病灶切除并止血完成后通過(guò)限制液體輸入、調(diào)節(jié)頭高腳低體位(頭高10-15°)及吸入異氟醚和持續(xù)微量泵注硝酸甘油0.1-2μg/（kg·min）把中心靜脈壓控制在CVP5mmHg；B、D兩組術(shù)中通過(guò)容量監(jiān)測(cè)按需常規(guī)輸液、輸血維持CVP在5-12mmHg。分別在手術(shù)開(kāi)始（T1）、病灶切除止血后（T2）、關(guān)腹后（T3）測(cè)血?dú)獠⒂涗汸H、PO2、Lac、BE；記錄血流動(dòng)力學(xué)指標(biāo)：心率（HR）、平均動(dòng)脈壓（MAP）、心輸出量（CO）、中心靜脈壓（CVP）、每搏輸出量（SV）、每搏變異量（SVV）、每搏變異指數(shù)（SVI）；記錄術(shù)中出血量、輸血量、輸血例數(shù)和血管活性藥物應(yīng)用情況，記錄術(shù)前和術(shù)后24h肌酐和尿素氮值。結(jié)果：（1）血流動(dòng)力學(xué)變化： A組T2時(shí)測(cè)得的CVP、SV、SVI低于B組，SVV高于B組（p0.05）；C組T2時(shí)測(cè)得的CVP低于D組，SVV高于D組（p0.05）。（2）血?dú)夥治觯和琓1比較，每組在T2、T3時(shí)點(diǎn)的PH、BE、Lac均有統(tǒng)計(jì)學(xué)差異(p 0.05)；四組各時(shí)間點(diǎn)組間觀察比較血?dú)夥治鰠?shù)均無(wú)明顯差異(p0.05)；（3）術(shù)中出血量及輸血情況： A組較B組術(shù)中出血量、異體血輸入量及輸血例數(shù)明顯減少(p0.05)， C組較D組術(shù)中出血量、異體血輸入量及輸血例數(shù)明顯減少（p0.05)；（4）血管活性藥物應(yīng)用：A組術(shù)中血管活性藥物應(yīng)用的劑量和例數(shù)較C組明顯增多(p0.05)，B組術(shù)中血管活性藥物應(yīng)用的劑量和例數(shù)較D組明顯增多(p0.05)，黃疸患者組內(nèi)和非黃疸患者組內(nèi)比較，CLCVP組較非CLCVP組血管活性藥物用量顯著增多(p0.05)，去氧腎上腺素用量與血總膽紅素濃度存在線性相關(guān)性。（5）四組患者術(shù)后24小時(shí)肌酐、尿素氮值同術(shù)前相比均無(wú)明顯差異(p0.05)。結(jié)論在伴有黃疸患者行肝門(mén)膽管癌根治術(shù)中應(yīng)用控制性低中心靜脈壓可明顯減少術(shù)中出血量及異體血輸入量，且對(duì)機(jī)體內(nèi)環(huán)境和術(shù)后腎功能無(wú)明顯影響；黃疸患者對(duì)容量變化較非黃疸患者敏感，，術(shù)中血流動(dòng)力學(xué)有較明顯的波動(dòng)，需要嚴(yán)密監(jiān)測(cè)并應(yīng)用血管活性藥物及時(shí)調(diào)節(jié)。
[Abstract]:Objective to observe the effect of controlled low central venous pressure on hemodynamics and internal environment in patients with obstructive jaundice after radical resection of hilar cholangiocarcinoma, and to evaluate the effect of controlled low central venous pressure on the hemodynamics and internal environment of patients with hilar cholangiocarcinoma. Feasibility and safety of liver lobectomy in patients with severe jaundice. Methods from December 2012 to October 2013, 60 patients with hilar cholangiocarcinoma with jaundice and 60 patients with normal liver function were selected. Two groups of patients were divided into four groups according to whether or not to use controlled low central venous pressure: control low central venous pressure jaundice group (group A), non-controlled low central venous pressure jaundice group (group B). There were 30 cases in each group in the control low central venous pressure group (C group) and non-controlled central venous pressure non-jaundice group (D group). Adjusting head height and low body position (head height 10-15 擄) and inhaling isoflurane and continuous micropump injection of nitroglycerin 0.1-2 渭 g / (kg min) to control central venous pressure at CVP5mmHg; In group B and D, CVP was maintained at 5-12 mmHg by volume monitoring and routine infusion. Blood gas was measured and PH,PO2,Lac,BE; was recorded at the beginning of operation (T1), after resection of the lesion (T2), and after abdominal closure (T3). Recording of hemodynamic indices: heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), central venous pressure (CVP), stroke output (SV), per beat variability (SVV), per beat variability index (SVI); Intraoperative blood loss, blood transfusion and vasoactive drug use were recorded. Creatinine and urea nitrogen values were recorded before and 24 hours after operation. Results: (1) Hemodynamic changes: the CVP,SV,SVI measured at T2 in group A was lower than that in group B and SVV was higher than that in group B (p0.05). The CVP measured at T2 in group C was lower than that in group D, and SVV was higher than that in group D (p0.05). (2). Compared with T1, the PH,BE,Lac of each group at T 2T 3 was significantly different (p 0.05). There was no significant difference in the parameters of blood gas analysis between the four groups at different time points (p0.05). (3) intraoperative blood loss and blood transfusion: the amount of intraoperative blood loss, allogeneic blood input and blood transfusion in group A were significantly lower than those in group B (p0.05), C group vs D group, P 0.05). The volume of allogeneic blood transfusion and the number of transfusion cases were significantly decreased (p0.05). (4) Application of vasoactive drugs: the dosage and the number of cases of intraoperative vasoactive drugs in group A were significantly higher than those in group C (p0.05), B group), the dosage and the number of cases of intraoperative vasoactive drugs in group A were significantly higher than those in group D (p0.05). The dosage of vasoactive drugs in CLCVP group was significantly higher than that in non-CLCVP group compared with that in non-jaundice group (p0.05). There was a linear correlation between the dosage of noradrenaline and the concentration of total bilirubin. (5) there was no significant difference in creatinine and urea nitrogen between the four groups at 24 hours after operation (p0.05). Conclusion the application of controlled low central venous pressure in the radical resection of hilar cholangiocarcinoma in patients with jaundice can significantly reduce the amount of intraoperative bleeding and the amount of allogeneic blood, and has no significant effect on the internal environment of the body and the renal function after operation. Patients with jaundice are more sensitive to volume changes than those without jaundice, and hemodynamics fluctuates obviously during operation, which needs close monitoring and timely regulation with vasoactive drugs.
