Objective: To preliminarily investigate the effect of intraoperative goal-directed fluid management (GDFM) on pulmonary function and oxygen dynamics in patients with severe burns. Methods: From February 2017 to May 2018, 30 patients admitted to Burn Department of our hospital with severe burns who met the criteria for inclusion and needed escharectomy and skin grafting were enrolled in this prospective randomized controlled trial. The patients were divided into group GDFM of 15 cases [14 males and 1 female, (45±14) years old] and conventional liquid management group of 15 cases [12 males and 3 females, (42±10) years old] according to the random number table. During escharectomy and skin grafting, volume of patients in group GDFM was managed according to the GDFM scheme, based on cardiac output index, stroke volume variation, stroke volume index, hemoglobin, central venous oxygen saturation (ScvO(2)), and other parameters; volume of patients in conventional liquid management group was managed according to clinical experience and conventional liquid management scheme, based on mean arterial pressure, central venous pressure, urine output, hemoglobin, and other parameters. At post operation hour (POH) 1, 6, 12, and 24, arterial and venous blood was collected from patients of the two groups to determine the levels of extravascular lung water index (ELWI), global end-diastolic volume index (GEDI), oxygenation index, ScvO(2), central venous-to-arterial blood carbon dioxide partial pressure difference (Pcv-aCO(2)), lactic acid, pH value, bicarbonate ion, and base excess routinely. Data were processed with Fisher's exact probability test, t test, analysis of variance for repeated measurement, and least significant difference test. Results: (1) The ELWI of patients in group GDFM was (4.3±1.1) mL/kg at POH 1, which was significantly lower than (6.5±3.6) mL/kg in conventional liquid management group (t=2.26, P<0.05). The ELWI levels of patients in group GDFM at POH 6, 12, and 24 were (6.8±2.2), (6.6±2.0), and (6.9±1.6) mL/kg, respectively, significantly higher than the level at POH 1 within the same group (P<0.01), and similar to (8.5±3.1), (7.8±2.3), and (8.0±3.5) mL/kg in conventional liquid management group (t=1.73, 1.53, 1.10, P>0.05). The GEDI levels between patients of the two groups were similar, and there was no significantly statistical difference between the two groups as a whole (treatment factor main effect F=2.35, time factor main effect F=0.44, interaction F=0.07, P>0.05). (2) The oxygenation index of patients in group GDFM was (350±78) mL/kg at POH 1, which was significantly higher than (259±109) mL/kg in conventional liquid management group (t=2.63, P<0.05). In conventional liquid management group, the oxygenation index of patients at POH 6 was significantly higher than that at POH 1, 12, or 24 (P<0.01). The ScvO(2) levels of patients in group GDFM at POH 1, 6, and 12 were 0.516±0.105, 0.679±0.121, and 0.713±0.104, respectively, which were significantly higher than 0.382±0.194, 0.545±0.194, and 0.595±0.191 in conventional liquid management group (t=2.35, 2.27, 2.10, P<0.05). The ScvO(2) levels of patients in the two groups at POH 6, 12, and 24 were significantly higher than those levels at POH 1 within the same group (P<0.01), and the ScvO(2) of patients in conventional liquid management group at POH 24 was significantly higher than that at POH 6 or 12 within the same group (P<0.05 or P<0.01). The Pcv-aCO(2) levels of patients in group GDFM were significantly lower than those in conventional liquid management group at POH 1 and 6 (t=2.55, 2.71, P<0.05). The Pcv-aCO(2) of patients in group GDFM at POH 12 was significantly lower than that at POH 6 or 24 within the same group (P<0.05). (3) The blood lactic acid levels and pH values between patients of the two groups were similar at POH 1, 6, 12, and 24 (t=0.89, 0.19, 0.26, 0.23; 1.55, 0.71, 0.77, 0.77, P>0.05). In conventional liquid management group, the blood lactic acid levels of patients at POH 6, 12, and 24 were significantly lower than the level at POH 1 within the same group (P<0.05), and the pH values of patients at POH 6, 12, and 24 were significantly higher than the value at POH 1 within the same group (P<0.05). The levels of bicarbonate ion and base excess between patients of the two groups were similar, and there were no significantly statistical differences between the two groups as a whole (treatment factor main effect F=0.06, 0.11, time factor main effect F=2.07, 1.59, interaction F=1.45, 0.91, P>0.05). Conclusions: GDFM is helpful to improve the pulmonary function and oxygen dynamics in patients with severe burns in the short term after escharectomy and skin grafting. It has certain significance in preventing and reducing pulmonary edema and pulmonary complications in patients with severe burn after operation.
