歲月麻醉

Anesthesia,Joyful Life
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圍術期液體管理

人體的靜脈系統,具有巨大的儲備功能reserve capacity,所以可以透過改變姿勢來增減回心血流。 理論上,在麻醉前與後,所有條件不變下,循環系統功能也應該不變,也就是心臟收縮力,與血管內容量不變,那血壓降低,就是週邊阻力下降,吊詭的是,通常血壓下降,麻醉醫師就會challenge fluid,自從有人研究到身體內水分『過多』不是一件好事,尤其是在某些胸腹手術,會對病人的恢復與預後產生不良影響,這就難為了麻醉醫師了! 在沒有侵入性監測儀器之下,在無法確知『安全』的最低血壓之下,如何保持輸入水液不會過多,又能保持『安全』血壓範圍,醫師要面對某些改變,不是冒著降低麻醉深度的風險,就是要使用某種收縮性血管活性藥物,而後者又有減損器官的末端微循環的潛在疑慮,那,還有什麼方法呢,傳統上,透過姿勢的調整,來增加回心血流,或者,減少呼吸次數,讓高二氧化碳血症,來增加內源性catecholamine的分泌,再則也可以使用彈性襪,來降低週邊靜脈血液的儲留pooling。三月份anesthesiology還有一篇不錯的文章,

Peristaltic pneumatic compression of the legs reduces fluid demand and improves hemodynamic stability during surgery: A randomized, prospective study. Anesthesiology 2011; 114:536–44

探討,使用Peristaltic pneumatic compression來增加回心血流量,從而降低水液的輸入。作法是:
1.基礎水液輸量2ml/kg/h(1--2 ml/kg/h 的 insensible loss + 尿液量 0.5-1 ml/kg/h)
2. BIS 監視麻醉深度
3. 低壓條件觸動 SAP <90, MAP <60 mmHg, PVI>14%, Bp drop >20% before skin incision, HR >90/min (個人覺得這個條件不好)給予250 cc bolus.直到 >2000cc/h 為止。
4. blood loss >500 以上,以colloid fluid 補 volume.


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