【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R614
本文編號(hào)：2385820
[Abstract]:Objective to observe the effect of controlled low central venous pressure on hemodynamics and internal environment in patients with obstructive jaundice after radical resection of hilar cholangiocarcinoma, and to evaluate the effect of controlled low central venous pressure on the hemodynamics and internal environment of patients with hilar cholangiocarcinoma. Feasibility and safety of liver lobectomy in patients with severe jaundice. Methods from December 2012 to October 2013, 60 patients with hilar cholangiocarcinoma with jaundice and 60 patients with normal liver function were selected. Two groups of patients were divided into four groups according to whether or not to use controlled low central venous pressure: control low central venous pressure jaundice group (group A), non-controlled low central venous pressure jaundice group (group B). There were 30 cases in each group in the control low central venous pressure group (C group) and non-controlled central venous pressure non-jaundice group (D group). Adjusting head height and low body position (head height 10-15 擄) and inhaling isoflurane and continuous micropump injection of nitroglycerin 0.1-2 渭 g / (kg min) to control central venous pressure at CVP5mmHg; In group B and D, CVP was maintained at 5-12 mmHg by volume monitoring and routine infusion. Blood gas was measured and PH,PO2,Lac,BE; was recorded at the beginning of operation (T1), after resection of the lesion (T2), and after abdominal closure (T3). Recording of hemodynamic indices: heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), central venous pressure (CVP), stroke output (SV), per beat variability (SVV), per beat variability index (SVI); Intraoperative blood loss, blood transfusion and vasoactive drug use were recorded. Creatinine and urea nitrogen values were recorded before and 24 hours after operation. Results: (1) Hemodynamic changes: the CVP,SV,SVI measured at T2 in group A was lower than that in group B and SVV was higher than that in group B (p0.05). The CVP measured at T2 in group C was lower than that in group D, and SVV was higher than that in group D (p0.05). (2). Compared with T1, the PH,BE,Lac of each group at T 2T 3 was significantly different (p 0.05). There was no significant difference in the parameters of blood gas analysis between the four groups at different time points (p0.05). (3) intraoperative blood loss and blood transfusion: the amount of intraoperative blood loss, allogeneic blood input and blood transfusion in group A were significantly lower than those in group B (p0.05), C group vs D group, P 0.05). The volume of allogeneic blood transfusion and the number of transfusion cases were significantly decreased (p0.05). (4) Application of vasoactive drugs: the dosage and the number of cases of intraoperative vasoactive drugs in group A were significantly higher than those in group C (p0.05), B group), the dosage and the number of cases of intraoperative vasoactive drugs in group A were significantly higher than those in group D (p0.05). The dosage of vasoactive drugs in CLCVP group was significantly higher than that in non-CLCVP group compared with that in non-jaundice group (p0.05). There was a linear correlation between the dosage of noradrenaline and the concentration of total bilirubin. (5) there was no significant difference in creatinine and urea nitrogen between the four groups at 24 hours after operation (p0.05). Conclusion the application of controlled low central venous pressure in the radical resection of hilar cholangiocarcinoma in patients with jaundice can significantly reduce the amount of intraoperative bleeding and the amount of allogeneic blood, and has no significant effect on the internal environment of the body and the renal function after operation. Patients with jaundice are more sensitive to volume changes than those without jaundice, and hemodynamics fluctuates obviously during operation, which needs close monitoring and timely regulation with vasoactive drugs.
【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R614
【參考文獻(xiàn)】
相關(guān)期刊論文 前5條
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3 何文政,林成新,胡振快;梗阻性黃疸病人圍麻醉期并發(fā)癥的防治[J];廣西醫(yī)學(xué);2005年02期
4 Cheng-Xin Lin;Ya Guo;Wan Yee Lau;Guang-Ying Zhang;Yi-Ting Huang;Wen-Zheng He;Eric CH Lai;;Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma[J];Hepatobiliary & Pancreatic Diseases International;2013年05期
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本文編號(hào)：2385820
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