PICCO监测在非体外循环冠状动脉搭桥术中血流动力学管理的指导作用
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摘要
目的:探讨非体外循环冠状动脉旁路移植术中脉搏指示连续心排血量(PICCO)与中心静脉压(CVP)监测指导下的围术期液体管理疗效及对预后的影响。方法:采用前瞻性随机对照研究,严格按照纳入标准和排除标准选取我院2016年1月～2018年6月拟行非体外循环冠状动脉旁路移植术患者83例,动态随机分为CVP组与PICCO组,两组分别根据术中CVP与PICCO相关参数指导液体管理,所有患者从颈内静脉置入三腔中心静脉导管,CVP组患者从股动脉置入动脉导管,PICCO组患者的股动脉置入PICCO导管。CVP组在CVP监测目标8～12 cmH2O压力导向下进行液体管理;PICCO组在容量指标EVLWI 3～7 mL/kg、ITBVI 850～1 000 mL/m2导向下进行液体管理。分别检测2组术前(T0)、搭桥后1 h(T1)、术后0 h(T2)、6 h(T3)、12 h(T4)、24 h(T5)的乳酸及B型脑钠肽(BNP)水平、心率(HR)、平均动脉压和CVP,记录不同时间点PICCO组患者血流动力学参数,分别记录2组患者术后血管活性药物使用时间、机械通气时间、多器官功能障碍综合征(MODS)发生率、ICU住院天数。结果:两组患者一般情况包括性别、年龄、术前心率、血压、平均动脉压、乳酸、BNP值、CVP均无统计学差异;与CVP组比较,PICCO组患者T1、T2、T3、T4时间点乳酸和BNP水平及HR均显著降低(P<0. 05);PICCO组术后各时间点血流动力学参数均优于术前,差异有统计学意义(P<0. 05);术后两组MODS发生率无统计学差异,但PICCO组患者血管活性药物使用时间、ICU住院时间及机械通气时间明显短于CVP组(P<0. 05)。结论:非体外循环冠状动脉旁路移植术中PICCO监测指导液体管理及用药优于CVP监测,具有积极的临床指导价值。
Objective: To evaluate off-pump coronary artery bypass grafting(PICCO) or central venous pressure(CVP) monitoring in off-pump coronary artery bypass(OPCABG) surgery patients.Methods: The study was a randomized controlled trial(RCT) with group sequential analysis using an interval of 83 patients who underwent OPCABG surgery in our hospital from January 2016 to June 2018.In PICCO group, fluid management aiming to optimize the effective circulatory volume and vasoactive agents were used to achieve a mean arterial blood pressure of at least 60 mmHg. In control group, volume status was assessed by using CVP, aiming to maintain a CVP between 8 and 12 cmH2 O. Patients in control arm did not receive PICCO monitoring, but acentral venous catheter was routinely inserted. The primary end point were lactic acid and B-type brain natriuretic peptide(BNP)levels, heart rate(HR), mean arterial pressure, CVP and hemodynamic parameters of preoperative(T0), 1 h after CABG(T1) and 0 h(T2), 6 h(T3), 12 h(T4), 24 h(T5) after operation. Secondary study endpoints included the ICU length of stay, the duration of ventilatory support, incidence of multiple organ dysfunction syndrome(MODS).Results: There was no difference between PICCO and control groups in baseline characteristics included gender and age. There was no significant difference in preoperative HR, blood pressure, mean arterial pressure, lactic acid, BNP, and CVP between the two groups. The levels of lactic acid, BNP and HR at T1, T2, T3, and T4 in PICCO group were significantly decreased(P<0. 05). The hemodynamic parameters of PICCO group were better than those before sursery, and there were statistical differences between the two groups(P<0. 05). There was no statistical difference in the incidence of MODS between the two groups after surgery, but the duration of vasoactive drugs, ICU hospitalization and mechanical ventilation in PICCO group were significantly shorter than those in CVP group(P<0. 05).Conclusion: PICCO-based fluid management could improve outcome when compared with CVP-based fluid management in peri-operation of OPCABG.
Objective: To evaluate off-pump coronary artery bypass grafting(PICCO) or central venous pressure(CVP) monitoring in off-pump coronary artery bypass(OPCABG) surgery patients.Methods: The study was a randomized controlled trial(RCT) with group sequential analysis using an interval of 83 patients who underwent OPCABG surgery in our hospital from January 2016 to June 2018.In PICCO group, fluid management aiming to optimize the effective circulatory volume and vasoactive agents were used to achieve a mean arterial blood pressure of at least 60 mmHg. In control group, volume status was assessed by using CVP, aiming to maintain a CVP between 8 and 12 cmH2 O. Patients in control arm did not receive PICCO monitoring, but acentral venous catheter was routinely inserted. The primary end point were lactic acid and B-type brain natriuretic peptide(BNP)levels, heart rate(HR), mean arterial pressure, CVP and hemodynamic parameters of preoperative(T0), 1 h after CABG(T1) and 0 h(T2), 6 h(T3), 12 h(T4), 24 h(T5) after operation. Secondary study endpoints included the ICU length of stay, the duration of ventilatory support, incidence of multiple organ dysfunction syndrome(MODS).Results: There was no difference between PICCO and control groups in baseline characteristics included gender and age. There was no significant difference in preoperative HR, blood pressure, mean arterial pressure, lactic acid, BNP, and CVP between the two groups. The levels of lactic acid, BNP and HR at T1, T2, T3, and T4 in PICCO group were significantly decreased(P<0. 05). The hemodynamic parameters of PICCO group were better than those before sursery, and there were statistical differences between the two groups(P<0. 05). There was no statistical difference in the incidence of MODS between the two groups after surgery, but the duration of vasoactive drugs, ICU hospitalization and mechanical ventilation in PICCO group were significantly shorter than those in CVP group(P<0. 05).Conclusion: PICCO-based fluid management could improve outcome when compared with CVP-based fluid management in peri-operation of OPCABG.
