The Treatment Of Goal Directed Fluid Therapy By Oesophageal Doppler Monitor In Craniotomy Hematoma Removal Surgery

ObjectiveHypertensive intracerebral hemorrhage（HICH）, a common disease of neurosurgery, is a high incidence, high morbidity and high mortality global disease. which probably accounted for about 75% of the spontaneous cerebral hemorrhage. The patients always had high intracranial pressure, partly due to the relatively increased cranial content following cerebral hemorrhage, on the other hand also due to "sympathetic storm" effect, during which process various reasons lead to a large number of catecholamine hormone release. It can make the peripheral vascular contraction, increasing of the systemic vascular resistance, cardiac output and blood pressure, leading to increased intracranial pressure. At present, the common treatment for hypertensive intracerebral hemorrhage is removal of hematoma craniotomy.when opening the dura, intracranial pressure decreases significantly, often leading to reducing in peripheral vascular resistance, dropping in blood pressure, and decreasing in blood flow of the brain.At the same time, for the hypertensive intracerebral hemorrhage patients, the damaged area and the surrounding brain tissue is hard to avoid some degrees of mechanical and anoxic injury; Combined with preoperative fasting, long time dehydration treatment and operation time and so on, in the event of high or low blood pressure, it can cause different degree of brain edema, ischemia and necrosis, even nerve cells energy metabolism disorder. In neurosurgery we often advocated restrictive fluid therapy in order to avoid the occurrence of postoperative brain edema, but it can decrease the blood pressure, lead to tissue hypoperfusion, insufficient cerebral oxygen supply, and also slow tissue healing. At the same time, it may increase the incidence of intracranial infection, pulmonary infection and other complications, go against the recovery of patients; While open infusion solution avoids the insufficient of capacity, but leads to high risk of intraoperative and postoperative brain edema. As a result,perioperative correct capacity treatment can maintain effective circulating blood volume and cerebral perfusion pressure. It,s of great significance in reduce mortality and strengthen the postoperative recovery of neurological function.Goal directed fluid therapy is a volume treatment which based on the patient’s age, weight, preoperative general situation, volume status and complications and so on, adopted accurate, real-time and continuous monitoring, and under the guidance of feedback information to conduct the individualized fluid therapy. Goal-directed fluid therapy has been shown quite effective in critically ill disease, such as Meningioma surgery and Glioma surgery. At present, we have so many monitoring methods of goal-directed fluid therapy, such as Flotrac-Veigileo, PiCCO, which have some shortcomings. while the noninvasive hemodynamic monitoring of the Oesophageal Doppler Monitor has a lot of advantages such as small trauma, simple operation, low cost, high safety, comprehensive monitoring indicators, and so on. At the same time, the clinical research about the application of the monitoris in neurosurgery havn,t seen yet.This project is to explore the effectiveness and safety of the application of Oesophageal Doppler Monitor in patients with severe hypertensive intracerebral hemorrhage. It can monitor correction of blood flow of time（FLTc）, stroke volume（SV） and systemic vascular resistance（SVR） and so on. We used the FLTc and SV as the guidance of Liquid infusion and then recorded the intraoperative hemodynamic parameters in different time points, selected crystal liquid or colloid according to the hemodynamic changes in order to maintain hemodynamics stable and improve the prognosis of patients. MethodsSelected 40 patients of hypertensive intracerebral hemorrhage from January 2015 to December 2015 who needed emergency neurosurgery operation, 40⁷0 years old, 50⁸0 kg, ASA Ⅰor Ⅲdegree, operation time 2.5⁴ hours,taking supine or lateral position for the procedure. Exclusion criteria included serious heart and lung disease, liver, kidney and blood coagulation dysfunction, esophageal stricture, tumor, varicose veins, and history of esophageal surgery.Patients were randomly divided into two groups: conventional liquid treatment group（group C, 30 cases）, and goal-directed fluid therapy group（group G, 50 cases）. Among the Group G, we also