目的： 初步探讨切痂植皮术中进行目标导向液体管理(GDFM)对严重烧伤患者术后肺功能和氧动力学的影响。 方法： 2017年2月—2018年5月，笔者单位烧伤科收治30例符合入选标准的严重烧伤且需进行切痂植皮手术的患者，纳入本前瞻性随机对照试验。采用随机数字表法将患者分为GDFM组15例(男14例、女1例)和常规液体管理组15例(男12例、女3例)，其年龄分别为(45±14)、(42±10)岁。切痂植皮术中，GDFM组患者按照GDFM方案，基于心排血指数、每搏输出量变异度、每搏输出量指数、血红蛋白、中心静脉血氧饱和度(ScvO(2))等参数进行容量管理；常规液体管理组患者按照临床经验和常规液体管理方案，基于平均动脉压、中心静脉压、尿量、血红蛋白等参数进行容量管理。术后1、6、12、24 h，采集2组患者动静脉血，常规检测血管外肺水指数(ELWI)、全心舒张末期容积指数(GEDI)、氧合指数、ScvO(2)、中心静脉－动脉血二氧化碳分压差(Pcv－aCO(2))、乳酸、pH值、碳酸氢根离子、碱剩余水平。对数据行Fisher确切概率法检验、t检验、重复测量方差分析和LSD检验。 结果： (1)GDFM组患者术后1 h的ELWI为(4.3±1.1)mL/kg，明显低于常规液体管理组的(6.5±3.6)mL/kg(t＝2.26，P<0.05)。GDFM组患者术后6、12、24 h的ELWI分别为(6.8±2.2 )、(6.6±2.0)、(6.9±1.6)mL/kg，均明显高于组内术后1 h(P<0.01)，且与常规液体管理组的(8.5±3.1)、(7.8±2.3)、(8.0±3.5)mL/kg相近(t＝1.73、1.53、1.10，P>0.05)。2组患者GEDI相近，总体比较差异无统计学意义(处理因素主效应F＝2.35，时间因素主效应F＝0.44，两者交互作用F＝0.07，P>0.05)。(2)GDFM组患者术后1 h的氧合指数为(350±78)mL/kg，明显高于常规液体管理组的(259±109)mL/kg(t＝2.63，P<0.05)。常规液体管理组患者术后6 h的氧合指数明显高于组内术后1、12、24 h(P<0.01)。GDFM组患者术后1、6、12 h的ScvO(2)分别为0.516±0.105、0.679±0.121、0.713±0.104，分别明显高于常规液体管理组的0.382±0.194、0.545±0.194、0.595±0.191(t＝2.35、2.27、2.10，P<0.05)。2组患者术后6、12、24 h的ScvO(2)水平均明显高于组内术后1 h(P<0.01)，常规液体管理组患者术后24 h的ScvO(2)明显高于组内术后6、12 h(P<0.05或P<0.01)。GDFM组患者术后1、6 h的Pcv－aCO(2)均明显低于常规液体管理组(t＝2.55、2.71，P<0.05)。GDFM组患者术后12 h的Pcv－aCO(2)明显低于组内术后6、24 h(P<0.05)。(3)2组患者术后1、6、12、24 h血乳酸水平、pH值均相近(t＝0.89、0.19、0.26、0.23，1.55、0.71、0.77、0.77，P>0.05)。常规液体管理组患者术后6、12、24 h的血乳酸水平明显低于组内术后1 h(P<0.05)，术后6、12、24 h的pH值明显高于组内术后1 h(P<0.05)。2组患者碳酸氢根离子、碱剩余水平相近，总体比较差异均无统计学意义(处理因素主效应F＝0.06、0.11，时间因素主效应F＝2.07、1.59，两者交互作用F＝1.45、0.91，P>0.05)。 结论： GDFM有助于改善严重烧伤患者切痂植皮术后短期的肺功能和氧动力学，对预防和减轻严重烧伤患者术后的肺水肿与肺部并发症具有一定意义。.
Keywords: Anesthesia; Burns; Goal-directed fluid management; Lactic acid; Lung function; Oxygen dynamics; Surgical procedures, operative.