Yu Ling, Sun Hongwei, Jin Huangmo, Tan Hongyu
Department of Anesthesiology, Key laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China.
BMC Surg. 2020 Feb 4;20(1):25. doi: 10.1186/s12893-020-0689-z.
This prospective randomized controlled study was designed to evaluate the effect of fluid restriction alone versus fluid restriction + low central venous pressure (CVP) on hepatic surgical field bleeding, intraoperative blood loss, and the serum lactate concentration in patients undergoing partial hepatectomy.
One hundred forty patients undergoing partial hepatectomy with intraoperative portal triad clamping were randomized into a fluid restriction group (Group F) or fluid restriction + low CVP group (Group L). Both groups received limited fluid infusion before the liver lesions were removed. Ephedrine was administered if the systolic blood pressure (SBP) decreased to <90 mmHg for 1 min. When the urine output was <20 ml/h or the SBP was <90 mmHg for 1 min more than three times, an additional 200 ml of crystalline solution was quickly infused within 10 min. In addition to fluid restriction, patients in Group L received continuous nitroglycerin and esmolol infusion to maintain a low CVP. The duration of portal triad clamping, frequency of additional fluid infusion, frequency of ephedrine administration, intraoperative blood loss, extent of liver resection, and bleeding score of the hepatic surgical field were recorded. Arterial blood gas analysis was performed before anesthesia (T1), after liver dissection and immediately before liver resection (T2), 10 min after removal of the liver lesion (T3), and before the patient was discharged from the postanesthesia care unit (T4).
Being in the fluid restriction Group (Group F) (odds ratio = 5.04) and cirrhosis (odds ratio = 3.28) were risk factors for hepatic surgical field bleeding. Factors contributing to intraoperative blood loss were the operation time, duration of portal triad clamping, and extent of resection. No significant between-group difference was observed for blood loss or blood transfusion. The serum lactate concentration peaked at T3 in both groups.
Maintaining a lower CVP during hepatectomy provides an optimal surgical field but has no significant effect on intraoperative blood loss. Moreover, lower CVP does not increase the serum lactate concentration.
"A comparative study of the effect fluid restriction and low CVP pressure on the oozing of blood in liver wounds and blood lactate in patients undergoing partial hepatectomy" was prospectively registered as a trial (registration number: ChiCTR-INR-17014172, date of registration: 27 December 2017).
本前瞻性随机对照研究旨在评估单纯液体限制与液体限制+低中心静脉压（CVP）对接受肝部分切除术患者肝手术野出血、术中失血量及血清乳酸浓度的影响。
140例接受肝部分切除术且术中行门静脉三联阻断的患者被随机分为液体限制组（F组）或液体限制+低CVP组（L组）。两组在切除肝脏病变前均接受有限的液体输注。如果收缩压（SBP）降至<90 mmHg持续1分钟，则给予麻黄碱。当尿量<20 ml/h或SBP<90 mmHg持续超过1分钟达3次以上时，在10分钟内快速额外输注200 ml晶体溶液。除液体限制外，L组患者接受持续静脉输注硝酸甘油和艾司洛尔以维持低CVP。记录门静脉三联阻断时间、额外液体输注频率、麻黄碱给药频率、术中失血量、肝切除范围及肝手术野出血评分。在麻醉前（T1）、肝游离后且即将进行肝切除前（T2）、切除肝脏病变后10分钟（T3）及患者从麻醉后护理单元出院前（T4）进行动脉血气分析。
处于液体限制组（F组）（比值比=5.04）和肝硬化（比值比=3.28）是肝手术野出血的危险因素。导致术中失血量的因素有手术时间、门静脉三联阻断时间及切除范围。两组间在失血量或输血方面未观察到显著差异。两组血清乳酸浓度均在T3时达到峰值。
肝切除术中维持较低的CVP可提供最佳手术视野，但对术中失血量无显著影响。此外，较低的CVP不会增加血清乳酸浓度。
“液体限制和低CVP压力对肝部分切除术患者肝创面渗血及血乳酸影响的比较研究”已作为一项试验进行前瞻性注册（注册号：ChiCTR-INR-17014172，注册日期：2017年12月27日）。
