Haas Sebastian, Eichhorn Volker, Hasbach Ted, Trepte Constantin, Kutup Asad, Goetz Alwin E, Reuter Daniel A
Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Martinistra β e 52, 20246 Hamburg, Germany.
Crit Care Res Pract. 2012;2012:687018. doi: 10.1155/2012/687018. Epub 2012 Jun 21.
Background. Goal-directed fluid therapy (GDT) guided by functional parameters of preload, such as stroke volume variation (SVV), seems to optimize hemodynamics and possibly improves clinical outcome. However, this strategy is believed to be rather fluid aggressive, and, furthermore, during surgery requiring thoracotomy, the ability of SVV to predict volume responsiveness has raised some controversy. So far it is not known whether GDT is associated with pulmonary fluid overload and a deleterious reduction in pulmonary function in thoracic surgery requiring one-lung-ventilation (OLV). Therefore, we assessed the perioperative course of extravascular lung water index (EVLWI) and p(a)O(2)/F(i)O(2)-ratio during and after thoracic surgery requiring lateral thoracotomy and OLV to evaluate the hypothesis that fluid therapy guided by SVV results in pulmonary fluid overload. Methods. A total of 27 patients (group T) were enrolled in this prospective study with 11 patients undergoing lung surgery (group L) and 16 patients undergoing esophagectomy (group E). Goal-directed fluid management was guided by SVV (SVV < 10%). Measurements were performed directly after induction of anesthesia (baseline-BL), 15 minutes after implementation OLV (OLVimpl15), and 15 minutes after termination of OLV (OLVterm15). In addition, postoperative measurements were performed at 6 (6postop), 12 (12postop), and 24 (24postop) hours after surgery. EVLWI was measured at all predefined steps. The p(a)O(2)/F(i)O(2)-ratio was determined at each point during mechanical ventilation (group L: BL-OLVterm15; group E: BL-24postop). Results. In all patients (group T), there was no significant change (P > 0.05) in EVLWI during the observation period (BL: 7.8 ± 2.5, 24postop: 8.1 ± 2.4 mL/kg). A subgroup analysis for group L and group E also did not reveal significant changes of EVLWI. The p(a)O(2)/F(i)O(2)-ratio decreased significantly during the observation period (group L: BL: 462 ± 140, OLVterm15: 338 ± 112 mmHg; group E: BL: 389 ± 101, 24postop: 303 ± 74 mmHg) but remained >300 mmHg except during OLV. Conclusions. SVV-guided fluid management in thoracic surgery requiring lateral thoracotomy and one-lung ventilation does not result in pulmonary fluid overload. Although oxygenation was reduced, pulmonary function remained within a clinically acceptable range.
背景。由前负荷功能参数（如每搏量变异度（SVV））指导的目标导向液体治疗（GDT）似乎能优化血流动力学，并可能改善临床结局。然而，这种策略被认为是相当激进的液体治疗，此外，在需要开胸手术的过程中，SVV预测容量反应性的能力引发了一些争议。到目前为止，尚不清楚在需要单肺通气（OLV）的胸科手术中，GDT是否与肺组织间隙液体量指数（EVLWI）增加及肺功能的有害性降低有关。因此，我们评估了在需要侧胸壁切开术和OLV的胸科手术期间及术后血管外肺水指数（EVLWI）和动脉血氧分压/吸入氧分数值（p(a)O(2)/F(i)O(2)）的围手术期变化过程，以评估由SVV指导的液体治疗会导致肺组织间隙液体量过载这一假设。方法。本前瞻性研究共纳入27例患者（T组），其中11例接受肺手术（L组），16例接受食管切除术（E组）。目标导向液体管理由SVV（SVV < 10%）指导。在麻醉诱导后即刻（基线 - BL）、实施OLV后15分钟（OLVimpl15）和OLV结束后15分钟（OLVterm15）进行测量。此外，术后在术后6小时（6postop）、12小时（12postop）和24小时（24postop）进行测量。在所有预定义步骤测量EVLWI。在机械通气期间的每个时间点测定p(a)O(2)/F(i)O(2)（L组：BL - OLVterm15；E组：BL - 24postop）。结果。在所有患者（T组）中，观察期内EVLWI无显著变化（P > 0.05）（BL：7.8 ± 2.5，2postop：8.1 ± 2.4 mL/kg）。L组和E组的亚组分析也未显示EVLWI有显著变化。观察期内p(a)O(2)/F(i)O(2)显著降低（L组：BL：462 ± 140，OLVterm15：338 ± 112 mmHg；E组：BL：389 ± 101，24postop：303 ± 74 mmHg），但除OLV期间外均保持>300 mmHg。结论。在需要侧胸壁切开术和单肺通气的胸科手术中，由SVV指导的液体管理不会导致肺组织间隙液体量过载。虽然氧合降低，但肺功能仍保持在临床可接受范围内。
