The Application Of Goal-directed Fluid Therapy In Patients Undergoing Laparoscopic Radical Cystectomy

Background:The patients with invasive bladder cancer are always elderly patients, many of them combined with many age related illnesses, such as chronic bronchitis and cardiac functional insufficiency. At the same time, the elderly patients are always with intestinal motility difference, weak tissue repair ability and are easy happened disorder of the intestinal microflora. And because of the preoperative fasting, bowel preparation and the underlying disease, abdominal operation can lead to volume relative insufficiency in the perioperative period easily. So volume therapy in the perioperative period is very important for the postoperative recovery in patients undergoing radical cystectomy. Now, radical cystectomy with urinary bladder is the standard treatment of bladder cancer. But this operation is a long duration and large scale operation, and the amount of urine not statistics in the process of operation, these add to the many difficulties of volume therapy in the perioperative period. Therefore, looking for a suitable strategy of volume therapy, which can ensure the effective organ perfusion and tissue oxygenation, and can accelelate the recovery of bowel function, is to be a focus of volume therapy research in the perioperative period of radical cystectomy.Goal-Directed Fluid Therapy (GDFT) is has become the dominant strategy of volume therapy in the perioperative period. It according to the physical condition of the patients and the different volume state in the perioperative period, take the individual transfusion plan in the guidance of effective monitoring index and feedback information. Execute the GDFT can provide suitable blood volume of circulation and make the hemodynamic more stable, thus GDFT become the optimization transfusion strategy in the abdominal operation. The implementation of GDFT need to rely on reliable and effective monitoring method and guidance index. The first condition of GDFT is the monitoring of effective circulatory volume. Stroke Volume Variation (SVV) which is a dynamic heart and lung interaction index, can be used as a reliability index to prediction of volume responsiveness during mechanical ventilation. Its sensitivity and specificity are better than the static index. Volume therapy strategy combined with SVV can make patients hemodynamic stability and reduce the organ dysfunction after operation. Determine the Cardiac Output (CO) of patients is the most direct and effective way to determination of entire body perfusion. Consequently, reach the correct CO become an important task or as an important index to judge the effectiveness of the Volume therapy, in getting the strategies of GDFT. But simple monitoring and the use of SVV and CI are not enough if you want guide the implementation of GDFT more reliable, because them evaluation of the effects on hemodynamic from the direction of overall circulation. Need to join the indicators which evaluation body microcirculation status. There is good agreement between central venous oxygen saturation (ScvO2) and mixed venous oxygen saturation (SvO2). ScvO2 is a monitoring index of venous blood oxygen quantity which is by the recent clinical use more, and it easier access than SvO2, so it is a good index to assess body microcirculation.The target of volume therapy in the perioperative period under laparoscopic radical cystectomy is ensure the proper circulating blood volume, and maintain the normal organ perfusion and function, at the same time accelerate the recovery of bowel function after operation, to minimize the risks of postoperative complication. GDFT use the transfusion strategies of titration, it is quite different with the scheme of traditional infusion which is using quantitative transfusion algorithm to fixed liquid input. GDFT is according to the different pathological and physiological status in the perioperative period, take the individual transfusion plan, it can reduce the postoperative complication of high risk operation and shortened hospital stay which have been proven by a number of research. SVV, CI and ScvO2 are all the high accuracy guidance parameters of GDFT, but the researches which use these parameters in the laparoscopic radical cystectomy are less.In this study, we continuous monitor the circulating blood volume in patients undergoing laparoscopic radical cystectomy through a combination of trans-cardiopulmonary thermodilution and pulse