目标导向液体治疗对胸科手术患者术中氧供需平衡及术后结局影响的Meta分析

doi:10.3969/j.issn.1004-583X.2021.08.001

摘要/Abstract

摘要：

目的系统评价目标导向液体治疗对胸科手术患者术中氧供需平衡及术后结局的影响。方法计算机检索PubMed、Cochrane Library、VIP、CNKI、WanFang Database(建库至2019年10月),按照纳入与排除标准选择文献、评价质量并提取资料后,采用RevMan 5.3软件进行Meta分析。结果共纳入符合条件的11个随机对照试验(RCT),共计810例患者。Meta分析结果显示:目标导向组增加患者术中氧合指数(OI)[单肺通气结束时:MD=57.04, 95%CI(24.04, 90.05),P=0.001;术毕:MD=97.33, 95%CI(27.21, 167.45),P=0.007],降低术毕血乳酸(Lac)水平[MD=-0.51, 95%CI(-0.84,-0.18),P=0.002],提高术中心脏指数(CI)[单肺通气结束时:MD=0.42, 95%CI(0.23, 0.61),P<0.01;术毕:MD=0.40, 95%CI(0.26, 0.54),P<0.01],降低术后肺部感染发生率[RR=0.35, 95%CI(0.16, 0.76),P=0.008]、急性肺损伤发生率[RR=0.15, 95%CI(0.04, 0.67),P=0.010]、术后恶心呕吐发生率[RR=0.39, 95%CI(0.22, 0.68),P=0.001],减少住院天数[MD=-0.66, 95%CI(-1.20, -0.12),P=0.020]。结论目标导向液体治疗可改善胸科手术患者组织灌注、维持氧供需平衡,减少术后恶心呕吐及肺部相关并发症,降低患者医疗花费, 提高预后。

关键词: 目标导向液体治疗, 胸外科手术, 氧供需平衡, 术后结局, Meta分析

Abstract:

Objective To systematically evaluate the effects of goal-directed fluid therapy (GDFT) on intraoperative balance between oxygen delivery and consumption and postoperative outcomes in patients undergoing thoracic surgery. Methods We searched PubMed, Cochrane Library, VIP, CNKI and WanFang Database from inception to October 2019, literature selection, quality evaluation and data extraction were performed according to inclusion and exclusion criteria, and meta-analysis was completed by RevMan 5.3. Results A total of 11 eligible randomized controlled trials (RCTs) were enrolled, including 810 patients. The results of meta-analysis showed that intraoperative oxygenation index (OI) was significantly increased by the use of GDFT for thoracic surgery patients (at the end of one-lung ventilation [OLV]: MD=57.04, 95%CI [24.04, 90.05], P=0.001; at the end of surgery: MD=97.33, 95%CI[27.21, 167.45], P=0.007), significantly decreased for postoperative blood lactic acid (Lac) (MD=-0.51, 95%CI[-0.84, -0.18], P=0.002), significantly increased for intraoperative cardiac index (CI) (at the end of OLV: MD=0.42, 95%CI [0.23, 0.61], P<0.01; at the end of surgery: MD=0.40, 95%CI[0.26, 0.54], P<0.01); meanwhile, incidence of postoperative complications were significantly decreased with use of GDFT, including the incidence of postoperative pulmonary infection (RR=0.35, 95%CI[0.16, 0.76], P=0.008), incidence of acute lung injury (ALI) (RR=0.15, 95%CI[0.04, 0.67], P=0.010), incidence of postoperative nausea and vomiting (PONV) (RR=0.39, 95%CI [0.22, 0.68], P=0.001), as well as reduced hospitalization time in GDFT group (MD=-0.66, 95%CI [-1.20, -0.12], P=0.020).Conclusion For thoracic surgery patients, using GDFT can effectively improve tissue perfusion and balance of oxygen delivery and consumption, reduce incidence of PONV and complications of pulmonary, decrease medical expenses, and improve the prognosis of patients.

Key words: goal-directed fluid therapy, thoracic surgical procedures, oxygen delivery and consumption, postoperative outcomes, meta-analysis

中图分类号:

R734.2

李冠珠, 来源, 郑筱卓, 蒋然, 魏珂. 目标导向液体治疗对胸科手术患者术中氧供需平衡及术后结局影响的Meta分析[J]. 临床荟萃, 2021, 36(8): 677-684.

Li Guanzhu, Lai Yuan, Zheng Xiaozhuo, Jiang Ran, Wei Ke. Effects of goal-directed fluid therapy on intraoperative balance between oxygen delivery and consumption and postoperative outcomes in thoracic surgery patients: a meta-analysis[J]. Clinical Focus, 2021, 36(8): 677-684.

