| Backgroud:Liquid therapy always is the main issue of debate during the perioperative of the neurosurgery. Appropriate fluid therapy can significantly improve patient’s organ function and prognosis in perioperative period. The operation of brain tumor resection not only cost time, it causes a certain degree of damage for nerve cell metabolism and the brain tissues. And the process of operation can cause varying degrees of mechanical damage, ischemia and hypoxia for the brain tissue near the tumor. Because of fasting, mannitol infusion, restriction of fluid intake can cause relatively insufficient of effective circulating volume, leading to hypotension, cerebral low perfusion, even ischemia and hypoxia damage of cerebral tissue. Yet, there may cause varying degrees of edema, and even the disorder of cells energy metabolism owing to increasing the amount of fluid infusion in order to maintain the stability of hemodynamics. Both the two methods are not conducive to the prognosis of patients. If the liquid infusion is appropriate during the surgery, it not only can maintain hemodynamic stability and ensure cerebral perfusion, there is a great significance reduction the incidence of postoperative complications and protect the nervous function of patients. There has been controversy about liquid therapy on brain surgery for many years:restricting intraoperative transfusion may reduce the incidence of cerebral edema during the surgery. However, excessive fluid restriction may lead to insufficient effective circulating blood volume and hemodynamics instability, and cause poor prognosis of the patients. To pursuit the stable hemodynamics and transfusion blindly can lead to fluid overload and brain tissue edema. Perioperative volume therapy, in addition to guarantee the stability of circulation, is more attend to individual infusion therapy. It focus more attention on improving microcirculation, to ensure that the brain and other vital organs oxygen supply and avoid shortage, and thus reduced postoperative complications. Recently, studies have indicated that Goal-Directed Fluid Therapy (GDFT) can reduce postoperative complications, accelerate the recovery of patients, shorten the hospital stay and reduce the cost of hospitalization. And it has been gradually used to guide perioperative transfusion, such as abdominal surgery, craniotomy and thoracic surgery. With clinical monitoring technology updating continuously, a new minimally invasive cardiac output monitoring technology, namely Flotrac/Vigileo system is gradually being application in clinic, and achieved positive results. This monitoring system obtained stroke volume (SV) through patient’s age, gender, height, weight and body surface area (BSA), and further calculating cardiac output (CO) and other hemodynamic parameters. So it provides a possibility method for individualized infusion therapy in perioperative period. Using GDFT to guide transfusion can ensure circulation blood volume, the body oxygen supply and organ perfusion during perioperative, which is great significance for protecting organ functions and reducing postoperative complications.GDFT is a new idea of current volume treatment. This "titration" infusion strategy si according to the different pathological and physiological conditions of the patients, Thus carrying the individual infusion treatment. To provide a suitable individualized fluid therapy for patients of supratentorial tumor resection, this study use Flotrac/Vigileo system monitoring hemodynamics changes continuously on supratentorial tumor resection in Neurosurgery in the supine position, Combined with central venous oxygen saturation (SjvCh), blood lactic acid (Lac), etc, to analyze the feasibility of GDFT and its effect on postoperative rehabilitation from preload heart function and microcirculation.Material and MethodMaterialIn this study, we selected 30 cases with supratentorial tumor resection in supine position during the period from March 2015 to December 2015. Approved by the Hospital Medical Ethics Committee. The chosen cases’age ranging from 18 to 60, American Society of anesthesiologists I or II degree. The patients’hemoglobin (Hb) should not less than 9 g/L, with hematocrit (Hct) not less than 30%. Without coagulation abnormalities, no other major organ disorders, the Glasgow score were 15 points. Cardiac insufficiency, arrhythmia and severe liver and renal insufficiency were excluded. Carotid artery plaque, puncture site or near the presence of infection and complicated with mental disorders were also excluded. The patients were randomly divided into two groups (group G,15 cases) and control group (group C,15 cases), and signed informed consent, central venous anesthesia and jugular bulb catheter consent before surgery. All patients received the same anesthesia.Anesthesia methodAll patients of the two groups fasted for 12 hours, forbidden