本文選題：老年人　切入點：SVV　出處：《大連醫(yī)科大學》2017年碩士論文　論文類型：學位論文

【摘要】：目的液體管理是危重患者復蘇的基石,尤其是老年患者的液體管理,一直是困擾麻醉醫(yī)生和外科醫(yī)生的棘手問題。若開放液體管理,會引起組織水腫、腸道梗阻、肺部并發(fā)癥等一系列不良后果,且延長ICU和住院時間;反之,若限制液體入量,則又會引起血壓降低導致組織低灌注、全身炎癥反應綜合征以及繼發(fā)多器官功能障礙;因此,液體超負荷或者過度限制液體入量,對患者都是有害的。近年來,研究者們發(fā)現(xiàn)了一種新的治療方法,即通過優(yōu)化心臟前、后負荷以及心肌收縮力來實現(xiàn)血流動力學平穩(wěn),達到機體氧供需平衡狀態(tài),因此提出了目標導向液體治療(Goal directed fluid therapy,GDFT)。GDFT是根據(jù)患者的年齡、體重、性別、疾病特點、患者全身情況等指標,制定的個體化補液方案,常用的監(jiān)測指標為肺動脈導管和超聲等,由于其高創(chuàng)傷性、高花費等原因限制了使用,而每搏量變異度(Stroke volume variation,SVV)是一種便捷、準確的測量容量反應性的血流動力學參數(shù),具有較高的靈敏度和特異性。隨著全球人口老齡化,老年患者的手術量呈幾何倍數(shù)增長,而老年患者由于自身心血管系統(tǒng)功能的衰退、術前腸道準備、麻醉藥物的心血管抑制作用等原因,術中極易發(fā)生血流動力學波動,影響組織器官灌注及氧供,甚至危及生命。然而老年患者在麻醉誘導期間發(fā)生的低血壓,通常主要是因為麻醉狀態(tài)下其外周血管阻力降低使得血管擴張導致,基于前人研究一般給予去甲腎上腺素來糾正,然而去氧腎上腺素也是一種選擇性a-受體激動劑,且可以反射性降低心率以及心輸出量,減少心臟做功。鑒于在svv導向液體治療中去甲腎上腺素與去氧腎上腺素的對比鮮有研究,因此我們設計了本課題。擬選用擇期行結直腸癌根治術的老年患者,在svv導向液體治療下,觀察去甲腎上腺素與去氧腎上腺素對老年患者血流動力學的維持以及組織氧合情況。方法我們收集了40位,asa分級為ii~iii的行結直腸癌手術的老年患者資料�；颊弑浑S機分為2組:去甲腎上腺素組(組1;n=20)和去氧腎上腺素組(組2;n=20)。兩組患者在術中均接受背景輸注量為5ml/kg/h的晶體液(乳酸林格液),當svv9%(由flotrac/vigileo3.0儀器監(jiān)測)時,則額外給予200ml膠體液(羥乙基淀粉130/0.4;6%),觀察5min后重復給予液體負荷量,直至svv9%;若svv在9-13%之間,給予8m/kg/h的晶體液(乳酸林格液)。在麻醉誘導開始時,血管活性藥(去甲腎上腺素或去氧腎上腺素)以5ml/h的背景速度輸注,以維持收縮壓90mmhg或map65mmhg。若血壓下降超過20%基礎值或ci2.5l/min/m2時,則給予多巴酚丁胺。所有患者均接受中心靜脈穿刺置管及橈動脈穿刺置管,并監(jiān)測ecg,map,cvp,脈搏氧,體溫,呼末二氧化碳和腦電雙頻指數(shù)。兩組患者均接受標準的麻醉誘導,分別在入室穿動脈后,誘導即刻,誘導后3min時,手術開始和手術結束時記錄血流動力學參數(shù):hr,spo2,cvp,bp,svv,sv,ci,co,尿量,bis,t,etco2,abg,vbg,crt。結果我們發(fā)現(xiàn)隨著手術的進行,兩組患者的hr和map呈下降趨勢。在手術結束時去氧腎上腺素組hr(65.45±10.25)低于去甲腎上腺素組(69.4±10.9)患者(p=0.751);而在手術結束時sv,ci和co值增加,去氧組明顯減低。術中晶體液的入量,去氧腎上腺素組(1682.5±837ml)明顯低于去甲腎上腺素組(2143.5±1014ml),p=0.125。同樣的,膠體液的入量比較,去氧腎上腺素組(488.5±153ml)也低于去甲腎上腺素組(713±529ml),p=0.082。術中血管活性藥的使用量,去氧腎上腺素組(18.87±20.68ml)比去甲腎上腺素組(38.35±40.9ml)略低,但P=0.065,兩組相比無明顯統(tǒng)計學差異。術中失血量,麻醉持續(xù)時間和CRT值,兩組相比均無統(tǒng)計學差異。結論在行結直腸癌根治術的老年患者中,去氧腎上腺素與去甲腎上腺素同樣安全,二者均可以維持老年患者的血流動力學平穩(wěn)以及組織氧供需平衡。在無嚴重心血管疾病的老年患者中,去氧腎上腺素也是一種不錯的選擇。
[Abstract]:The purpose of fluid management is the cornerstone of resuscitation in critically ill patients, especially elderly patients with liquid management, has been a thorny problem to doctors and surgeons anesthesia problems. If the open fluid management, causes tissue edema, intestinal obstruction, pulmonary complications and a series of adverse consequences, and prolong ICU and hospitalization time; on the contrary, if the restriction of fluid intake it will lead to lower blood pressure, leading to tissue hypoperfusion, systemic inflammatory response syndrome and multiple organ dysfunction secondary; therefore, fluid overload or excessive fluid restriction, is harmful to the patients. In recent years, the researchers found a new treatment method, namely by optimizing the heart before and after load and myocardial contractility to achieve stable hemodynamics, reach the balance of supply and demand of oxygen, therefore proposed the goal-directed