导出引用管理器 EndNote|Ris|BibTeX

链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2021.08.001

https://huicui.hebmu.edu.cn/CN/Y2021/V36/I8/677

图/表 13

参考文献 25

[1]	De la Gala F, Piñeiro P, Reyes A, et al. Effect of intraoperative paravertebral or intravenous lidocaine versus control during lung resection surgery on postoperative complications: A randomized controlled trial[J]. Trials, 2019, 20(1):622. doi: 10.1186/s13063-019-3677-9 URL
[2]	Lederman D, Easwar J, Feldman J, et al. Anesthetic considerations for lung resection: Preoperative assessment, intraoperative challenges and postoperative analgesia[J]. Ann Transl Med, 2019, 7(15):356. doi: 10.21037/atm.2019.03.67 pmid: 31516902
[3]	黄剑, 柳开忠, 刘文生. 胸部恶性肿瘤根治术后患者目标导向液体治疗的价值研究[J]. 中华危重症医学杂志, 2017, 10(3):182-187.
[4]	Wrzosek A, Jakowicka-Wordliczek J, Zajaczkowska R, et al. Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery[J]. Cochrane Database Syst Rev, 2019, 12:CD012767.
[5]	Hasanin A, Zanata T, Osman S, et al. Pulse pressure variation-guided fluid therapy during supratentorial brain tumour excision: A randomized controlled trial[J]. Open Access Maced J Med Sci, 2019, 7(15):2474-2479. doi: 10.3889/oamjms.2019.682 pmid: 31666850
[6]	Froghi F, Soggiu F, Ricciardi F, et al. Ward-based Goal-Directed Fluid Therapy (GDFT) in Acute Pancreatitis (GAP) trial: Study protocol for a feasibility randomised controlled trial[J]. BMJ Open, 2019, 9(10):e028783. doi: 10.1136/bmjopen-2018-028783 URL
[7]	Zhang J, Chen CQ, Lei XZ, et al. Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: A pilot study[J]. Clinics (Sao Paulo), 2013, 68(7):1065-1070. doi: 10.6061/clinics/2013(07)27 pmid: 23917675
[8]	Xu H, Shu SH, Wang D, et al. Goal-directed fluid restriction using stroke volume variation and cardiac index during one-lung ventilation: A randomized controlled trial[J]. J Thorac Dis, 2017, 9(9):2992-3004. doi: 10.21037/jtd URL
[9]	刘娜, 徐悦利, 李汝鸿, 等. 不同容量治疗方案对老年食管癌切除术患者血流动力学、血乳酸及氧供需平衡的影响[J]. 中国煤炭工业医学杂志, 2015, 18(6):966-970.
[10]	王会东, 冀晋杰, 徐学敏, 等. 麻醉期间目标导向液体治疗对肺叶切除术后急性肺损伤的影响[J]. 解放军医学院学报, 2015, 36(11):1109-1112.
[11]	雷敏, 鲍琪, 钟泰迪. 每搏变异度指导的液体目标导向治疗在胸腔镜手术中的应用[J]. 中国医药, 2019, 14(2):275-278.
[12]	许辉, 疏树华, 王迪, 等. 目标导向液体治疗单肺通气肺癌根治术患者术中肺功能及中心静脉血炎症因子水平观察[J]. 山东医药, 2017, 57(19):94-96.
[13]	汪悦, 李娟, 康芳, 等. 目标导向液体治疗对老年单肺通气患者局部脑氧饱和度及血流动力学的影响[J]. 临床麻醉学杂志, 2017, 33(9):837-841.
[14]	刘铁军, 杨占魁, 高晓增, 等. 目标导向液体治疗对老年肺癌根治术患者术中凝血状态的影响[J]. 浙江临床医学, 2016, 18(3):516-517.
[15]	郭小琦, 薛锋, 王鹏国, 等. 目标导向液体治疗对老年食管癌根治术患者围手术期血流动力学、血乳酸及细胞免疫功能的影响[J]. 癌症进展, 2017, 15(10):1209-1212.
[16]	白晓蕾, 解雅英, 都义日, 等. 经食管超声心动描计术引导下目标导向液体治疗在肺叶切除术中的应用[J]. 中国现代医学杂志, 2019, 29(15):102-107.
[17]	杨丽. 每搏量变异度在胸科手术全麻复合硬膜外麻醉患者中临床应用[D]. 中国医科大学, 2015:1-31.
[18]	Coeckelenbergh S, Delaporte A, Ghoundiwal D, et al. Pleth variability index versus pulse pressure variation for intraoperative goal-directed fluid therapy in patients undergoing low-to-moderate risk abdominal surgery: A randomized controlled trial[J]. BMC Anesthesiol, 2019, 19(1):34. doi: 10.1186/s12871-019-0707-9 pmid: 30851740
[19]	Yin K, Ding J, Wu Y, et al. Goal-directed fluid therapy based on noninvasive cardiac output monitor reduces postoperative complications in elderly patients after gastrointestinal surgery: A randomized controlled trial[J]. Pak J Med Sci, 2018, 34(6):1320-1325.
[20]	Torregiani G, Claroni C, Covotta M, et al. Impact of a goal-directed fluid therapy on length of hospital stay and costs of hepatobiliarypancreatic surgery: A prospective observational study[J]. J Comp Eff Res, 2018, 7(12):1171-1179. doi: 10.2217/cer-2018-0041 URL
[21]	Jin J, Min S, Liu D, et al. Clinical and economic impact of goal-directed fluid therapy during elective gastrointestinal surgery[J]. Perioper Med (Lond), 2018, 7:22.
[22]	Wu H, Wang W, Zhao G, et al. Effect of intraoperative fluid administration on perioperative outcomes in patients undergoing McKeown esophagogastrectomy[J]. Chin J Cancer Res, 2019, 31(5):742-748. doi: 10.21147/j.issn.1000-9604.2019.05.04 URL
[23]	Deng QW, Tan WC, Zhao BC, et al. Is goal-directed fluid therapy based on dynamic variables alone sufficient to improve clinical outcomes among patients undergoing surgery? A meta-analysis[J]. Crit Care, 2018, 22(1):298. doi: 10.1186/s13054-018-2251-2 URL
[24]	Weinberg L, Mackley L, Ho A, et al. Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: A single centre retrospective observational study[J]. BMC Anesthesiol, 2019, 19(1):135. doi: 10.1186/s12871-019-0803-x URL
[25]	Bahlmann H, Hahn RG, Nilsson L, et al. Pleth variability index or stroke volume optimization during open abdominal surgery: A randomized controlled trial[J]. BMC Anesthesiol, 2018, 18(1):115. doi: 10.1186/s12871-018-0579-4 pmid: 30121072

