【摘要】：容量管理是影響患者圍術(shù)期并發(fā)癥和病死率的關(guān)鍵因素之一。傳統(tǒng)指導(dǎo)容量管理的指標(biāo)不能準(zhǔn)確反映容量狀態(tài)。近幾年研究發(fā)現(xiàn)，每搏量變異(SVV)、脈搏壓變異(PPV)、脈搏氧飽和度波形變異(PVI)等動態(tài)血流動力學(xué)指標(biāo)能夠較為精準(zhǔn)地預(yù)測機(jī)體對補(bǔ)液治療的反應(yīng)性，并認(rèn)為這些指標(biāo)指導(dǎo)容量管理可以改善預(yù)后。然而，SVV、PPV、PVI等在梗阻性黃疸患者判斷容量狀態(tài)的有效性還未見報道。 本研究主要探索動態(tài)血流動力學(xué)指標(biāo)在梗阻性黃疸患者預(yù)測液體反應(yīng)的能力，以及這些指標(biāo)對預(yù)后的影響。 第一部分：動態(tài)血流動力學(xué)指標(biāo)在梗阻性黃疸患者預(yù)測液體反應(yīng)能力的比較 目的：分析和比較SVV、PPV、PVI等在梗阻性黃疸患者預(yù)測液體反應(yīng)的能力。方法：35例梗阻性黃疸患者，分別于術(shù)前(麻醉誘導(dǎo)插管機(jī)械通氣后)和術(shù)中(腹腔探查后)進(jìn)行液體反應(yīng)實驗，在5到10min內(nèi)輸注250ml膠體。分別記錄液體治療前后的血流動力學(xué)指標(biāo)。液體治療后每搏量指數(shù)(SVI)增加大于10%標(biāo)記為液體反應(yīng)陽性。繪制受試者操作特征曲線(ROC曲線)，分析和比較SVV、PPV、PVI等預(yù)測液體反應(yīng)的能力。結(jié)果：術(shù)前液體反應(yīng)實驗，SVV、PPV、PVI等ROC曲線下面積分別為：0.955、0.875、0.593，判斷閾值(敏感度/特異度%)分別為：10%(100.0/92.3)、8%(91.7/69.2)、13%(58.3/53.8)。術(shù)中液體反應(yīng)實驗，SVV、PPV、PVI等ROC曲線下面積分別為：0.699、0.710、0.567，判斷閾值(敏感度/特異度%)分別為：10%(45.5/85.73)、7.5%(63.6/71.4)、15%(63.6/57.1)。結(jié)論：術(shù)前，SVV和PPV都能夠準(zhǔn)確的預(yù)測液體反應(yīng)而PVI預(yù)測液體反應(yīng)失��；術(shù)中，除了PPV有中等的預(yù)測液體反應(yīng)能力以外，SVV和PVI均不能準(zhǔn)確的預(yù)測液體反應(yīng)。 第二部分：應(yīng)用PPV指導(dǎo)梗阻性黃疸患者圍術(shù)期容量管理的研究 目的：分析PPV指導(dǎo)梗阻性黃疸患者圍術(shù)期容量管理對預(yù)后的影響。方法：60例梗阻性黃疸患者隨機(jī)分為PPV組(n=30)和對照組(n=30)，PPV組通過輸注膠體維持PPV在8%以下，對照組由麻醉醫(yī)生根據(jù)臨床經(jīng)驗確定容量管理方案。比較兩種容量管理方案對患者乳酸水平、術(shù)后30天并發(fā)癥及死亡率、術(shù)后住院日以及ICU住院日等的影響。結(jié)果：手術(shù)過程中PPV組輸注了更多的膠體(1245±350vs776±391ml，，P＜0.001)，但兩組液體總出入量以及血管活性藥物用量無差別。手術(shù)結(jié)束時PPV組乳酸水平低于對照組(1.45±0.63vs1.93±0.88mmol/L，P=0.024)。實驗組術(shù)后并發(fā)癥發(fā)病率低于對照組但未達(dá)到統(tǒng)計學(xué)差異(25.9%vs39.3%，P=0.291)。兩組在死亡率、ICU及術(shù)后住院日等方面沒有差別。結(jié)論：應(yīng)用PPV指導(dǎo)梗阻性黃疸患者圍術(shù)期容量管理有減少術(shù)后并發(fā)癥的趨勢。
[Abstract]:Volume management is one of the key factors affecting perioperative complications and mortality. The traditional index of capacity management can not accurately reflect the capacity state. In recent years, it has been found that dynamic hemodynamic indices such as variation of pulse pressure per stroke volume, (SVV), pulse pressure variation, (PPV), pulse oxygen saturation waveform variation, (PVI) can accurately predict the body's response to fluid resuscitation. It is suggested that these indexes can improve the prognosis. However, the effectiveness of SVV,PPV,PVI et al in judging volume status in patients with obstructive jaundice has not been reported. The purpose of this study was to explore the ability of dynamic hemodynamic indexes to predict fluid response in patients with obstructive jaundice and their influence on prognosis. Part I: comparison of dynamic hemodynamic indices in predicting fluid response in patients with obstructive jaundice objective: to analyze and compare the ability of SVV,PPV,PVI and others to predict fluid response in patients with obstructive jaundice. Methods: 35 patients with obstructive jaundice underwent fluid reaction test before operation (after anesthesia induced intubation and mechanical ventilation) and during operation (after abdominal exploration). 