控制性低中心静脉压在肝门胆管癌根治手术中的应用
发布时间：2018-12-18 12:05
【摘要】：目的对比观察控制性低中心静脉压在梗阻性黄疸患者行肝门胆管癌根治术中对其血流动力学和内环境的影响，评价控制性低中心静脉压技术在中、重度黄疸患者行肝叶切除手术中应用的可行性和安全性。方法选择解放军总医院2012年12月—2013年10月伴有黄疸的肝门胆管癌患者和肝功能正常行肝叶切除的患者各60例，两类患者按是否采用控制性低中心静脉压各分两组共四组：控制性低中心静脉压黄疸组(A组）、非控制性低中心静脉压黄疸组（B组）、控制性低中心静脉压非黄疸组（C组）、非控制性低中心静脉压非黄疸组（D组），每组30例。A、C两组从手术开始至病灶切除并止血完成后通过限制液体输入、调节头高脚低体位(头高10-15°)及吸入异氟醚和持续微量泵注硝酸甘油0.1-2μg/（kg·min）把中心静脉压控制在CVP5mmHg；B、D两组术中通过容量监测按需常规输液、输血维持CVP在5-12mmHg。分别在手术开始（T1）、病灶切除止血后（T2）、关腹后（T3）测血气并记录PH、PO2、Lac、BE；记录血流动力学指标：心率（HR）、平均动脉压（MAP）、心输出量（CO）、中心静脉压（CVP）、每搏输出量（SV）、每搏变异量（SVV）、每搏变异指数（SVI）；记录术中出血量、输血量、输血例数和血管活性药物应用情况，记录术前和术后24h肌酐和尿素氮值。结果：（1）血流动力学变化： A组T2时测得的CVP、SV、SVI低于B组，SVV高于B组（p0.05）；C组T2时测得的CVP低于D组，SVV高于D组（p0.05）。（2）血气分析：同T1比较，每组在T2、T3时点的PH、BE、Lac均有统计学差异(p 0.05)；四组各时间点组间观察比较血气分析参数均无明显差异(p0.05)；（3）术中出血量及输血情况： A组较B组术中出血量、异体血输入量及输血例数明显减少(p0.05)， C组较D组术中出血量、异体血输入量及输血例数明显减少（p0.05)；（4）血管活性药物应用：A组术中血管活性药物应用的剂量和例数较C组明显增多(p0.05)，B组术中血管活性药物应用的剂量和例数较D组明显增多(p0.05)，黄疸患者组内和非黄疸患者组内比较，CLCVP组较非CLCVP组血管活性药物用量显著增多(p0.05)，去氧肾上腺素用量与血总胆红素浓度存在线性相关性。（5）四组患者术后24小时肌酐、尿素氮值同术前相比均无明显差异(p0.05)。结论在伴有黄疸患者行肝门胆管癌根治术中应用控制性低中心静脉压可明显减少术中出血量及异体血输入量，且对机体内环境和术后肾功能无明显影响；黄疸患者对容量变化较非黄疸患者敏感，，术中血流动力学有较明显的波动，需要严密监测并应用血管活性药物及时调节。
[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 掳) 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.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614
本文编号：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 掳) 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.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R614
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