纳入研究	样本量(例)		年龄(岁)		手术类型	干预措施		结局指标
纳入研究	G	C	G	C	手术类型	G	C	结局指标
Zhang 2013 ^[7]	30	30	59.9±8.9	61.0±8.7	胸腔镜下肺叶切除术	基于SVV、CI的目标导向法	限制法	①③④⑤⑥
Xu 2017 ^[8]	84	84	49±6	49±5	胸腔镜下肺叶切除术	基于SVV、CI的目标导向法	限制法	②③④⑤⑥
刘娜 2015^[9]	20	20	69.1±4.2	68.5±3.8	食管癌根治术	基于ITBVI的目标导向法	限制法	①②
王会东 2015^[10]	40	40	47±12	53±9	肺叶切除术	基于SVV的目标导向法	开放法	②③④
雷敏 2019^[11]	22	22	56±8	58±8	胸腔镜下肺叶切除术	基于SVV的目标导向法	开放法	①④⑤⑥
许辉 2017^[12]	30	30	51±6	52±4	肺癌根治术	基于SVV、CI的目标导向法	限制法	③
汪悦 2017^[13]	29	29	68±4	67±5	食管癌根治术	基于SVV、CI的目标导向法	限制法	②
刘铁军 2016^[14]	61	61	66.1±5.8	66.3±4.5	肺癌根治术	基于SVV、CI的目标导向法	开放法	①②
郭小琦 2017^[15]	49	49	70.5±6.3	69.1±8.2	食管癌根治术	基于ITBVI的目标导向法	正常法	①②
白晓蕾 2019^[16]	20	20	59.75±3.83	60.10±3.10	胸腔镜下肺叶切除术	基于LVETc及SV的目标导向法	限制法	①④⑤⑥
杨丽 2015^[17]	20	20	57±6	58±9	开胸下肺叶切除术	基于SVV的目标导向法	正常法	①

纳入研究	样本量(例)		年龄(岁)		手术类型	干预措施		结局指标
纳入研究	G	C	G	C	手术类型	G	C	结局指标
Zhang 2013 ^[7]	30	30	59.9±8.9	61.0±8.7	胸腔镜下肺叶切除术	基于SVV、CI的目标导向法	限制法	①③④⑤⑥
Xu 2017 ^[8]	84	84	49±6	49±5	胸腔镜下肺叶切除术	基于SVV、CI的目标导向法	限制法	②③④⑤⑥
刘娜 2015^[9]	20	20	69.1±4.2	68.5±3.8	食管癌根治术	基于ITBVI的目标导向法	限制法	①②
王会东 2015^[10]	40	40	47±12	53±9	肺叶切除术	基于SVV的目标导向法	开放法	②③④
雷敏 2019^[11]	22	22	56±8	58±8	胸腔镜下肺叶切除术	基于SVV的目标导向法	开放法	①④⑤⑥
许辉 2017^[12]	30	30	51±6	52±4	肺癌根治术	基于SVV、CI的目标导向法	限制法	③
汪悦 2017^[13]	29	29	68±4	67±5	食管癌根治术	基于SVV、CI的目标导向法	限制法	②
刘铁军 2016^[14]	61	61	66.1±5.8	66.3±4.5	肺癌根治术	基于SVV、CI的目标导向法	开放法	①②
郭小琦 2017^[15]	49	49	70.5±6.3	69.1±8.2	食管癌根治术	基于ITBVI的目标导向法	正常法	①②
白晓蕾 2019^[16]	20	20	59.75±3.83	60.10±3.10	胸腔镜下肺叶切除术	基于LVETc及SV的目标导向法	限制法	①④⑤⑥
杨丽 2015^[17]	20	20	57±6	58±9	开胸下肺叶切除术	基于SVV的目标导向法	正常法	①