to drink 8 hours before anesthesia. Routine monitoring were taken after patients arrived at the operation room:noninvasive blood pressure (NIBP), electrocardiogram (ECG) and pulse oxygen saturation(SpO2), provided oxygen through mask and oxygen flow 5 L. Pre-anesthetic drugs were given from peripheral venous access 30mins before the induction. And drugs included midazolume 0.05 mg/kg, Penehyclidine hydrochloride 0.01 mg/kg Dezocine 0.1 mg/kg, flurbiprofen injection 0.1 mg/kg were used to comfort the patient. With the ultrasound guidance, a central venous catheter was inserted into the right internal jugular vein. A catheter was inserted into the right radial artery and linked to the Flotrac/Vigileo system, monitoring the patients hemodynamics parameters continuously such as stroke volume variation (SVV), cardiac index (CI), stroke volume index (SVI). A single lumen venous catheter was inserted into the jugular bulb on surgical side for blood drawing. General anesthesia induction was under the TCI control:propofol 3-3.5 μg/ml, remifentanil 2-6 ng/ml. After the patient lost consciousness, cisatracuronium 0.2mg/kg was injected. Then inserted a tracheal catheter into the trachea 3mins after cisatracuronium. Connected the anesthesia machine for volume control ventilation: tidal volume (8～10 ml/kg), respiratory rate (10～15 bpm), respiratory ratio 1:2, fraction of inspired oxygen 40%, fresh gas flow 1 L/min, and PETCO2 maintained at about 30～40 mmHg during the anesthesia period. Anesthesia maintenance drugs included propofol 2.5～3.5 μg·ml-1 and remifentanil 2～6 ng/ml through TCI, and cisatracuronium 2 μg·kg-1·min-1. Bispectral index was maintained 40～55 during the surgery.Surgical interventionThe group G:compensatory volume expansion (CVE) was injected before the operation. Lactate Ringers solution injection was infused as a background at a speed of 5 ml·kg-1·h-1 during the period of surgery. We use the SW, CI and SjvO2 as guide parameters of GDFT, based on normal blood pressure and heart rate, use of the VE, dobutamine, vasoactive drugs to achieve SVV≤13%, CI≥ 2.5 L·min-1·m-2 and SjvO2 ≥ 55%. If SVV> 13%, then a total of 250 ml HES was infused in 15mins till SVV≤ 13%. If SVV≤ 13%, then assess the CI and SjvO2 using dobutamine to maintain CI not less than 2.5 L·min-1·m-2 and SjvO2 moer then 55%.The group C:the total amount of infusion= compensatory volume expansion (CVE)+physiological requirement+continued loss+the cumulative loss+add extra weight. Tthe CVE injection before the operation as the way of group G Physiological requirement supplement follows the 4-2-1 rule, extra supplement amount 4 ml/kg, compensatory volume expansion and cumulative loss was replaced by 6% hydroxyethyl starch 130/0.4 (Voluven(?), Fresenius Kabi, Louviers, France).Parameters were given up when arrhythmia occurred. Warm the patients after the induction of anesthesia use the warm air machine to make the nasopharyngeal temperature between 35 ℃～36℃.Monitoring1. Time points include:before induction of anesthesia (T0),3mins after intubation (T1), skin incision (T2), separate tumor (T3), resection of tumor (T4), end of the surgery (T).2. The indexes of circulating blood volume:recording the hemodynamic parameters SVV, CI, SVI,HR, MAP by Flotrac/Vigileo system throughout the surgery.3. The indexes of tissue perfusion:blood samples were taken from jugular bulb and artery for blood gas analysis at the time points of To, T1, T2, T3; T4, T5 and to monitor the plasma glucose, jv-aLac, Pcv-aCO2 and SjvO2, and to calculate the DO2I and CER O2, GluER, LacPR.4 The indexes of postoperative rehabilitation:recorded postoperative complications, postoperative hospitalization time, using the US. National Institutes of Health Stroke Scale (NIHSS) assessing neural function of patients on one day before the operation and 24h after operation and at discharge, to evaluate the postoperative early survival quality.Statistcal analysisUsing SPSS 19.0 statistical software to analyze all data, The enumeration data was compared by x2 test. Measurement date are express as mean ± standard deviations (mean ± SD), the data must progress homogeneity of variance test at first. Groups within the different time points were analyzed with analysis of variance for repeated measurements. Multiple comparisons use the way of LSD, the comparison between the two groups at the same time point use two sample t test. Categorical dates were tested with Fisher’s exact test. The level of test is bilateral α= 0.05. Differences were considered significanly at P< 0.05.Results1. General informationIn this study, we monitored the circulating blood volume in 30 patients. One patient of GDFT group quit the study, because appear severe arrhythmia which can interference the data acquisition. Two patient of control group were quit, one of them appear severe arrhythmia which can interference the data acquisition. Another