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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2023, Vol. 17 ›› Issue (02) : 134 -138. doi: 10.3877/cma.j.issn.1674-0793.2023.02.010

论著

目标导向液体管理策略在腹腔镜肝切除术中对患者组织灌注及应激反应的影响
王增鲜1,†(), 王婧2, 杨淑怡1   
  1. 1. 261000　潍坊，中国人民解放军第80集团军医院麻醉科
    2. 264200　威海市中心医院麻醉科
  • 收稿日期:2022-08-05 出版日期:2023-04-01
  • 通信作者: 王增鲜

Investigating the effect of goal-directed fluid management strategy on tissue perfusion and stress response in patients undergoing laparoscopic hepatectomy

Zengxian Wang1,†(), Jing Wang2, Shuyi Yang1   

  1. 1. Department of Anesthesiology, the 80th Group Military Hospital of the Chinese People's Liberation Army, Weifang 261000, China
    2. Department of Anesthesiology, Weihai Central Hospital, Weihai 264200, China
  • Received:2022-08-05 Published:2023-04-01
  • Corresponding author: Zengxian Wang
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王增鲜, 王婧, 杨淑怡. 目标导向液体管理策略在腹腔镜肝切除术中对患者组织灌注及应激反应的影响[J/OL]. 中华普通外科学文献(电子版), 2023, 17(02): 134-138.

Zengxian Wang, Jing Wang, Shuyi Yang. Investigating the effect of goal-directed fluid management strategy on tissue perfusion and stress response in patients undergoing laparoscopic hepatectomy[J/OL]. Chinese Archives of General Surgery(Electronic Edition), 2023, 17(02): 134-138.

目的

探讨目标导向液体管理策略在腹腔镜肝切除术（LH）中对患者组织灌注及应激反应的影响。

方法

前瞻性选取2018年1月至2021年6月中国人民解放军第80集团军医院收治的58例行LH肝癌患者的临床资料，根据液体管理策略的不同分为常规组（30例）和目标导向组（28例）。比较两组围手术期相关指标、血流动力学和组织灌注、应激反应及肝肾功能相关指标。

结果

目标导向组术中出血量、胶体液量、总输液量、尿量、术后排气时间及术后住院时间较常规组显著降低（t=1.807、2.008、2.274、4.492、1.888、2.146；均P<0.05），晶体液量显著升高（t=-4.399，P<0.001），差异均有统计学意义。时间与方法在HR、MAP、CVP、ScvO2、Lac及Glu上不存在交互作用，在HR、MAP、CVP、ScvO2、Lac及Glu上主效应显著（P<0.05）。术后1 d两组E、IL-6及CRP水平较术前均显著升高（P<0.05），且目标导向组E、IL-6及CRP水平均显著低于常规组（P<0.05）；两组CD4+水平及CD4+/CD8+较术前均显著降低（P<0.05），且目标导向组均显著高于常规组（P<0.05）。时间与方法在ALB、TBil、AST、ALT、BUN及Cr上不存在交互作用，在ALB、TBil、AST及ALT上主效应显著（P<0.05），在BUN及Cr上主效应不显著。

结论

在LH中目标导向液体管理策略可有效减少术中损伤，维持血流动力学稳定及机体的免疫功能，保证组织充分灌注，保护肝功能，加快患者术后恢复。

关键词: 目标导向液体管理, 腹腔镜, 肝切除术, 组织灌注, 应激反应
Objective

To investigate the effect of goal-directed fluid management strategy on tissue perfusion and stress response in patients undergoing laparoscopic hepatectomy (LH).

Methods

The clinical data of 58 patients with LH hepatocellular carcinoma admitted to the 80th Group Military Hospital of the Chinese People's Liberation Army from January 2018 to June 2021 were prospectively analyzed. They were divided into routine group (30 cases) and goal-directed group (28 cases) according to different fluid management strategies. Routine liquid management strategy was used in the routine group and goal-directed fluid management strategy was used in the goal-directed group. The perioperative parameters, hemodynamics and tissue perfusion parameters, stress response parameters and liver and kidney function parameters were compared between the two groups.

Methods

Compared with the routine group, the intraoperative blood loss, colloidal fluid volume, total infusion volume, urine output, postoperative exhaust time and postoperative hospital stay were significantly reduced in the goal-directed group (t=1.807, 2.008, 2.274, 4.492, 1.888, 2.146; all P<0.05) and the amount of crystalloid increased significantly (t=-4.399, P<0.001), and the differences were statistically significant. There was no interaction between time and method on HR, MAP, CVP, ScvO2, Lac and Glu, but the main effect of time and method on HR, MAP, CVP, ScvO2, Lac and Glu was significant (P<0.05). 1 day after surgery, the levels of E, IL-6 and CRP in both groups were significantly higher than those before surgery (P<0.05), and the levels of E, IL-6 and CRP in the goal-directed group were significantly lower than those in the routine group (P<0.05). The levels of CD4+ and CD4+/CD8+ in both groups were significantly decreased compared with those before surgery (P<0.05), and the levels of CD4+ and CD4+/CD8+ in the goal-directed group were significantly higher than those in the routine group (P<0.05). There was no interaction between time and method on ALB, TBil, AST, ALT, BUN and Cr. The main effect of time and method on ALB, TBil, AST and ALT was significant (P<0.05), while the main effect of time and method on BUN and Cr was not significant.

