非转流下原位肝移植术患者术中脑氧饱和度的变化

Changes in regional cerebral oxygen saturation (rSO2) during orthotopic liver transplantation without veno-venous bypass

目的通过观察术中脑氧饱和度(rSO2)的变化来探讨非转流下原位肝移植术患者无肝期和新肝早期脑氧供需平衡情况。方法 20例行非转流下原位肝移植术的晚期肝病患者采用异氟醚吸入复合异丙酚、芬太尼静脉维持麻醉。术中按需输注乳酸林格氏液、红细胞、血浆和白蛋白,维持红细胞压积≥30％。无肝期适当控制输血、输液,必要时可用多巴胺和肾上腺素维持术中血液动力学稳定。在门、腔静脉开放前开始增加潮气量,避免开放初期动脉血二氧化碳分压(PaCO2)过度增加。术中持续监测ECG、呼气末二氧化碳分压(PERCO2)、脉搏血氧饱和度(SpO2)、平均动脉压(MAP)、中心静脉压(CVP)、平均肺动脉压(MPAP)、心输出量(CO)以及体温等。rSO2探头(Invos 3100)分别置于左右前额,并记录开腹前(T1)、门、腔静脉阻断前5 min(T2)、门、腔静脉阻断即刻(T3)、门、腔静脉阻断30min(T4)、门、腔静脉开放3min(T5)、15min(T6)、30min(T7)、90min(T8)、3 h(T9)等各时点的左右两侧rSO2。同时抽取桡动脉血测定血红蛋白(Hb)和PaCO2。结果与T1相比,T3、T4的CVP、MPAP、CO明显降低、T9-9时明显升高,T3、T4、T6的MAP明显下降(P<0.05),其余各时点无显著性差异(P>0.05);与T4相比,新肝期各时点CVP、MPAP、CO以及MAP明显升高(P<0.05);各时点左右两侧的rSO2?

Objective To evaluate the changes in regional cerebral oxygen saturation (rSO2) monitored by near infrared spectroscopy during orthotopic liver transplantation (OLT) without veno-venous bypass. Methods Twenty ASA Ⅲ-Ⅳ patients of both sexes (12 males, 8 females) with end-stage liver diseases aged 2O-58 yrs undergoing OLT without veno-venous bypass were studied. Radial artery was cannulated and Swan-Ganz catheter was placed via right internal jugular vein. ECG, MAP, HR, CVP, MPAP, cardiac output (CO) , SpO2, PETCO2 and T were monitored during operation. rSO2 was monitored by near-infrared spectroscopy (INVOS 31OO) . The probes were placed on the forehead on both sides. rSO2 was recorded at the skin incision (T1 ), 5 min before and at the beginning of anhepatic stage (T2, T3 ) , at 30 min after the start of anhepatic stage (T4 ) and 5 min (T5), 15 min (T6 ) , 30 min (T7) , 90 min (T8 ) and 3 h (T9 ) after the start of neohepatic stage. Anesthesia was induced with midazolam 0.1 mg·kg-1 , fentanyl 5-10μg·kg-1 , scopolamine 0.6 mg and vecuronium 0.1 mg·kg-1 , and maintained with isoflurane 0.5%-1.0% and propofol infusion (1-2 mg·kg-1·h-1 ) in combination with intermittent i.v. boluses of midazolam, fentanyl and vecuronium. The patients was mechanically ventilated after tracheal intubation, PaCO2 was maintained between 35-45 mm Hg, SpO2 was maintained at 100% and Hct≥30% .Results MAP, CVP, MPAP and CO decreased significandy during anhepatic stage (T3, T4 ) compared with the baseline values at T1 (P < 0.05) and returned to the baseline levels during the neohepatic stage (T5-9 ) . The changes in bilateral rSO2 were similar. rSO2 decreased significandy during the anhepatic stage (T3,T4) compared with the baseline values at T1 ( P<0.05) and then returned to the baseline levels during the neohepatic stage. PaCO2 increased significantly at the start of neohepatic stage (T5 ) compared with the baseline value at T1 and then gradually decreased during neohepatic stage (T6-9) but still significantly higher than that at T4 (P<0.05) Conclusion There is a tendency toward imbalance between cerebral O2 delivery and consumption during anhepatic and early neohepatic stage during OLT without veno-venous bypass.