原位肝移植围手术期成分输血相关问题的探讨

Peri-operative blood component transfusion in orthotopic liver transplantation

目的 探讨成人原位肝移植围手术期出凝血功能的变化及输血对手术预后的影响。方法 对肝移植术前肝功能Child分级均为C级 ,出凝血功能均存在异常的 19名患者通过补充凝血因子、血小板等成分进行纠正。无肝期采用体外静脉转流 ,术中动态监测血流动力学、出凝血功能变化及出血量 ,根据无肝前期、无肝期、新肝期各项出凝血功能指标的变化 ,给予相应的输血处理 ,分别以术后生存情况和围手术期输血量分组 ,分析各种输血因素对移植术中、术后的影响。结果 在术前肝功能分级、出凝血功能、手术方式、方法、时间无明显差异的情况下 ,输血总量、红细胞用量、冰冻血浆用量与术后存活率呈明显负相关 ,偏相关系数分别为 - 0 .75 18(P <0 .0 1)、- 0 .710 4 (P<0 .0 1)、- 0 .5 14 4 (P <0 .0 5 )。死亡组输血量明显高于存活组 ,差异显著 (P <0 .0 5 ) ;输血量≥ 10 0 0 0ml组死亡率明显高于输血量 <10 0 0 0ml组 ,差异显著 (P <0 .0 5 ) ;所有病例中无一发生输血后巨细胞病毒 (CMV)感染、颅内出血。结论 术前充分纠正出凝血功能异常 ,术中进行动态监测 ,及时通过各种血液成分在品种和剂量上的合理输注进行调控及应用去白细胞输血等新技术 ,可保证原位肝移植手术顺利进行 ,有效降低输血总量 ,减少术后并发症。

Objective To investigate the peri-operative changes of coagulation function and effect of blood transfusion on the prognosis of patients after orthotopic liver transplantation(OLT). Methods Retrospective analysis of clinical data of 19 patients operated in our hospital between June 2002 and June 2003 was performed. All patients had Child-C preoperative hepatic function and abnormal coagulation tests. Coagulation factors and platelets were transfused preoperatively for replacement. During anhepatic phase, extracorporeal veno-venous bypass (EVVB) was established. Hemodynamics, coagulation function and the amount of blood loss were monitored. According to different coagulation function indexes of the pre-anhepatic, anhepatic and neohepatic phases during OLT, the corresponding blood components were transfused. Patients were divided into groups based on postoperative survival and the total volume of blood transfused. We analyzed the effect of all kinds of factors on operation and postoperative courses. Results Without significant differences in preoperative hepatic function , coagulation function and surgical procedure, the total volume of blood transfusion, the volume of erythrocyte and the volume of fresh frozen plasma transfused had significant independent association with postoperative survival with R=-0.7518(P<0.01)、-0.7104(P<0.01)、-0.5144(P<0.05) respectively. The volume of blood transfusion in the death group was significantly higher than that in the survival group(P<0.05). The survival rate of patients receiving less than 10000ml of blood was significantly higher than those receiving more than 10000ml(P<0.05). None of the patients had CMV infection after blood transfusion or intracranial hemorrhage after OLT. Conclusion Monitoring the coagulation function during perioperative period,transfusing patients with appropriate components and using leukocyte-depleted blood components are important factors to ensure uneventful operation course, can effectively reduce the total volume of blood transfusion and postoperative complications.