| BackgroundColorectal cancer is one of the most common gastrointestinal cancers.With the aging of the population,the proportion of elderly is increasing.Laparoscopic colorectal cancer surgery is widely used because it can reduce postoperative pain,postoperative infection,hospitalization and 30-day mortality.But surgery may disrupt fluid balance,increase oxygen consumption,increase cardiac output and oxygen supply.In laparoscopic colorectal cancer surgery,on the one hand,artificial pneumoperitoneum increases the abdominal pressure,resulting in the redistribution of blood flow in abdominal organs and lower extremity veins,increased vascular resistance,and decreased indexed oxygen delivery(DOI).On the other hand,the increase of partial pressure of carbon dioxide stimulates the neuroendocrine system to release catecholamine,renin-angiotensin system and vasopressin,increases peripheral vascular resistance,inhibits myocardial strength and reduces cardiac output.Trendelenburg’s position during the operation will also cause the blood"redistribution",resulting in increased intracranial pressure.In the elderly patients,due to the decreased function of cardiovascular and cerebrovascular compensation,preoperative fasting,intestinal preparation and the influence of general anesthesia drugs during the operation,how to maintain perioperative fluid management with appropriate blood volume and oxygen supply becomes particularly important.In the past,monitoring heart rate,blood pressure,urine volume and central venous pressure were often used to guide liquid infusion.Now it is found that these indicators can’t reflect the change of blood volume correctly,and their reliability has been questioned.In recent years,goal-directed fluid therapy(GDFT)is considered to be the better predict fluid responsiveness.It has also been applied to enhanced recovery after surgery(ERAS).GDFT can help clinicians quantify the cardiac response,judge which part of Frank starling curve is in,and guide the application of liquid infusion or vasoactive drugs by monitoring dynamic parameters such as cardiac index(CI)and stroke volume variation(SVV).It can achieve optimal tissue perfusion and oxygen supply through individualized infusion treatment.Compared with the traditional infusion strategy,GDFT shortens first exhaust and eating time,reduces the time of hospitalization,reduces the incidence of postoperative complications and mortality,and improves the quality of prognosis significantly.However,in recent years,some meta-analysis found that GDFT could not reduce the time of hospitalization,postoperative complications,or improve postoperative outcomes.Therefore,the application value of GDFT in colorectal cancer surgery is still controversial.Incision healing,anti-infection and recovery of gastrointestinal function depend on tissue perfusion and oxygenation.Near infrared spectroscopy(NIRS)can continuously,real-time and noninvasively monitor regional tissue oxygen saturation(rSO2)by using light wave absorption ratio of oxyhemoglobin to total hemoglobin Compared with arterial oxygen partial pressure,pulse oxygen saturation,regional tissue oxygen saturation can reflect the changes of tissue perfusion and oxygenation earlier,so it can be used to evaluate the effect of liquid therapy.ObjectiveThe purpose of this study was to compare the changes of tissue oxygen saturation of upper and lower extremity,brain oxygen saturation and postoperative outcome,and to explore the influence factors of regional tissue oxygen saturation,monitoring significance and the value of GDFT,so as to provide references for clinical decision-making.MethodsThis study was approved by the hospital ethics committee and registered in Chinese clinical trial registry.From September 2017 to December 2018,80 patients aged 65-80 years who underwent laparoscopic colorectal cancer surgery in our hospital were selected.According to random number table,the subjects were divided into two groups:group G and group C.All patients were monitored for heart rate,blood pressure,bispectral index and body temperature.Midazolam,sufentanil,atracurium and etomidate were used to induce anesthesia.After tracheal intubation,volume controlled ventilation was used and BIS value of 40-60 maintained.FloTrac system was used to monitor continuous cardiac output.In group G,SVV and CI were used to guide the infusion.When SVV>was 13%,200ml hydroxyethyl starch was infused.When SVV<13%,CI was further observed.If CI<2,5L/min/min2,dobutamine was used.If CI is 2.5-4.0 L/min/min2,no treatment is given.If CI>4.0 L/min/min2,the infusion should be controlled and anesthesia should be deepened or vasoactive drugs should be applied.In group C,5-10ml/kg/h lactate ringer’s solution and hydroxethyl starch was administrated,and the ratio was 2:1.In group C,the urine volume was no less than 0.5ml/kg/h,and the change of heart rate and blood pressure was no more than 20%.Vasoactive drugs were used during the operation.NIRS was used to monitor rSO2 of brachioradialis,gastrocnemius and forehead.All three parts use 25mm probe.HR,MAP,CI,SVV and rSO2 were observed before anesthesia induction(T1),5 minutes after tracheal intubation(T2),5 minutes after pneumoperitoneum head down(T3),60 minutes after pneumoperitoneum head down(T4),120 minutes after pneumoperitoneum head down(T5),5 minutes after abdominal deflation(T6),and 5 minutes at the end of operation in the supine position(T7).Arterial blood gas analysis was performed at T1,T4 and T7.Lactate,pH,hemoglobin were recorded and DOI was calculated.Special personnel was assigned to record the exhaust time,eating time,hospitalization time,postoperative complications and renal function.Results1.A total of 74 patients were included in the study,37 in each group.There was no significant difference between the two groups in age,gender,body mass index,ASA classification,operation and disease type.No statistical difference was found in operation time,anesthesia time,infusion volume,urine volume and blood loss.But the amount of crystalloid in group G was significantly less than that in group C,and the amount of colloid was more than that in group C(P<0.05).The dosage and frequency of dobutamine in group G were higher than those in group C,and the dosage and frequency of noradrenaline were lower than those in group C(P<0.05).2.There was no significant difference in HR and MAP between the two groups.At the time points of T5,T6 and T7,SW of group G was lower than that of group C(P<0.05).CI value of group G was significantly higher than that of group C at the time points of T4-T7(P<0.05)3.There was no significant difference in cerebral rSO2 between the two groups.At the time points of T4-T7,rSO2 of upper and lower extremity in group G was significantly higher than that in group C(P<0.05).The Pearson correlation coefficient between the mean rSO2 of upper extremity and the mean CI was r=0.443,P=0.000;the coefficient of the mean rSO2 of lower extremity and the mean CI was r=0.304,P=0.008.4.There was no significant difference in pH,lactate and Hb between the two groups.At the time points of T4 and T7,DOI of group G was significantly higher than that of group C(P<0.05).5.There was no significant difference in the postoperative exhaust time,eating time and hospitalization time between the two groups.Although one patient in group C had a second operation due to anastomotic leakage,the incidence of complications between the two groups had no statical difference.Conclusions1.The results showed that goal-directed fluid therapy increased the oxygen saturation of upper and lower extremity,but had little effect on cerebral oxygen saturation.2.Regional tissue oxygen saturation has a certain correlation with cardiac index.3.In liquid therapy,the change of tissue oxygen saturation was earlier than that of mean arterial pressure and lactate.4.Compared with conventional infusion therapy,goal-directed fluid therapy has no significant advantage in the prognosis of laparoscopic colorectal cancer surgery for elderly patients. |
PDF Full Text Request