Conclusion

In LH, the goal-directed fluid management strategy can effectively reduce intraoperative injury, maintain hemodynamic stability and immune function, ensure adequate tissue perfusion, maintain the immune function of the body, protect liver function and accelerate postoperative recovery of patients.

Key words: Goal-directed fluid management, Laparoscopes, Hepatectomy, Tissue perfusion, Stress response
表1 58例行腹腔镜肝切术患者不同液体管理策略术前资料的比较
组别 例数 性别 年龄(岁) BMI(kg/m2) 基础疾病 ASA分级 Child-Pugh分级 病灶部位
男 女 有 无 Ⅰ Ⅱ A B 左 右
常规组 30 20 10 57.3±8.6 23.3±2.2 9 21 17 13 23 7 18 12
目标导向组 28 16 12 58.0±8.4 22.8±2.3 8 20 18 10 23 5 15 13
统计值   0.558 0.314a 0.806a 0.014 0.351 0.164 0.244
P值   0.455 0.378 0.212 0.905 0.553 0.685 0.621
表2 58例行腹腔镜肝切除术肝癌患者不同液体管理策略围手术期相关指标(±s)
组别 例数 手术时间（min） 术中出血量（min） 胶体液量（ml） 晶体液量（ml） 总输液量（ml） 尿量（ml） 术后排气时间（d） 术后住院时间（d）
常规组 30 144.3±38.2 223.6±57.8 1 307.8±238.1 943.6±196.4 2 203.4±328.5 493.7±55.6 2.1±0.7 9.4±2.1
目标导向组 28 150.7±35.4 200.3±39.2 1 203.7±149.6 1 124.1±105.6 2 014.3±304.9 437.8±38.1 1.8±0.5 8.3±1.8
t值   0.662 1.807 2.008 -4.399 2.274 4.492 1.888 2.146
P值   0.255 0.038 0.025 <0.001 0.014 <0.001 0.032 0.018
表3 58例行腹腔镜肝切除术肝癌患者不同液体管理策略血流动力学和组织灌注相关指标(±s)
组别 例数 时间 HR(次/分) MAP(mmHg) CVP(cmH2O) ScvO2(%) Lac(mmol/L) Glu(mmol/L)
常规组 30 T0 66.5±5.4 81.2±5.1 5.9±1.7 73.4±3.3 1.1±0.3 5.6±0.7
T1 73.8±6.4 65.7±6.0 5.9±1.6 75.7±3.7 1.7±0.4 6.5±0.9
T2 77.5±6.0 90.6±5.2 6.0±1.3 76.1±4.3 2.1±0.5 8.2±1.2
T3 81.1±4.9 95.8±6.5 7.8±1.0 75.2±4.0 2.5±0.6 7.9±0.7
目标导向组 28 T0 66.8±5.5 81.6±5.3 5.8±1.5 73.6±3.5 1.2±0.3 5.7±0.6
T1 70.3±5.7 69.5±6.0 5.9±1.4 77.7±3.9 1.3±0.4 6.2±0.5
T2 73.8±6.1 85.8±5.6 8.0±1.0 82.6±3.7 1.5±0.3 7.3±1.0
T3 76.2±5.0 87.2±6.1 8.7±1.1 84.1±4.5 1.7±0.4 7.0±0.7
表4 58例行腹腔镜肝切除术肝癌患者不同液体管理策略应激反应相关指标(±s)
组别 例数 时间 E(μg/L) IL-6(μg/L) CRP(mg/L) CD4+(%) CD8+(%) CD4+/CD8+
常规组 30 术前 119.2±15.5 55.5±7.8 9.1±2.1 42.7±3.3 33.1±2.3 1.3±0.2
术后1 d 234.1±25.4a 101.4±20.3a 38.6±10.2a 34.8±2.6a 34.0±2.4 1.0±0.2a
目标导向组 28 术前 120.6±14.7 56.3±8.3 8.6±1.8 42.4±3.1 33.2±2.2 1.3±0.3
术后1 d 205.4±22.1ab 87.3±16.4ab 27.3±9.7ab 38.4±2.3ab 34.0±2.1 1.2±0.3ab
表5 58例行腹腔镜肝切除术肝癌患者不同液体管理策略肝肾功能相关指标(±s)
组别 例数 时间 ALB (g/L) TBil (μmol/L) AST (U/L) ALT (U/L) BUN (mmol/L) Cr (μmol/L)
常规组 30 术前 40.8±4.0 13.9±6.6 35.8±16.5 38.4±18.5 5.4±1.6 65.3±9.8
术后3 d 32.5±3.7 22.4±9.4 238.5±112.5 216.4±79.3 5.9±1.3 59.2±8.7
术后7 d 34.1±2.2 17.5±8.0 63.1±18.4 68.4±28.1 5.7±1.2 54.7±9.2
目标导向组 28 术前 41.3±3.9 14.2±6.4 35.1±16.8 37.7±18.8 5.5±1.4 66.2±9.6
术后3 d 34.5±3.1 20.1±9.2 212.6±98.8 201.1±65.6 6.1±1.4 61.3±8.4
术后7 d 36.8±2.1 15.3±7.5 51.9±22.4 55.7±23.9 5.6±1.5 55.8±9.7
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