fluid therapy (Goal directed fluid therapy, GDFT) is based on the.GDFT The patient's age, weight, gender, disease characteristics, the general condition of patients and other indicators, individual replacement schemes, monitoring indicators commonly used for pulmonary artery catheter and ultrasound, due to its high traumatic high cost and other reasons, restrictions on the use and stroke volume variation (Stroke volume, variation, SVV) is a a convenient measurement of volume responsiveness in hemodynamic parameters accurately, has higher sensitivity and specificity. With the global population aging, the amount of surgery in elderly patients is increasing exponentially, and because of the recession itself in elderly patients with cardiovascular function, preoperative bowel preparation, anesthetic inhibition of cardiovascular and other reasons, prone to hemodynamic fluctuation during the operation, effect of tissue perfusion and oxygen supply, and even life-threatening. However in elderly patients during the induction of anesthesia hypotension, usually mainly because of anesthesia. Vascular resistance under peripheral vascular expansion leads to decrease in the previous research, the general noradrenaline corrected based on, however, phenylephrine is a selective a- receptor agonist, and can reduce reflex heart rate and cardiac output, reduced cardiac work. Few study contrast in norepinephrine and phenylephrine in SVV oriented liquid in the treatment, so we design this topic. To select elective radical resection for colorectal cancer in elderly patients, SVV guided fluid therapy, observation of norepinephrine and phenylephrine on hemodynamics in elderly patients undergoing maintenance and tissue oxygenation. Methods we collected 40 elderly patients with ASA, data classification ii~iii for colorectal cancer surgery. The patients were randomly divided into 2 groups: norepinephrine group (group 1; n=20) and phenylephrine group (group 2; n=20 two). All patients received background infusion of 5ml/kg/h in liquid crystal operation (Ringer), when svv9% (flotrac/vigileo3.0 instrument monitoring), is additional 200ml colloid (130/0.4 hydroxyethyl starch; 6%), 5min was observed after repeated given liquid load, straight to svv9%; if SVV in 9-13% liquid crystal, giving 8m/kg/h (Ringer). At the beginning of induction of anesthesia, vasoactive drugs (norepinephrine or phenylephrine) in the background of 5ml/h speed infusion to maintain systolic blood pressure 90mmHg or map65mmhg. if the blood pressure drop over 20% basic value or ci2.5l/min/m2, were given dobutamine. All patients received center vein puncture and radial artery catheterization, and monitoring of ECG, map, CVP, oxygen pulse, body temperature, end expiratory carbon dioxide and bispectral index. Two groups were treated with standard anesthesia induction in perforating artery after burglary, 璇卞鍗沖埢,璇卞鍚，

本文編號：1594909