【罂粟摘要】目标导向液体治疗与常规液体治疗在颅内动脉瘤夹闭术中的比较：一项前瞻性随机对照试验

目标导向液体治疗与常规液体治疗在颅内动脉瘤夹闭术中的比较：一项前瞻性随机对照试验

贵州医科大学       麻醉与心脏电生理课题组

翻译：潘志军       编辑：宋雨婷        审校：曹莹

背景:

动脉瘤性蛛网膜下腔出血后液体失衡较为常见，且对临床预后存在负面影响。我们比较了经食管超声心动图测量的左心室流出道速度时间积分（LVOT-VTI）导向的目标导向液体治疗（GDFT）与中心静脉压（CVP）导向的液体治疗在动脉瘤夹闭术中对动脉瘤性蛛网膜下腔出血患者的影响。

方法：

择期行颅内动脉瘤夹闭术的50例成人患者随机分为两组：G组（n= 25）接受LVOT-VTI导向的GDFT，C组（n= 25）接受CVP导向的液体管理。主要观察指标为术中平均动脉压（MAP）。次要观察指标包括给予的液体量和其他一些术中和术后变量，包括出院时和30天及90天时的神经功能结果。

结果：

尽管G组患者接受的液体量低于C组患者（分别为2503.6 ± 534.3比3732.8 ± 676.5 mL；P < 0.0001），但两组之间MAP无差异。心率和舒张压在两组之间具有可比性，而收缩压在多个术中时间点上G组高于C组。其他术中变量，包括失血量、尿量和乳酸水平在两组之间无差异。术后变量，包括肌酐、术后机械通气时间、重症监护室和住院时间以及急性肾损伤、肺炎和血管痉挛的发生率在两组之间具有可比性。两组之间在出院时（改良Rankin量表）、出院后30天以及出院后90天（扩展格拉斯哥结局评分）的神经功能结果无差异。

结论：

与CVP导向的液体治疗相比，经食管超声心动图导向的GDFT能够以较低的静脉液体量维持行颅内动脉瘤夹闭术患者的MAP，且不增加术后并发症。

原始文献来源：

Summit D. Bloria,Nidhi B. Panda, Nidhi B. Panda,et al.Goal-directed Fluid Therapy Versus Conventional Fluid Therapy During Craniotomy and Clipping of Cerebral Aneurysm: A Prospective Randomized Controlled Trial [J]. (J Neurosurg Anesthesiol. 2022 Oct 1;34(4):407-414.)

英文原文

Goal-directed Fluid Therapy Versus Conventional Fluid Therapy During Craniotomy and Clipping of Cerebral Aneurysm: A Prospective Randomized Controlled Trial           

Background: Fluid imbalance is common after aneurysmal subarachnoid hemorrhage and negatively impacts clinical outcomes.We compared intraoperative goal-directed fluid therapy (GDFT) using left ventricular outflow tract velocity time integral (LVOTVTI) measured by transesophageal echocardiography with central venous pressure (CVP)-guided fluid therapy during aneurysmclipping in aneurysmal subarachnoid hemorrhage patients.

Methods: Fifty adults scheduled for urgent craniotomy for aneurysm clipping were randomly allocated to 2 groups: group G (n= 25) received GDFT guided by LVOT-VTI and group C (n= 25) received CVP-guided fluid management. The primary outcome was intraoperative mean arterial pressure (MAP). Secondary outcomes included volume of fluid administered and several other intraoperative and postoperative variables, including neurological outcome at hospital discharge and at 30 and 90 days.

Results: There was no difference in MAP between the 2 groups despite patients in group G receiving lower volumes of fluid compared with patients in group C (2503.6±534.3 vs. 3732.8±676.5 mL, respectively; P< 0.0001). Heart rate and diastolic blood pressure were also comparable between groups, whereas systolic blood pressure was higher in group G than in group C at several intraoperative time points. Other intraoperative variables, including blood loss, urine output, and lactate levels were not different between the 2 groups. Postoperative variables, including creatinine, duration of postoperative mechanical ventilation, length of intensive care unit and hospital stay, and incidence of acute kidney injury, pneumonitis, and vasospasm were also comparable between groups. There was no difference in neurological outcome at hospital discharge (modified Rankin scale) and at 30 and 90 days (Extended Glasgow Outcome Scale) between the 2 groups.

Conclusion: Compared with CVP-guided fluid therapy, transesophageal echocardiography–guided GDFT maintains MAP  with lower volumes of intravenous fluid in patients undergoing clipping of intracranial aneurysms with no adverse impact on postoperative complications.