个体化优化血流动力学治疗可减少重症监护病房并发症和住院时间：一项前瞻性、随机对照试验。
Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: a prospective, randomized controlled trial.
机构信息
* Senior Physician Anesthesiologist, † Anesthesiologist, § Resident, # Professor of Anesthesiology, Director, ** Professor of Anesthesiology, Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. ‡ Statistician, Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf. ‖ Professor of Cardiac Surgery, Director, Department of Cardiovascular Surgery, University Heart Center, University Medical Center Hamburg-Eppendorf.
出版信息
Anesthesiology. 2013 Oct;119(4):824-36. doi: 10.1097/ALN.0b013e31829bd770.
BACKGROUND
The authors hypothesized that goal-directed hemodynamic therapy, based on the combination of functional and volumetric hemodynamic parameters, improves outcome in patients with cardiac surgery. Therefore, a therapy guided by stroke volume variation, individually optimized global end-diastolic volume index, cardiac index, and mean arterial pressure was compared with an algorithm based on mean arterial pressure and central venous pressure.
METHODS
This prospective, controlled, parallel-arm, open-label trial randomized 100 coronary artery bypass grafting and/or aortic valve replacement patients to a study group (SG; n = 50) or a control group (CG; n = 50). In the SG, hemodynamic therapy was guided by stroke volume variation, optimized global end-diastolic volume index, mean arterial pressure, and cardiac index. Optimized global end-diastolic volume index was defined before and after weaning from cardiopulmonary bypass and at intensive care unit (ICU) admission. Mean arterial pressure and central venous pressure served as hemodynamic goals in the CG. Therapy was started immediately after induction of anesthesia and continued until ICU discharge criteria, serving as primary outcome parameter, were fulfilled.
RESULTS
Intraoperative need for norepinephrine was decreased in the SG with a mean (±SD) of 9.0 ± 7.6 versus 14.9 ± 11.1 µg/kg (P = 0.002). Postoperative complications (SG, 40 vs. CG, 63; P = 0.004), time to reach ICU discharge criteria (SG, 15 ± 6 h; CG, 24 ± 29 h; P < 0.001), and length of ICU stay (SG, 42 ± 19 h; CG, 62 ± 58 h; P = 0.018) were reduced in the SG.
CONCLUSION
Early goal-directed hemodynamic therapy based on cardiac index, stroke volume variation, and optimized global end-diastolic volume index reduces complications and length of ICU stay after cardiac surgery.
背景
作者假设基于功能和容积血流动力学参数的组合进行目标导向的血流动力学治疗可以改善心脏手术患者的预后。因此，与基于平均动脉压和中心静脉压的算法相比，作者比较了一种由每搏变异度、个体化优化的全心舒张末期容积指数、心指数和平均动脉压指导的治疗方法。
方法
这项前瞻性、对照、平行臂、开放标签试验将 100 例冠状动脉旁路移植术和/或主动脉瓣置换术患者随机分为研究组（SG；n = 50）和对照组（CG；n = 50）。在 SG 中，通过每搏变异度、优化的全心舒张末期容积指数、平均动脉压和心指数指导血流动力学治疗。在体外循环脱机前后和重症监护病房（ICU）入院时定义优化的全心舒张末期容积指数。CG 中的血流动力学目标为平均动脉压和中心静脉压。治疗从麻醉诱导后立即开始，并持续到满足 ICU 出院标准作为主要结局参数。
结果
SG 术中去甲肾上腺素的需求量为 9.0 ± 7.6 µg/kg，而 CG 为 14.9 ± 11.1 µg/kg（P = 0.002）。SG 的术后并发症（40 例比 CG 的 63 例；P = 0.004）、达到 ICU 出院标准的时间（SG 的 15 ± 6 h，CG 的 24 ± 29 h；P < 0.001）和 ICU 住院时间（SG 的 42 ± 19 h，CG 的 62 ± 58 h；P = 0.018）都较 CG 缩短。
结论
基于心指数、每搏变异度和优化的全心舒张末期容积指数的早期目标导向血流动力学治疗可减少心脏手术后的并发症和 ICU 住院时间。
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