文章摘要
下腔静脉扩张指数指导目标导向液体治疗对老年患者全膝关节置换术后并发症的影响
Effect of goal-directed fluid therapy guided by inferior vena cava distensibility index on postoperative complications in elderly patients undergoing total knee replacement
  
DOI：10.12089/jca.2023.02.003
中文关键词: 目标导向液体治疗  下腔静脉扩张指数  每搏量变异度  膝关节置换术  术后并发症
英文关键词: Goal-oriented fluid therapy  Inferior vena cava distensibility index  Stroke volume variation  Knee replacement  Postoperative complications
基金项目:贵州省卫生健康委科学技术基金项目(gzwkj2022-126)；贵州省人民医院青年基金（GZSYQN〔2018〕13号，GZSYQN〔2019〕20号）
作者单位E-mail
彭晶 550002,贵阳市,贵州省人民医院麻醉科  
王骜 550002,贵阳市,贵州省人民医院麻醉科  
章放香 550002,贵阳市,贵州省人民医院麻醉科 zfx1205@126.com 
马熠 550002,贵阳市,贵州省人民医院麻醉科  
曾德亮 550002,贵阳市,贵州省人民医院麻醉科  
何福娟 550002,贵阳市,贵州省人民医院麻醉科  
秦晨光 550002,贵阳市,贵州省人民医院麻醉科  
黄玲 550002,贵阳市,贵州省人民医院麻醉科  
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中文摘要:
      
目的 探讨下腔静脉扩张指数（IVC-DI）指导的目标导向液体治疗（GDFT）对老年患者全膝关节置换术术后并发症的影响。
方法 选择2019年3月到2021年8月行全膝关节置换术的老年患者120例，男29例，女91例，年龄65~85岁，BMI 18~30 kg/m2，ASA Ⅰ—Ⅲ级。采用随机分组法分为三组：经胸IVC-DI监测组（I组）、每搏量变异度（SVV）监测组（S组）和血压监测组（C组），每组40例。I组IVC-DI>18%时，补充胶体液250 ml；若IVC-DI≤18%，而MAP低于基础值的80%，给予升压药物。S组SVV>13%时，补充胶体液250 ml；若SVV≤13%，而MAP低于基础值的80%，给予升压药物。C组MAP低于基础值的80%时，补充胶体液250 ml，当胶体液量达20 ml/kg时血压仍未改善，给予升压药物。记录麻醉药物用量、出血量、晶体和胶体输注量、总输注量、升压药物使用和输血情况。记录术后6 h、1、2、3 d活动（抬腿屈膝）时VAS疼痛评分。记录手术时间、术后首次下床活动时间、首次肛门排气时间、术后48 h内镇痛泵总按压次数和有效按压次数、恶心呕吐、切口感染、入ICU情况、术后住院时间。记录术后30 d并发症发生情况。
结果 与C组比较，I组和S组晶体输注量明显增多（P＜0.05），胶体输注量和总输注量明显减少（P＜0.05），升压药物使用率明显升高（P＜0.05）。与术后6 h比较，术后1、2、3 d三组活动时VAS疼痛评分明显升高（P＜0.05）。与I组比较，术后3 d S组和C组活动时VAS疼痛评分明显升高（P＜0.05）。与C组比较，I组和S组术后首次肛门排气时间明显缩短（P＜0.05），总并发症发生率明显降低（P＜0.05）。三组手术时间、术后首次下床活动时间、镇痛泵总按压次数和有效按压次数、恶心呕吐、切口感染、入ICU率、术后住院时间、术后30 d并发症发生率差异无统计学意义。
结论 与常规监测比较，IVC-DI指导目标导向液体治疗可通过减少术后并发症加快老年患者全膝关节置换术后康复。
英文摘要:
      
Objective To investigate the effect of goal-directed fluid therapy (GDFT) guided by the inferior vena cava distensibility index (IVC-DI) on the postoperative complications in elderly patients undergoing total knee replacement.
Methods A total of 120 patients underwent total knee arthroplasty from March 2019 to August 2021, 29 males and 91 females, aged 65-85 years, BMI 18-30 kg/m2, ASA physical status Ⅰ-Ⅲ, were randomly divided into three groups: fluid therapy guided by transthoracic IVC-DI monitoring (group I), stroke volume variation monitoring (group S), and blood pressure monitoring (group C), 40 patients in each group. Patients in group I were treated with colloid solution 250 ml when IVC-DI > 18%, if IVC-DI ≤ 18% and MAP less than 80% of the basal blood pressure, vasopressors were given. Patients in group S were treated with colloid solution 250 ml when SVV > 13%, if SVV≤ 13% and MAP less than 80% of the basal blood pressure, vasopressors were given. Patients in group C were treated with colloid solution 250 ml when MAP less than 80% of the basal blood pressure and repeated until MAP more than 80% of the baseline. If it was not improved when the colloid volume reached 20 ml/kg, vasopressors was administered until MAP more than 80% of the baseline. Anesthetic drug dosage, bleeding volume, crystal and colloidal infusion, total infusion volume, vasopressor drug use, and blood transfusion were recorded. The VAS pain score was recorded 6 hours, 1, 2, and 3 days after surgery (leg lift and knee flexion). The time of operation, the first time of getting out of bed, the first time of exhaust, the total number of analgesia pump compressions and effective compressions within 48 hours after surgery, nausea and vomiting, incision infection, ICU admission, and postoperative hospital stay were recorded. The occurrence of complications in each system was followed up and recorded 30 days after surgery.
Results Compared with group C, the crystal infusion volume in groups I and S was significantly increased (P < 0.05), colloid infusion volume and total infusion volume were significantly decreased (P < 0.05), and the utilization rate of vasopressor drugs was significantly increased (P < 0.05). Compared with 6 hours after surgery, the VAS pain scores in three groups 1, 2 and 3 days after surgery were significantly increased (P < 0.05). Compared with group I, the VAS pain scores in groups S and C were significantly increased 3 days after surgery (P < 0.05). Compared with group C, groups I and S had significantly shorter time for first exhaust (P < 0.05), the total complication rate was significantly reduced (P < 0.05). There were no significant differences in the operation time, the first time to get out of bed, the total and effective times of analgesic pump compressions, nausea and vomiting, incision infection, ICU admission, postoperative hospital stay, and complications 30 days after surgery among the three groups.
Conclusion Compared with routine monitoring, goal-directed fluid therapy of IVC-DI can accelerate the rehabilitation of elderly patients after knee arthroplasty by reducing postoperative complications.
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