contour analysis. We use the SVV, CI and ScvO2 as guide parameters of GDFT, based on normal blood pressure and heart rate, use of the VE, dobutamine, vasoactive drugs and diuretic drugs to achieve SVV≤ 13%, CI≥ 2.5 L·min-1·m-2 and ScvO2≥ 73%. A comprehensive guide on intraoperative fluid from front loading, heart function to systemic tissue perfusion, combined with blood gas analysis index to analyse of the feasibility of GDFT strategy and its effect on systemic perfusion and postoperative rehabilitation. All of these are confirmed to guide a better strategy for the basis of GDFT in the perioperative period with the patients undergoing laparoscopic radical cystectomy.Material and MethodMaterialThe study was endorsed by the Hospital Medical Ethics Committee approved, patients and family members signed the informed consent. We chose 32 patients undergoing laparoscopic radical cystectomy in our hospital, ASA Ⅰ or Ⅱ degree, Hct≥ 30% and Hb≥ 10 g·dL-1 before surgery, coagulation and liver function are normal, no other important organs disease. Thirty-two patients were randomly divided into routine fluid replacement group (group C, n= 15) and GDFT group (group G, n= 17).Anesthesia MethodThe two groups patients fasted for 8 hours, forbidden to drink 6 hours before the surgery. Pre-anesthesia drugs were carried out 30mins before the induction. Drugs included antichloneride (0.01 mg·kg-1) and midazolume (0.04 mg·kg-1) were used to comfort the patients. The patients were monitored with the non invasive blood pressure, ECG and pulse oxygen saturation after entering operation room, and inhalated the oxygen by the mask, oxygen flow of 3 L·min-1. Acentral venous catheter was inserted into the right internal jugular vein under local anesthesia, to monitor the CVP and collection the central venous blood specimen. A thermodilution femoral artery catherter was inserted into the femoral artery under local anesthesia in the sedative patients. This catheter was connected to a PiCCO system to monitor CI, intrathoracic blood volume index (ITBI), extravascular lung water index (ELWI) and pulmonary vascular permeability index (PVPI). Anesthesia was induced with sufentanil (0.6～0.8 μg·kg-1), etomidate (0.15～0.3 mg·kg-1) and rocuronium (0.6 mg·kg-1) through intravenous injection. A tracheal catheter was inserted into the trachea after the muscle relaxants completely, and then connected the anesthesia machine for volume control ventilation. Ventilation parameter was set to:tidal volume (8～10 ml·kg-1), respiratory rate (12～16 bpm), respiratory ratio 1:2, fraction of inspired oxygen 50%, fresh gas flow 1 L·min-1, PETCO2 was maintained from 35 to 45 mmHg during the anesthesia period. Anesthesia maintenance was achieved with propofol (50～100 ug·kg-1·min-1), remifentanil (0.1～0.2 μg·kg-1·min-1) and cisatracurium (1～2 ug·kg-1·min-1). Sevoflurane concentration was keep in 1%～2% in end expiration. And make the number of Narcotrend was maintained D2 to El.Monitoring1. Time points:before the induction of anesthesia (T1),5 minutes after insertion of a tracheal catheter (T2),5 minutes after pneumoperitoneum and change position (T3),1 hour after pneumoperitoneum (T4),5 minutes after open the abdominal (T5),1 hour after open the abdominal (T6), the end of the operation (T7).2. The indexes of circulating blood volume:injected of 15ml ice brine to the intraneck vein to monitor the CI, ITBI, ELWI and PVPI at different time points through the trans-cardiopulmonary thermodilution, measurement of three times and took the average at each time point., and monitored the CVP and MAP at the same time.3. The indexes of tissue perfusion:blood samples were taken from central vein and artery for blood gas analysis at the time points of T1, T3, T4, T5, T6 and T7 to monitor the aLac, Pcv-aCO2 and ScvO2, and to calculate the DO2I and O2ERe.4. The general indexes:recorded the patients’ height, weight, age and classification of ASA; the HR, CVP and MAP after sedation; the duration time of pneumoperitoneum and operation; the intake of liquid, the amount of urine and throughput at 24 hours after operation.5. The indexes of postoperative rehabilitation:we scored the patients with the score of quality of recovery (The QoR-15) after general anaesthesia at 1 day before operation,24 hours after operation,4 days after operation and 14 days after operation. Recorded the time of exhaust, defecate, consumption of liquid, eat common food, end parenteral nutrition and hospitalization at the postoperative. We recorded the