The Application Of Goal-directed Fluid Therapy In Surgical Patients With Prolonged Fasting Time

Background: Fasting before elective surgery is an effective means of preventingperioperative regurgitation, mistake inhalation and postoperative abdominal distention.Nevertheless, overlong fasting can also potentially cause lower preoperative comfort,intraoperative physiological disorder, abnormal glucose metabolism andhemodynamic instability. It is not uncommon that patients undertake a prolongedfasting period (>12h) before afternoon-operation in China, due to various factors. It isan important clinic problem needs to be addressed, how to rectify the problem ofnegative effects caused by prolonged fasting period. Whereas previous studies haveshown, goal-directed fluid therapy (GDT) based on stroke volume variation (SVV)can effectively increase tissue infusion and oxygen supply, improve the prognosis ofsurgical patients. We hypothesized: SVV-based GDT can correct the intraoperativephysiological disorder, abnormal glucose metabolism and hemodynamic instabilitycaused by the prolonged fasting time; In addition, GDT can also reduce postoperativenausea and vomiting, reduced tissue lactate content.Objectives: Observe (1) the impact of different fasting time on preoperative comfort,intraoperative physiological disorder, glucose metabolism and hemodynamicinstability in patients undergoing elective thoracic surgery.(2) the impact ofSVV-based GDT on preoperative comfort, intraoperative physiological disorder,glucose metabolism and hemodynamic instability in prolonged fasting patientsundergoing elective thoracic surgery (3) the impact of SVV-based GDT onpostoperative nausea and vomiting and tissue lactate content.Methods:(1)40cases of patients undergoing elective thoracic surgery and divideinto2groups based on the length of fasting time: Group A (fasting period of12hours),Group B (fasting period longer than16hours). Before the operation, patients arescored for comfort degree based on Kolcaba table. Monitoring indicators included HR,MAP, CVP, Temp, PETCO; using Flotrac/Vigileo Cardio monitor to measure cardiacindex (CI) and stroke volume variation (SVV). The value of blood gases electrolytes,blood glucose and lactate are recorded before the operation, at the beginning of operation,30minutes after one-lung ventilation and after the operation; Insulinconcentrations were measured by Chemiluminescence Immumo-Assay (CLIA) at themoment before and after the operation, from which to obtain Insulin Resistance level(HOMA-IR).(2)40patients with16-hour fasting time undergoing elective thoracicsurgery were randomly divide into2groups with20cases each, Group I wasconducted targeted fluid therapy under the goal of SVV <10and Group II was theconventional liquid treatment group. The monitoring indexes are the same with part1.(3)60patients undergoing elective thoracic surgery were randomly divided into2groups with30cases each. Group I was GDT group and Group II was conventionalliquid treatment group. The occurrence of postoperative nausea and vomiting and thevalue of blood lactate are monitored and compared between2groups.Results:(1) Comfort value of Group A scored77.06±6.06, group B was76.69±5.793. Both only reached moderate level. However, thirsty comfort of A group rated2.61±0.502, significantly higher than group B’s value2.12±0.697(P <0.05). Afterinduction of anesthesia, MAP of A group was significantly higher than that of group B(P <0.05). Intraoperative blood glucose values at each time point in group A weresignificantly higher than in group B (P <0.05). But the difference of HOMA-IR valuebetween the two groups before and after surgery was not significant (P>0.05).(2)The fluid volume (1050±272.9) of Group I (GDT group) was significantly greaterthan Group II (700±196.5), P <0.05. The MAP of Group I at the moments ofbefore intubation, one-lung ventilation (OLV)20min and40min were significantlyhigher than that of Group II, P <0.05. The CVP value of Group I at each time pointwas higher than that of Group II. CI at the moments of before intubation, OLV20minand40min, after surgery were higher than Group II. SVV value at each time point wassignificantly lower than group II, P <0.05. At OLV40min, when blood lactate levelswas significantly lower than that of group II, blood PaO2value was significantlygreater than that of group II. Intraoperative glucose values of Group I at each timepoint was significantly higher than that in group II, P <0.05.(3) The incidence ofpostoperative1~24h PONV is7%for Group I and30%for Group II, P <0.05. Thenausea rating of Group I postoperative1~24h,24~48h, scored lower than group II (P <0.05); The vomiting rating of Group I postoperative1~24h scored lower thangroup II (P <0.05). Compared with group II, the number of patients in Group I neededadditional antiemetic was significantly lower (10cases vs.2cases, P <0.05).Conclusions:(1) Prolonged fasting period before surgery resulted in significantpatient discomfort feeling thirsty, and comfort degree declining. In addition, it alsoreduced blood glucose level and increased hemodynamic instability;(2) GDT basedon SVV can improve hemodynamic parameters, reduce blood lactate and improve theoxygen partial pressure of OLV in patients with long fasting period (3) GDT based onSVV can significantly reduce the occurrence of postoperative nausea and vomiting,and tissue lactate content...