引文
[1] Kumada Y, Ishii H, Aoyama T, et al. Long-term clinical outcomes after coronary artery bypass graft versus everolimus-eluting stent implantation in chronic hemodialysis patients[J]. Coron Artery Dis, 2018, 29(6):489-494.
[2] Souto Moura T, Aguiar Rosa S, Germano N, et al.The accuracy of PiCCO?in measuring cardiac output in patients under therapeutic hypothermia:Comparison with transthoracic echocardiography[J]. Med Intensiva, 2018,42(2):92-98.
[3] Buggeskov KB. Pulmonary artery perfusion versus no pulmonary per-fusion during cardiopulmonary bypass[J]. Dan Med J, 2018,65(3):pii:B5473.
[4] Munos E, Calderon J, Pillois X, et al. Beating-heart coronary artery bypass surgery with the help of mini extracorporeal circulation for very high-risk patients[J].Perfusion, 2011,26(2):123-131.
[5] Borde DP, Asegaonkar B, Apsingekar P, et al. Influence of time interval between coronary angiography to off-pump coronary artery bypass surgery on incidence of cardiac surgery associated acute kidney injury[J]. Indian J Anaesth, 2019,63(6):475-484.
[6] Song Z, Shen L, Zheng Z, et al. One-stop hybrid coronary revascularization versus off-pump coronary artery bypass in patients with diabetes mellitus[J]. J Thorac Cardiovasc Surg, 2016,151(6):1 695-1 701. e1.
[7] Zhang Q, Zhou D, Zeng X. Highly wearable cuff-less blood pressure and heart rate monitoring with singlearm electrocardiogram and photoplethysmogram signals[J]. Biomed Eng Online, 2017,16(1):23.
[8] Yang L, Sun DF, Han J, et al. Effects of intraoperative hemodynamics on incidence of postoperative delirium in elderly patients:a retrospective study[J]. Med Sci Monit, 2016,22:1 093-1 100.
[9] Breukers RM, Trof RJ, de Wilde RB, et al. Relative value of pressures and volumes in assessing fluid responsiveness after valvular and coronary artery surgery[J].Eur J Cardiothorac Surg, 2009,35(1):62-68.
[10] Donadio C, Bozzoli L, Colombini E, et al. Effective and timely evaluation of pulmonary congestion:qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients[J]. Medicine(Baltimore), 2015,94(6):e473.
[11] Gupta HV, Finlay CW, Jacob S, et al. Can admission bnp level predict outcome after intravenous thrombolysis in acute ischemic stroke[J]? Neurologist, 2019, 24(1):6-9.
[12] Reynolds T, Cecconi M, Collinson P, et al. Raised serum cardiac troponinⅠconcentrations predict hospital mortality in intensive care unit patients[J]. Br J Anaesth, 2012,109(2):219-224.
[2] Souto Moura T, Aguiar Rosa S, Germano N, et al.The accuracy of PiCCO?in measuring cardiac output in patients under therapeutic hypothermia:Comparison with transthoracic echocardiography[J]. Med Intensiva, 2018,42(2):92-98.
[3] Buggeskov KB. Pulmonary artery perfusion versus no pulmonary per-fusion during cardiopulmonary bypass[J]. Dan Med J, 2018,65(3):pii:B5473.
[4] Munos E, Calderon J, Pillois X, et al. Beating-heart coronary artery bypass surgery with the help of mini extracorporeal circulation for very high-risk patients[J].Perfusion, 2011,26(2):123-131.
[5] Borde DP, Asegaonkar B, Apsingekar P, et al. Influence of time interval between coronary angiography to off-pump coronary artery bypass surgery on incidence of cardiac surgery associated acute kidney injury[J]. Indian J Anaesth, 2019,63(6):475-484.
[6] Song Z, Shen L, Zheng Z, et al. One-stop hybrid coronary revascularization versus off-pump coronary artery bypass in patients with diabetes mellitus[J]. J Thorac Cardiovasc Surg, 2016,151(6):1 695-1 701. e1.
[7] Zhang Q, Zhou D, Zeng X. Highly wearable cuff-less blood pressure and heart rate monitoring with singlearm electrocardiogram and photoplethysmogram signals[J]. Biomed Eng Online, 2017,16(1):23.
[8] Yang L, Sun DF, Han J, et al. Effects of intraoperative hemodynamics on incidence of postoperative delirium in elderly patients:a retrospective study[J]. Med Sci Monit, 2016,22:1 093-1 100.
[9] Breukers RM, Trof RJ, de Wilde RB, et al. Relative value of pressures and volumes in assessing fluid responsiveness after valvular and coronary artery surgery[J].Eur J Cardiothorac Surg, 2009,35(1):62-68.
[10] Donadio C, Bozzoli L, Colombini E, et al. Effective and timely evaluation of pulmonary congestion:qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients[J]. Medicine(Baltimore), 2015,94(6):e473.
[11] Gupta HV, Finlay CW, Jacob S, et al. Can admission bnp level predict outcome after intravenous thrombolysis in acute ischemic stroke[J]? Neurologist, 2019, 24(1):6-9.
[12] Reynolds T, Cecconi M, Collinson P, et al. Raised serum cardiac troponinⅠconcentrations predict hospital mortality in intensive care unit patients[J]. Br J Anaesth, 2012,109(2):219-224.