complications and its species. we scored the patients with the score of Karnofsky Performance Status (KPS) at 1 day before operation and the time of discharge.Surgical interventionThe group C:the total amount of infusion compensatory volume expansion (CVE)+ physiological requirement+ continued loss+ the cumulative loss+ add extra weight.The group G:the CVE (5 ml·kg-1) injection before the operation as the way of control group. Before open the abdominal lactate Ringers solution injection was infused as a background at a speed of 2 ml·kg-1·h-1, and 5 ml· kg-1·h-1 crystal as a background infusion during the period of open abdominal operation. We use the SVV, CI and ScvO2 as guide parameters of GDFT, based on normal blood pressure and heart rate, use of the VE, dobutamine, vasoactive drugs and diuretic drugs to achieve SVV≤ 13%, CI≥2.5L·min-1·m-2 and ScvO2≥ 73%.Parameters were given up when arrhythmia occurred. Warm the patients after the induction of anesthesia use the warm air machine to make the body temperature between 35℃～36℃.Statistical AnalysisThe data are analyzed using the software of SPSS 13.0. Measurement dates 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 information:in this study, we monitored the circulating blood volume in 32 patients. One patient of GDFT group quit the study, because found the tumor has been widely transfer in abdominal cavity, and without further operation treatment. One another patient of GDFT group also quit the study, because appear severe arrhythmia which can interference the data acquisition. The remaining 30 patients were successfully completed operation. Group G of input crystal volume was significantly lower and input colloid was significantly higher than that in group C (P < 0.05). Other clinical data showed no significant differences (P> 0.05).2. Comparison of circulating blood volume indexes:the CI, ITBI and MAP in two groups differences were no significant differences (P> 0.05) at each time point. MAP in group C in time pointT6 was significantly lower than that in time point T1 (P < 0.05). There was interaction between the grouping and monitoring time point of CI (P< 0.05). This suggests that the different ways of volume therapy have different change trend at the time points of CI. CI in group G in time point T6 and T7 was significantly higher than that in group C (P< 0.05). The other indexes between two groups were no statistically significant (P> 0.05). ELWI and PVPI in group G between the different time points were also no statistically significant (P> 0.05).3. Comparison of tissue perfusion indexes:ScvO2, aLac, DO2I and O2ERe were all have significant differences at the time points in the same group (P< 0.05). The aLac in group G in time point T4 and T5 were significantly lower than that in group C (P< 0.05). The other indexes between two groups were no statistically significant (P>0.05).4. Comparison of postoperative rehabilitation indexes:the time of defecate, consumption of liquid, eat common food, end parenteral nutrition and hospitalization at the postoperative between two groups were all no statistically significant (P> 0.05), the time of exhaust in group G was significantly lower than that in group C (P< 0.05); the score of The QOR-15 and KPS between two groups were no statistically significant (P> 0.05); the patients in group G founded a total of 8 cases of complications during 30 days after operation,3 patients of complicated with 2 complications, so had 5 patients with complications; the patients in group C founded a total of 9 cases of complications during 30 days after operation,4 patients of complicated with 2 complications, so had 5 patients with complications; the various complications between two groups were no statistically significant (P> 0.05).Conclusion1. The GDFT which guided with the SVV, CI and ScvO2 can keep the effective circulatory volume, improve CI and make the hemodynamic more stable in laparoscopic radical cystectomy. At the same time, it do not increase the risk of pulmonary edema.2. The GDFT which guided with the SVV, CI and ScvO2 can ensure the whole body perfusion, reduce the aLac and improve microcirculation in laparoscopic radical cystectomy, without effecting the balance of oxygen supply and demand.3. The GDFT which used the SVV, CI and ScvO2 as guide parameters can shorten the time of exhaust and accelerate the postoperative recovery of bowl recovery in laparoscopic radical cystectomy, without effecting the postoperative complications and the early survival quality.