Application Of Different Infusion Strategies Combined With Low Central Venous Pressure Technique In Hepatectomy Comparison Of Clinical Effects

Objective（s）:To compare the clinical effects of different intraoperative infusion strategies combined with controlled low central venous pressure（CLCVP）in hepatectomy.Methods:96 patients who were scheduled to undergo hepatectomy from October 2022 to January 2023 were randomly divided into three groups according to different infusion strategies during operation:1m L/（kg·h）+SVV>13%group（Group A,n=32）,1m L/（kg·h）+SV<60m L group（Group B,n=32）and 3m L/（kg·h）group（Group C,n=32）.During the period from the patient entering the operating room and opening the peripheral vein to the complete disconnection of the liver parenchyma,group A received volume treatment with Ringer’s acetate solution at a constant speed of 1m L/（kg·h）.When the cardiac output monitoring showed that SVV was more than13%and more than 3min,100 m L of liquid impact treatment was given in the central venous catheter each time until SVV was less than 13%,and the number of liquid impact was recorded;Group B received volume treatment with Ringer’s solution of acetic acid at a constant speed of 1m L/（kg·h）.When the cardiac output monitoring showed that SV was less than 60m L for more than 3min,100 m L of liquid impact treatment was given in the central venous catheter each time until SV was more than60m L,and the number of liquid impact was recorded;Group C received volume treatment with Ringer’s solution of acetic acid at a constant speed of 3m L/（kg·h）,without liquid impact treatment.Since the induction of anesthesia,the patients in the three groups have always maintained the mean arterial pressure（MAP）≥70mm Hg.If（MAP）<70mm Hg,pump norepinephrine（NA）,and the initial dose is 0.05μG/（kg·min）,adjust the NA dose according to the patient’s condition,and record the amount of NA used.If the central venous pressure（CVP）of patients in three groups is higher than 5cm H2O during hepatectomy,add nitroglycerin to pump continuously,and the initial dose is 0.2μg/（kg·min）,and then Adjust the speed of 0.1μg/（kg·min）and record the usage of nitroglycerin.After the liver parenchyma was severed,liquid resuscitation was given immediately until the CVP reached the preoperative base value or≥8cm H2O.Record the patient’s height,weight,basic disease and other basic conditions.Observation indexes:（1）hemodynamics:CVP,MAP,SV and systemic vascular resistance（SVR）were recorded at 6 time points before anesthesia induction（T₀）,the beginning of surgery（T₁）,the beginning of hepatectomy（T₂）,the complete disconnection of liver parenchyma（T₃）,the completion of fluid resuscitation（T₄）,and the exit of the operating room（T₅）;（2）Take arterial blood and central venous blood at T₀,T₃and T₄for blood gas analysis,record lactic acid value and central venous oxygen saturation(S_CVO₂);（3）Record the intraoperative conditions such as the number of fluid impact treatment,the number of hilar block,the duration of hilar block,the scope of hepatectomy,the amount of intraoperative hemorrhage,the amount of intraoperative infusion,the amount of urine,the classification of surgical field of vision,and the duration of operation;（4）Record the dosage and maximum dosage of NA and the dosage of nitroglycerin after operation;（5）Record and track liver function[aspartate aminotransferase（AST）,glutamic acid aminotransferase（ALT）],renal function[creatinine（Crea）]index,myocardial injury marker[high-sensitivity troponin（hs-TNT）]before and after operation;（6）Record the length of admission to the intensive care unit（ICU）and the number of days in hospital;（7）Postoperative complications[atelectasis（imaging）,pulmonary infection（imaging）,new liver,kidney,cardiac insufficiency,death 30 days after operation].Results:（1）Four patients changed the operation mode after intraoperative exploration and obtaining intraoperative freezing results,and two patients were removed due to massive hemorrhage.Finally,a total of 90 patients completed the study.There was no statistically significant difference in the age,height,weight,basic disease and other basic conditions among the three groups（P>0.05）;（2）Perianesthesia hemodynamic indexes:At T₄,SV of group A was lower than that of group B and group C（P<0.05）.At T₅,SV of group A was lower than that of group B（P<0.05）.At T₄and T₅,SVR of group A was higher than that of group C（P<0.05）;（3）Blood gas results:The lactic acid at T₃was significantly higher than that at T₀and T₄,and the difference was statistically significant（P<0.05）.S_CVO₂at T₃and T₄was significantly higher than central venous oxygen saturation（Scv O₂）at T₀（P<0.01）;There was no significant difference between the three groups in lactic acid and central venous oxygen saturation（P>0.05）;（4）Frequency of liquid impact treatment:the frequency of liquid impact treatment in Group C was less than that in Group A and Group B（P<0.05）.There was no statistically significant difference between the three groups in the amount of intraoperative bleeding,visual field grading,urine volume,the number of hepatic hilus occlusion,the duration of hepatic hilus occlusion and the duration of operation（P>0.05）;（5）There was no statistically significant difference in the use of vasoactive drugs（norepinephrine and nitroglycerin）among the three groups（P>0.05）;（6）Liver and kidney function and myocardial injury markers:ALT and AST in group C were higher than those in group A on the first day after operation,with statistically significant difference（P<0.05）.There was no significant difference in renal function and myocardial injury markers among the three groups（P>0.05）;（7）There was no statistically significant difference in the length of ICU and the length of hospitalization among the three groups（P>0.05）.（8）The postoperative complications[atelectasis（imaging）,pulmonary infection（imaging）,new liver,kidney,cardiac insufficiency,and death 30 days after operation]of the three groups were not statistically significant.Conclusion:The three infusion strategies,guided by the combination of1m L/（kg·h）of crystalloid solution+stroke volume variability>13%,1m L/k（kg·h）of crystalloid solution+stroke volume<60m L,and 3m L/（kg·h）of crystalloid solution with controlled low central venous pressure,showed similar results in reducing intraoperative bleeding and grading intraoperative visual field;The infusion strategy guided by a combination of 1m L/（kg·h）of crystalloid solution and a stroke volume variability greater than 13%,combined with controlled low central venous pressure,has a smaller impact on liver function on the first day after surgery compared to the traditional strategy of only 3m L/（kg·h）of crystalloid solution with low central venous pressure.