控制性低中心静脉压技术对腹腔镜肝切除术患者脑氧饱和度的影响

Influence of controlled low central venous pressure on cerebral oxygen saturation in patients underwent laparoscopic hepatectomy

摘要:

目的 运用控制性低中心静脉压（CLCVP）技术的腹腔镜肝切除术，会增加患者神经系统并发症的风险，该研究拟评估该类患者术中脑去氧饱和度事件（CDE）的发生率。方法 选择拟行择期腹腔镜肝切除术的患者94例，随机分为CLCVP组（A组）及非CLCVP组（B组），各47例。两组患者均采用全凭静脉麻醉。分别观察术前（T₀）、麻醉诱导气管插管后5 min（T₁）、患者置于30°头高脚低位后5 min（T₂）、手术切皮后5 min（T₃）、切肝前5 min（T₄）［A组实施CLCVP，中心静脉压（CVP）控制在5 cmH₂O以内；B组维持CVP在正常范围］、切肝结束后5 min（T₅）和术毕（T₆）的血流动力学变化、脑氧饱和度（rSO₂）和升压药使用情况。记录CDE的发生情况、麻醉后监测治疗室（PACU）复苏时间、术后复苏室视觉模拟评分（VAS）≥4分、术后躁动、恶心和呕吐等发生情况。结果 两组患者平均动脉压（MAP）在T₄、T₅和T₆时点较T₀时点更低，且在T₄时点A组MAP下降更明显，两组患者比较，差异有统计学意义（P < 0.05）。两组患者rSO₂在T₄、T₅和T₆时点较T₁时点降低，且A组降低更明显，差异有统计学意义（P < 0.05）。A组CDE发生率较B组高（35.6%和4.3%，P = 0.001），升压药物使用率较B组高（48.9%和19.6%，P = 0.003）。A组恶心及呕吐发生率较B组高，差异有统计学意义（26.7%和8.7%，P = 0.024）。结论 运用CLCVP技术的腹腔镜肝切除术，较常规腹腔镜肝切除术可明显降低患者术中rSO₂，增加术中CDE发生率。

Abstract:

Objective Patients underwent laparoscopic hepatectomy surgery under controlled low central venous pressure (CLCVP) may be at risk for adverse neurologic events due to cerebral ischemia. In this study, we sought to determine the incidence of cerebral desaturation events (CDE) during laparoscopic hepatectomy surgery under CLCVP.Methods 94 patients scheduled for elective laparoscopic hepatectomy were randomly divided into CLCVP group (group A) and non CLCVP group (group B), 47 patients in each group. Total intravenous anesthesia were used for the two groups of patients. The hemodynamic changes, the regional cerebral oxygen saturation (rSO₂) and vasoactive drug use were recorded before operation (T₀), 5 min after tracheal intubation (T₁), 5 min after 30° head high foot low position (T₂), 5 min after skin incision (T₃), 5 min before hepatectomy (T₄) (group A controlled the CVP within 5 cmH₂O, group B controlled the CVP within the normol range), 5 min after hepatectomy procedure (T₅), and at the end of operation (T₆). The incidence of CDE, extubation time, post-anesthesia care unit (PACU) recovery time, visual analogue scale (VAS) ≥ 4, postoperative agitation, nausea and vomiting were recorded.Results The mean arterial pressure (MAP) in two groups at T₄ , T₅ and T₆ were lower than those at T₀, and the vaule of group A decreased more significantly at T₄ than group B, the difference was statistically significant (P < 0.05). The rSO₂ in two groups at T₄, T₅ and T₆ were lower than those at T₁, and the decrease in group A was more obvious, the difference was statistically significant (P < 0.05). The incidence of CDE in group A was higher (35.6% and 4.3%, P = 0.001), and the incidence of vasoconstrictor using in group A was higher (48.9% and 19.6%, P = 0.003). The incidence of nausea and vomiting in group A was higher than that in group B (26.7% vs 8.7%, P = 0.024).Conclusion Laparoscopic hepatectomy with CLCVP is associated with significantly reductions in rSO₂ compared with values obtained in the conventional laparoscopic hepatectomy, CLCVP is associated with high incidence of intraoperative CDE.