250ml colloid was infused in 5 to 10min. The hemodynamic indexes before and after fluid therapy were recorded. After fluid therapy, (SVI) increased by more than 10% and marked as liquid positive. The operating characteristic curve (ROC curve) was drawn to analyze and compare the ability of SVV,PPV,PVI and so on to predict liquid reaction. Results: in the preoperative fluid reaction test, the area under the ROC curve of SVV,PPV,PVI was 0.955 / 0.8750.593.The threshold value (sensitivity / specificity%) was 10% (100.0 / 92.3), respectively. 8% (91.7% 69.2), 13% (58.3% 53.8). In the intraoperative fluid reaction test, the area under the ROC curve of SVV,PPV,PVI and so on were 0.699v 0.71010 / 0.567.The threshold value (sensitivity / specificity%) were 10% (45.5 / 85.73), 7.5% (63.6 / 71.4), respectively, and the sensitivity / specificity% were 10% (45.5 / 85.73), 7.5% (63.6 / 71.4), respectively. 15% (63.6% 57.1). Conclusion: before operation, both SVV and PPV can predict the liquid reaction accurately while PVI can predict the liquid reaction failure. In addition to the moderate ability of PPV to predict the liquid reaction, SVV and PVI can not predict the liquid reaction accurately. Part two: study on perioperative volume management in patients with obstructive jaundice by PPV objective: to analyze the effect of perioperative volume management guided by PPV on the prognosis of patients with obstructive jaundice. Methods: sixty patients with obstructive jaundice were randomly divided into PPV group (n = 30) and control group (n = 30), which maintained PPV below 8% by infusion of colloid. The effects of two volume management schemes on lactic acid levels, postoperative complications and mortality, postoperative hospitalization days and ICU hospitalization days were compared. Results: more colloids were injected into PPV group during operation (1245 鹵350vs776 鹵391ml, P < 0.001), but there was no difference in the total volume of liquid and the dosage of vasoactive drugs between the two groups. At the end of operation, the lactate level in PPV group was lower than that in control group (1.45 鹵0.88 mmol / L). The incidence of postoperative complications in the experimental group was lower than that in the control group, but there was no statistical difference (25.9 vs 39.3%, 0.291). There was no difference in mortality, ICU and postoperative hospital stay between the two groups. Conclusion: perioperative volume management for obstructive jaundice patients with PPV has a tendency to reduce postoperative complications.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R614

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