randomly divided them into two groups according to the change of SVR, Group G1（Dopanine） and Group G2（Norpinephrine）. Compensatory volume expansion with succinyl gelatin 7ml/kg was inflused before induction of anesthesia.The fluid replacement regime in group C included five parts: physiological requirements, continued loss（4-2-1 rule）, extra supplement amount（5 ml/kg）,compensatory volume expansion and cumulative loss, maintaining MAP60 110 mmHg, CVP6¹2 cmH2O; Patients in group G were infused according to the indicator of FTc and SV in the Oesophageal Doppler Monitor,maintaining FLTc 0.35s⁰.4s.When FLTc is less than 0.35 s,suggesting possiblely capacity lack, give patients 200 ml succinyl gelatin injection in 15 mins. After FLTc is more than 0.4s, to maintain the current status, slow down the rehydration. When FLTc was less than 0.35 s or SV declined more than 10%, with the above plan to continue rehydration. When it is necessary, choosing some appropriate vascular active drugs to maintain the hemodynamics stable. At the same time, when SVR was sharply decreased, Group G1（dopamine） began with 5μg·kg-1·min-1,increasing every 2 mins, no more than 15μg·kg-1·min-1; Group G2（norepinephrine） also began with 0.05μg·kg-1·min-1, increasing every 2 mins, no more than 0.15μg·kg-1·min-1.When systemic vascular resistance increased to the appropriate levels,comparison of the dosage and duration of two drugs.All patients adopted general anesthesia. After they went into the operation room, opening venous pathway, and monitoring of blood pressure, heart rate, blood oxygen saturation and so on. A central venous catheter was inserted into the right internal jugular vein and a radial artery catherter was inserted into the radial artery under local anesthesia. Anesthesia induction with midazolam 0.05mg/kg,sufentanil 0.4μg/kg, cisatracuronium 0.2mg/kg and propofol 2mg/kg.After tracheal intubation, set ventilation parameters for: VT 6⁸ml/kg, RR 12¹5 times/min, oxygen concentration 70%. After anesthesia induction, placing the esophageal doppler ultrasound probe, the depth of the adult generally is 30-35 cm, adjust to the appropriate location and fixed it. Anesthesia maintenance was achieved by propofol 4⁶mg·kg-1·h-1, ruifentanyl 0.1⁰.3μg·kg-1·min-1, sevoflurane 1³%, PETC02 was maintained from 30 to 33 mmHg.Narcotrend was maintained E0 to E1 during anesthesia. Stop sevoflurane inhalation 15 min before the end of surgery and stop the infusion of propofol and ruifentanyl at the end of surgery.Collecting the basic information of the patients, such as gender, age, height, weight, BMI,etc. The hemodynamic indexes and tissue perfusion index were also recorded before induction of anesthesia（T0, baseline）, open the skull flap instantly（T1）, open dura instantly（T2）,0.5h after open the dura（T3）,the end of operation（T4）, 12 hours after operation（T5） and 24 hours after operation（T6）; Recording the amount of liquid, blood loss, urine volume and postoperative hospital stay and other indicators of all patients; At the same time, recording the number of patients whose systemic vascular resistance was obviously decreased due to opening the dura. When systemic vascular resistance increased to the appropriate levels,comparison of the dosage and duration of the equivalent dose of two drugs. ResultsThe general information of two groups had no statistical significance（p > 0.05）; Compared with group C, group G intraoperative intravenous transfusion volume decreased significantly, but the colloid increased（P < 0.05）, intraoperative and postoperative hemodynamic more stable; 0.5h after open the dura, the end of operation,12 hours after operation the ScvO₂ levels of group G was obviously higher than that of group C（P < 0.05）; the end of operation and 12 hours after operation the level of Lac of group G was lower than that of group C（P < 0.05）; The postoperative hospital stay and intracranial infection, pulmonary infection had no obvious difference（P > 0.05）, but the incidence of cerebral edema in group G was much lower（P < 0.05）;Compared with dopamine, the equivalent dose of norepinephrine needed shorter time and less dosage（P < 0.05）. Conclusions :1.The Oesophageal Doppler Monitor guided goal directed fluid therapy can make hypertensive intracerebral hemorrhage patients stable hemodynamics, better tissue perfusion, and lower incidence of complacations, improve the prognosis of patients;2.In our study, norepinephrine had better effect than that of dopamine in improving vascular peripheral resistance.