氧供目标导向灌注体外循环在全胸腔镜二尖瓣手术中的应用被引量：1

Application of oxygen supply goal-directed perfusion cardiopulmonary bypass in total thoracoscopic mitral valve surgery

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摘要目的观察全胸腔镜二尖瓣手术中采用氧供目标导向灌注进行体外循环管理的效果,探讨其安全性。方法行全胸腔镜二尖瓣手术患者60例,依据术中体外循环管理方法分为常规组和目标导向组各30例。常规组依据体表面积计算灌注流量;目标导向组依据氧供、氧耗、氧供指数设定氧供目标值,低于目标值时通过调整超滤量和/或增加灌注流量维持组织氧供。比较2组体外循环时间、循环阻断时间、最低及最高灌注流量、最低鼻咽及膀胱温度、最低血红蛋白水平、转中液体总入量、超滤量、苯肾上腺素用量、术后机械通气时间、ICU治疗时间及急性肾损伤发生率、院内病死率;记录2组麻醉诱导后(T_(0))、体外循环阻断10 min(T_(1))、体外循环阻断60 min(T_(2))、开放升主动脉前(T_(3))、停机前(T_(4))、鱼精蛋白中和后30 min(T_(5))时血乳酸水平、红细胞比容。结果目标导向组苯肾上腺素用量[(50.0±29.0)μg]、急性肾损伤发生率(13.3%)均低于常规组[(74.0±34.0)μg, 36.7%](t=2.896,P=0.005;χ2=4.356,P=0.037),体外循环时间、循环阻断时间、最低及最高灌注流量、最低鼻咽及膀胱温度、最低血红蛋白水平、转中液体总入量、超滤量、术后机械通气时间、ICU治疗时间与常规组比较差异均无统计学意义(P>0.05)。2组均无院内死亡病例。目标导向组血乳酸水平在T_(2)[(0.90±0.29)mmol/L]、T_(3)[(1.22±0.41)mmol/L]、T_(4)[(2.33±0.80)mmol/L]、T_(5)[(2.85±0.93)mmol/L]时均低于常规组[(1.06±0.23)、(1.75±0.38)、(3.15±0.70)、(3.93±0.82)mmol/L](t=2.333,P=0.023;t=5.119,P<0.001;t=4.269,P<0.001;t=4.791,P<0.001),在T_(0)[(0.96±0.36)mmol/L]、T_(1)[(0.72±0.22)mmol/L]时与常规组[(0.90±0.26)、(0.67±0.18)mmol/L]比较差异均无统计学意义(P>0.05);红细胞比容在T_(2)[(26.57±1.27)%]、T_(3)[(27.42±1.73)%]时均高于常规组[(23.98±2.02)%、(25.73±1.63)%](t=-5.945,P<0.001;t=-3.894,P<0.001),在T_(0)[(33.44±2.72)%]、T_(1)[(21.44±2.27)%]、T_(4)[(29.48±2.22)%]、T_(5)[(31.86±2.47)%]时与常规组[(32.95±2.37)%、(21.14±2.02)%、(28.73±1.63)%、(31.26±1.97)%]比较差异均无统计学意义(P>0.05);2组血乳酸水平及红细胞比容均在T_(1)时低于T_(0)时,T_(1)~T_(5)时依次增高(P<0.05)。结论全胸腔镜二尖瓣手术中采用氧供目标导向灌注体外循环管理可及时调节超滤和灌注量,维持血红蛋白水平,减少血乳酸生成,降低急性肾损伤发生率。 Objective To observe the efficacy of oxygen supply goal-directed perfusion(GDP)cardiopulmonary bypass(CPB)in total thoracoscopic mitral valve surgery and to investigate its safety.Methods Sixty patients undergoing thoracoscopic mitral valve surgery were equally divided into conventional group and GDP group according to the CPB management.In conventional group,body surface area measurement was used to calculate the flow,and GDP group was managed by calculating oxygen supply and setting oxygen supply target based on the oxygen supply,oxygen consumption and oxygen supply index.When the oxygen supply was lower than the target,the tissue oxygen supply was maintained by adjusting the ultrafiltration volume and/or increasing the perfusion flow.The CPB time,circulation blocking time,minimum and maximum perfusion flow,minimum nasopharyngeal and bladder temperature,lowest hemoglobin level,total fluid intake,ultrafiltration volume,phenylephrine dosage,postoperative mechanical ventilation time,ICU treatment time,incidence of acute kidney injury and in-hospital mortality were compared between two groups.The serum lactate level and hematocrit value were recorded after induction of anesthesia(T_(0)),10 min of CPB blockade(T_(1)),60 min of CPB blockade (T_(2)),before opening aortic clamp (T_(3)),at the end of CPB (T_(4)),and 30 min after protamine neutralization(T_(5)).Results The dosage of phenylephrine and incidence of acute kidney injury were lower in GDP group[(50.0±29.0)μg,13.3%)than those in conventional group[(74.0±34.0)μg,36.7%](t=2.896,P=0.005;χ~2=4.356,P=0.037),and there were no significant differences in CPB time,circulation blocking time,minimum and maximum perfusion flow,minimum nasopharyngeal and bladder temperature,lowest hemoglobin level,total fluid intake,ultrafiltration volume,postoperative mechanical ventilation time,and ICU treatment time between two groups(P>0.05).There was no in-hospital death in two groups.The serum lactate values were lower in GDP group at T_(2)[(0.90±0.29)mmol/L],T_(3)[(1.22±0.41)mmol/L],T_(4)[(2.33±0.80)mmol/L]and T_(5)[(2.85±0.93)mmol/L]than those in conventional group[(1.06±0.23),(1.75±0.38),(3.15±0.70),(3.93±0.82)mmol/L](t=2.333,P=0.023;t=5.119,P<0.001;t=4.269,P<0.001;t=4.791,P<0.001),and showed no significant differences at T_(0)and T_(1)between GDP group[(0.96±0.36),(0.72±0.22)mmol/L]and conventional group[(0.90±0.26),(0.67±0.18)mmol/L](P>0.05).The hematocrit values were higher in GDP group at T_(2)and T_(3)[(26.57±1.27)%,(27.42±1.73)%]than those in conventional group[(23.98±2.02)%,(25.73±1.63)%](t=-5.945,P<0.001;t=-3.894,P<0.001),and showed no significant differences at T_(0),T_(1),T_(4)and T_(5)between GDP group[(33.44±2.72)%,(21.44±2.27)%,(29.48±2.22)%,(31.86±2.47)%]and conventional group[(32.95±2.37)%,(21.14±2.02)%,(28.73±1.63)%,(31.26±1.97)%](P>0.05).The serum lactate level and hematocrit value in two groups were lower at T_(1)than those at T_(0),and increased gradually in turn at T_(1)to T_(5)(P<0.05).Conclusion In the management of CPB in total thoracoscopic mitral valve surgery,oxygen supply GDP is used to timely regulate ultrafiltration and perfusion volume,maintain hemoglobin concentration,reduce serum lactic acid production,and decrease the incidence of acute kidney injury.