due to intracranial hemorrhage underwent secondary surgery. The remaining 27 patients were successfully completed operation. Group G of input crystal volume was significantly lower and input colloid was Statistcally higher than that of group C (P< 0.05). Other clinical data showed no significant differences (P> 0.05).2. hemodynamics parameters2.1 CI was different at all intervals in both groups (P< 0.05). In group G, the T3-T6 were significant lower than T1 (P< 0.05). In group C, T3, T5, T6 were significant lower than T1. No significant differences were found between two groups CP>0.05).2.2 The SVI were lower in T4-T6 when compared to T1 in both two groups (P< 0.05). SVI at T3 of group G was higher than that of the group C(P< 0.05), There were no significant differences between the two groups at other time points (P> 0.05).2.3 Both two groups’HR decreased after induction till the end of surgery. When compared to T1,it significant lower at T3-T6 in both two groups (P< 0.05). There was no significant difference between the two groups. (P> 0.05).2.4 Both two groups’MAP decreased slightly after induction(T2), then increased slightly at T3.When compared to T1,it significant lower at T4～T6 in both two groups (P< 0.05). There was no significant difference between the two groups. (P> 0.05).3 Cerebral circulation parameters3.1 Comparison of SjvO2 between two groups:The SjvO2 was significant lower at T3-T6 when compared to T1 in both group G and group C (P< 0.05). There was no significant difference between the two groups. (P> 0.05).3.2 Comparison of Pjv-aCO2 between two groups:The Pjv-aCO2 was significant higher at T3-T6 than T1 in both group G and group C (P< 0.05). There was no significant difference between the two groups.(P> 0.05).3.3 Comparison of a-jvpH between two groups:The a-jvpH was significant higher at T2～T6 than T1 in both group G and group C (P< 0.05). a-jvpH was significantly lower in group G atT3 (P< 0.05).3.4 Comparison of CERO2 between two groups:Compared with T1, CERO2 was significantly higher in both group G and group C at T2-T6 (P< 0.05). There were no differences between two groups in CERO2 (P> 0.05).3.5 Comparison of CERGlu between two groups:Compared with T1, GluPR was significantly higher in both group G and group C at T2(P< 0.05). Other time points were no statistical difference compared to T1. There were no differences between two groups in CERO2 (P> 0.05).3.6 Comparison of jvLac between two groups:There were statistical differences on jvLac in both two groups at all intervals. jvLac was significant higher at T5 compared to T1 in group G (P< 0.05). jvLac was significant higher at T4-T6 compared to T1in group C (P< 0.05). though no statistical differences were found between two groups, jvLac was lower in group G than groupC.3.7 Comparison of LacPR between two groups:There was no significant difference in LacPR in both two groups (P> 0.05). The LacPR of group G was slightly lower than the group C, but the difference was not statistically significant (P > 0.05).3.8 Comparison of LOI between two groups:The LOI of group G was higher at T2 compared to Ti (P< 0.05); and the LOIat T2, T3 was higher than Ti in group C (P < 0.05), the other time points were not significantly different compared to Ti (P> 0.05). LOI of group G was slightly lower than the group C, but the difference was not statistically significant (P> 0.05).4 Complication of two groupsThere were no statistically significant of incidence on dizziness and headache, Nausea and vomiting, dysphoria between two groups (P> 0.05).5 Postoperative rehabilitation and neurological function scores of two groupsThere were no statistically significant on intensive care unit stay, postoperative hospital days, time to start to eat between two groups (P> 0.05). But the NIHSS score of group G at 24h postoperative was significantly lower than that of the group C (P< 0.05). The NIHSS scores of the two groups were significantly higher than that before operation in both groups (P< 0.05), but the scoers were no statistical difference between the two groups when discharge time (P> 0.05).Conclusion1 The GDFT which guided with the SVV, CI and SjvO2 can keep the effective circulatory volume, Avoid large amounts of crystals, and has no obvious effect on SjvO2. At the same time, it do not increase the risk of brain edema.2 The GDFT which guided with the SVV, CI and SjvO2 can ensure the whole cerebra perfusion and improve microcirculation, reduce Lac production in supratentorial tumor resection in supine position, improving cerebral aerobic metabolism, correction of brain supply and demand balance partially.3 The GDFT which guided with the SVV, CI and SjvO2 can reduce the NIHSS score after operation in supratentorial tumor resection in supine position, without affecting the postoperative complications,but do not affected the early recovery of neurological function. |
