Nayak Pratyasa, Singha Subrata Kumar, Khetrapal Monica, Sharma Anil
Department of Anaesthesia, All India Institute of Medical Services - Raipur, Raipur, Chhattisgarh, India.
Department of Neurosurgery, All India Institute of Medical Services - Raipur, Raipur, Chhattisgarh, India.
Rom J Anaesth Intensive Care. 2023 Apr 20;30(1):18-25. doi: 10.2478/rjaic-2023-0003. eCollection 2023 Apr.
Fluid management in the perioperative period is a grey zone in clinical practice of late. Looking back on previous practices, static parameters were the only options. Now, dynamic parameters indicating fluid responsiveness have become a significant part of goal-directed fluid therapy (GDFT). However, the efficacy of this approach has yet to be established in neurosurgery cases where patients are already on lot of diuretics, thus making fluid management more challenging. The present study aims to determine the efficacy of the Pleth Variability Index (PVI) with pulse pressure variation (PPV) in guiding GDFT in patients undergoing neurosurgery for supra-tentorial intracranial space occupying lesions (ICSOLs), in the form of a randomised controlled trial. After randomisation, the patients were categorised into either PVI or PPV groups. Both received a baseline 2 ml/kg/h Lactated Ringer's (RL) infusion. Additional fluid boluses consisted of 250 ml of colloid infused over a 10 min period if PVI was > 15% or PPV was > 13% for at least five minutes. The primary outcome was to determine the serum lactate difference between preoperative and postoperative values, which could fairly predict fluid deficit leading to inadequate perfusion. A total of 74 patients were analysed. Both PVI- and PPV-guided GDFT strategies showed no significant difference in the postoperative lactate values, with a P-value of 0.18. Similarly, the mean total fluid administered, mean blood loss, length of CCU stay, and emetic and hypotension episodes also showed no significant differences among the groups with P-values of 0.41, 0.78, 0.25, 0.30, and 0.67, respectively. For patients undergoing neurosurgery (supratentorial ICSOLs), PVI seems to guide GDFT comparably to PPV regarding tissue perfusion and postoperative complications. However, both the parameters had low sensitivity and specificity, with an area of curve of 0.577 for PPV and 0.423 for PVI, as far as GDFT was concerned.
围手术期的液体管理在临床实践中一直是个灰色地带。回顾以往的做法，静态参数是唯一的选择。如今，指示液体反应性的动态参数已成为目标导向液体治疗（GDFT）的重要组成部分。然而，在患者已大量使用利尿剂的神经外科手术病例中，这种方法的疗效尚未得到证实，这使得液体管理更具挑战性。本研究旨在通过一项随机对照试验，确定脉搏变异指数（PVI）与脉压变异（PPV）在指导幕上颅内占位性病变（ICSOL）神经外科手术患者进行GDFT中的疗效。随机分组后，患者被分为PVI组或PPV组。两组均接受2 ml/kg/h的乳酸林格氏液（RL）基线输注。如果PVI>15%或PPV>13%至少持续五分钟，则额外的液体推注为在10分钟内输注250 ml胶体。主要结局是确定术前和术后血清乳酸值的差异，这可以合理预测导致灌注不足的液体缺乏情况。共分析了74例患者。PVI和PPV指导的GDFT策略在术后乳酸值方面均无显著差异，P值为0.18。同样，平均总液体输入量、平均失血量、CCU住院时间以及呕吐和低血压发作在各组之间也均无显著差异，P值分别为0.41、0.78、0.25、0.30和0.67。对于接受神经外科手术（幕上ICSOL）的患者，就组织灌注和术后并发症而言，PVI在指导GDFT方面似乎与PPV相当。然而，就GDFT而言，这两个参数的敏感性和特异性均较低，PPV的曲线下面积为0.577，PVI为0.423。
