预加载依赖与大型腹部手术后舌下微循环减少有关。
Preload Dependence Is Associated with Reduced Sublingual Microcirculation during Major Abdominal Surgery.
机构信息
From the University Hospitals of Paris-Sud, Assistance Publique Des Hôpitaux De Paris, Critical Care and Anesthesia Department, Antoine Béclère Hospital, Clamart, France (K.B.) University Hospitals of Paris-Sud, Assistance Publique Des Hôpitaux De Paris, Medical Intensive Care Unit (J.-L.T.) Critical Care and Anesthesia Department (L.V., J.D.), Bicêtre Hospital, Le Kremlin Bicêtre, France Clinical Research Unit, UMR 942, Lariboisiere University Hospital, Paris, France (E.V.).
出版信息
Anesthesiology. 2019 Apr;130(4):541-549. doi: 10.1097/ALN.0000000000002631.
BACKGROUND
Dynamic indices, such as pulse pressure variation, detect preload dependence and are used to predict fluid responsiveness. The behavior of sublingual microcirculation during preload dependence is unknown during major abdominal surgery. The purpose of this study was to test the hypothesis that during abdominal surgery, microvascular perfusion is impaired during preload dependence and recovers after fluid administration.
METHODS
This prospective observational study included patients having major abdominal surgery. Pulse pressure variation was used to identify preload dependence. A fluid challenge was performed when pulse pressure variation was greater than 13%. Macrocirculation variables (mean arterial pressure, heart rate, stroke volume index, and pulse pressure variation) and sublingual microcirculation variables (perfused vessel density, microvascular flow index, proportion of perfused vessels, and flow heterogeneity index) were recorded every 10 min.
RESULTS
In 17 patients, who contributed 32 preload dependence episodes, the occurrence of preload dependence during major abdominal surgery was associated with a decrease in mean arterial pressure (72 ± 9 vs. 83 ± 15 mmHg [mean ± SD]; P = 0.016) and stroke volume index (36 ± 8 vs. 43 ± 8 ml/m; P < 0.001) with a concomitant decrease in microvascular flow index (median [interquartile range], 2.33 [1.81, 2.75] vs. 2.84 [2.56, 2.88]; P = 0.009) and perfused vessel density (14.9 [12.0, 16.4] vs. 16.1 mm/mm [14.7, 21.4], P = 0.009), while heterogeneity index was increased from 0.2 (0.2, 0.4) to 0.5 (0.4, 0.7; P = 0.001). After fluid challenge, all microvascular parameters and the stroke volume index improved, while mean arterial pressure and heart rate remained unchanged.
CONCLUSIONS
Preload dependence was associated with reduced sublingual microcirculation during major abdominal surgery. Fluid administration successfully restored microvascular perfusion.
背景
脉动压变异等动态指标可探测前负荷依赖性，并用于预测液体反应性。在大型腹部手术中，前负荷依赖性期间舌下微循环的行为尚不清楚。本研究旨在验证假设，即在腹部手术期间，液体管理后前负荷依赖性期间微脉管灌注受损，并且在液体管理后恢复。
方法
本前瞻性观察性研究纳入了行大型腹部手术的患者。当脉压变异大于 13%时，使用液体冲击试验来识别前负荷依赖性。每 10 分钟记录宏观循环变量（平均动脉压、心率、每搏量指数和脉压变异）和舌下微循环变量（灌注血管密度、微血管血流指数、灌注血管比例和血流异质性指数）。
结果
在 17 名患者中，共有 32 次前负荷依赖性，大型腹部手术中前负荷依赖性的发生与平均动脉压（72 ± 9 比 83 ± 15mmHg[平均值±标准差]；P = 0.016）和每搏量指数（36 ± 8 比 43 ± 8ml/m；P < 0.001）的降低相关，同时伴随着微血管血流指数（中位数[四分位间距]，2.33[1.81，2.75]比 2.84[2.56，2.88]；P = 0.009）和灌注血管密度（14.9[12.0，16.4]比 16.1mm/mm[14.7，21.4]；P = 0.009）的降低，而异质性指数从 0.2（0.2，0.4）增加到 0.5（0.4，0.7；P = 0.001）。液体冲击试验后，所有微血管参数和每搏量指数均得到改善，而平均动脉压和心率保持不变。
结论
在大型腹部手术中，前负荷依赖性与舌下微循环减少有关。液体管理成功恢复了微血管灌注。
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