作者姚东风黄佳鑫钱晓亮葛畅杨雷一程兆云 YAO Dong-feng;HUANG Jia-xin;QIAN Xiao-liang;GE Chang;YANG Lei-yi;CHENG Zhao-yun(Department of Eatracorporeal Circulation,Zhengzhou University People's Hospital,Heart Central of Henan Provincial People's Hospital,FuwaiCentral China Cardiovascular Hospital,Zhengzhou,Henan 450003,China;Departmentof Cardiac Surgery,Zhengzhou University People's Hospital,Heart Central of Henan Provincial People's Hospital,Fuwai Central China Cardiovascular Hospital,Zhengzhou,Henan 450003,China)

机构地区郑州大学人民医院、河南省人民医院心脏中心、阜外华中心血管病医院体外循环科郑州大学人民医院、河南省人民医院心脏中心、阜外华中心血管病医院心外科

出处《中华实用诊断与治疗杂志》 2022年第11期1105-1109,共5页 Journal of Chinese Practical Diagnosis and Therapy

基金河南省医学科技攻关计划项目(LHGJ20200088)。

关键词二尖瓣手术全胸腔镜体外循环目标导向灌注管理 mitral valve surgery total thoracoscopy cardiopulmonary bypass goal-directed perfusion management

分类号 R654.2 [医药卫生—外科学]

作者简介通信作者:程兆云,E-mail:chengzhy@zzu.edu.cn。