Clinical Observation Of Fluid Therapy Directed By FloTrac/Vigileo Monitoring SVV In Surgical Patients With Severe Traumatic Brain Injury

Objective: In this study FloTrac/Vigileo monitoring system was applied to guide fluid therapy on the patients with severe traumatic brain injury（sTBI）during anesthesia.The changes of jugular venous bulb oxygen saturation（SjvO₂）,cerebral arterial-venous blood oxygen content difference（Da-jvO₂）and cerebral extraction rate of oxygen（CERO）were observed,and the content of S100 B of peripheral venous blood was detected to speculate its brain protective effect.The change of GCS score and the length of hospital stay were recorded to explore the effect of fluid therapy directed by FloTrac/Vigileo monitoring system on the patients with severe traumatic brain injury.Methods:Thirty patients with sTBI were selected.Inclusion criteria: admitted within 24 h after the injury,Glasgow Coma score（GCS）≤8 points,confirmed by CT to be cerebral contusion or intracranial hematoma and no other organ damage and or failure.Patients with severe heart or lung disease,liver and kidney dysfunction,mental history,cognitive dysfunction,drug abuse and so on were passed.All patients were randomly to receive FloTrac/Vigileo monitoring system（group G）or control（group C）.Noninvasive blood pressure（BP）,electrocardiogram（ECG）and pulse blood oxygen saturation（SpO₂）were monitored and upper extremity venous channels were opened after patients entering the room.After left radial artery puncture under local anesthesia,direct arterial blood pressure was monitored and the FloTrac/Vigileo monitor was connected at the same time in group G.The induction of anesthesia were conducted with Atropine 0.5mg,dexamethasone 10 mg,propofol 2mg/kg,sufentanil 0.5ug/kg and cisatracurium 0.2mg/kg.Endotracheal intubation mechanical ventilation was performed 3 minute later.Tidal volume was set to be 8ml/kg,and end-tidal PCO₂ is maintained between 30⁴0mmHg by adjusting respiratory frequency.Then puncturing right subclavian vein（group C）and internal jugular vein retrograde were performed.Anesthesia was maintained with remifentanyl 0.1⁰.3 ug·kg-1·min-1,propofol 4⁶mg·kg-1·h-1 and intermittent intravenous injection of cisatracurium during operation.After the operation all patients were back to ICU with trachea cannula.In group G,when SVV was more than 13%,it was a indication that the vessels were in lack of effective circulating blood volume,and infusion fluid to make it below 13%.when SVV was below 13%,maintain the liquid transfusion at a rate of 1 to 2 ml /（kg·h）.In group C,conventional liquid treatment was performed according to the mean arterial pressure（MAP）,heart rate（HR）and central venous pressure（CVP）.Urine volume of both the two groups were maintained > 1ml/（kg·h）.Red blood cells were transfused when the Hb was less than 8g/dl.Hemodynamics index were monitored in the beginning of operation（T0）,opening the dura mater（T1）,1h after opening the dura mater（T2）,suturing the dura mater（T3）,at the end of operation（T4）separately.At the same time,arterial blood and internal jugular vein bulb blood were collected for blood gas analysis and the arterial oxygen saturation（SaO₂）,jugular bulb oxygen saturation（SjvO₂）,arterial oxygen partial pressure（PaO₂）,jugular bulb oxygen partial pressure（PjvO₂）,jugular bulb lactate were recorded to calculation the arterial blood oxygen content（CaO₂）,the internal jugular bulb blood oxygen content（CjvO₂）,the cerebral artery and internal jugular vein bulb oxygen content difference（Da-jvO₂）and the cerebral oxygen uptake rate（CERO）.Three ml peripheral venous blood were respectively extracted at preoperative（a1）,opening the dura mater（a2）,1h after opening the dura mater（a3）,at the end of operation（a4）,postoperative 24h（a5）,and the serum concentrations of S100 B protein was tested by ELISA.The average volume of infusion,blood loss,usage of vasoactive drugs and urine volume were recorded.The number of the two groups of patients with postoperative pulmonary complications,cerebral edema and hospitalization time,GCS of the patients before surgery（d0）,postoperative 24h（d1）,postoperative 3d（d2）,postoperative 7d（d3）and postoperative two weeks（d4）were respectively recorded.All the patients were undergo Glasgow Outcome Score by language and motor function recovery state evaluation before discharge to evaluate the early quality of life.Results:1 There were no significant differences of age,sex,body mass index and anesthesia time between the two groups（P>0.05）.2 There were no significant differences of HR between the two groups（P>0.05）.There were no significant differences of MAP at T0 time between the two groups（P>0.05）,but the MAP of T1 in group G were higher than group C（P<0.05）.The MAP of T1,T2 in group C were significantly lower than T0（P<0.05）.3 There was no significant difference of the cerebral oxygen metabolism indexes at T0 time between the two groups（P>0.05）.The SjvO₂ of T1^T4 in both the two groups were higher than T0,and all SjvO₂ of T2,T3,T4 in two groups were significantly higher than T0（P<0.05）.Compared with group C,the SjvO₂ of T2,T3 in group G were significantly higher（P<0.05）.The Da-jvO₂ of T1^T4 in both the two groups were significantly lower than T0（P<0.05）.The CERO of T1^T4 in both the two groups were lower than T0,while all CERO of T2,T3,T4 in group C but just T3 in Group C were significantly lower than T0（P<0.05）.Compared with group C,the CERO of T2,T3,T4 in group G were significantly Lower（P<0.05）.The Lactate of T1^T4 in both the two groups were lower than T0,but just the Lactate of T4 in group G were significantly lower than T0（P<0.05）.4 Compared with group C,the urine volume in group G were significantly increased（P<0.05）.5 There was no significant difference of the serum S100 B concentration at a1 time between the two groups（P>0.05）.Compared with a1,the serum S100 B concentrations of both two groups were increased at each time point of a2^a5,but the S100 B of group G was increased slowly and was significantly lower than group C at the a3 point（P < 0.05）.6 There was no significant difference of the GCS at d0 time between the two groups（P>0.05）.The GCS of d1^d4 in both the two groups were higher than d0.Compared with group C,the GCS of d2 in group G were significantly higher（P<0.05）.7 There was no significant difference of the GOS and hospital stay between the two groups（P>0.05）.8 There was no significant difference of the postoperative pulmonary complications and brain edema between the two groups（P>0.05）.Conclusions:1 Fluid therapy directed by FloTrac/Vigileo monitoring SVV can maintain the stability of hemodynamics in surgical patients with sTBI and ensure adequate tissue perfusion.2 Fluid therapy directed by FloTrac/Vigileo monitoring SVV can improve the SjvO₂ in surgical patients with sTBI and reduce the CERO and the level of nerve injury marker S100 B protein,so it has better protective effects on brain.3 Fluid therapy directed by FloTrac/Vigileo monitoring SVV can improve the GCS score in surgical patients with sTBI in the early stage and is conducive to improve the prognosis.