背驼式原位肝移植术的麻醉处理

Anesthetic Management of Piggyback Orthotopic Liver Transplantation

目的探讨背驼式原位肝移植术病人围术期血流动力学、电解质、酸碱度及凝血功能的变化和相应的麻醉处理。方法背驼式原位肝移植病人14例,ASAII^V级,均采用静吸复合全麻联合硬膜外阻滞,术前凝血功能障碍者则采用静吸复合全麻。静脉给予咪唑安定、芬太尼、依托咪酯及阿曲库铵诱导,术中异氟醚吸入及持续静脉输注异丙酚、芬太尼、阿曲库铵及硬膜外输注罗哌卡因维持麻醉。分别监测术前(T0)、无肝前期(T1)、无肝期30 min(T2)、新肝期即刻(T3)及新肝期30 min(T4)5个时点的心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、肺动脉压(PAP)、肺动脉毛细血管楔压(PCWP)、凝血功能及血气和生化功能指标。并观察记录术中的尿量和出入量。根据背驼式原位肝移植各期的不同特点,给予相应的麻醉处理治疗。结果T2的HR与T0相比有较明显的增快,而在T3时点则明显降低;T2、T3时点MAP与T0时点相比则有显著降低,尤以T3最为显著(P<0.01)。T2和T3的CVP、PAP及PCWP与T0相比有显著降低(P<0.01)。从T0至T3时点血小板计数(PLT)呈现进行性减少,而凝血酶原时间(PT)、部分凝血活酶时间(APTT)及凝血酶时间(TT)则有进行延长的趋势(P<0.01),直至T4时点又分别出现PLT回升而PT、APTT及TT则又缩短的趋势。T3的血钾和T0相比有明显的增高,而T3的血钙则出现明显的降低,T3时点的PH值和BE值与T0相比有显著性差异(P<0.01)。结论及时、积极、具有针对性的临床处理措施是维持背驼式原位肝移植病人围麻醉期血流动力学的稳定,电解质和酸碱度平衡以及改善其凝血功能的关键。

Objective To study the changes of hemodynamics, electrolure, acid-base balance, blood coagulation function and the corresponding anesthetic treatment in patients during orthotopic livers transplantation. Methods Fourteen ASA Ⅱ -Ⅴ patients undergoing piggyback orthotopic livers transplantation were adopted combined generalepidural anesthesia. Anesthesia was induced with midazolam 0.05-0. 08 mg/kg, fentanyl 3-5μg/kg,etomidate 0. 2-0. 3 mg/kg and atracurium 0.5-0.6 mg/kg and maintained with isoflurane and propofol, fentanyl, atracurium infusion supplemented with 1% ropivacaine epidural infusin（4-5 mL/h）. HR, MAP, CVP, PAP, PCWP, blood coagulation function,blood gas analysis and biochemical analysis were recorded immediately before operation（T0 ）, anhepatic prophase（T1 ）, 30min after anhepatic phase（T2 ）, new hepatic phase（T3）and 30 min after graft reperfusion. As well as,urine volume, bleed volume and input volume were observed. The corresponding nacro-treatment was offered to patients undergoing piggyback orthotopic liver transplantation according to each phase of the aniso-behavior. Resuits HR increased significantly at T2 as compared with those at To. HR was significantly decreased at T2 and T3 as compared with those at T0. MAP,CVP,PAP and PCWP were significantly decreased at T2 and T3 as compared with those at T0. Blood coagulation function were decreased from To to T3, but blood coagulation function were ameliorated at T4. Blood kalium increased significantly at T3 as compared with those at To. Blood calcium was significantly decreased at T3 as compared with those at To. There was significant difference in PH and base excess between To and T3. Cone｜usion The active clinical treatment is key point to maintain hemodynamics, electrolure, acid-base balance and ameliorate blood coagulation fuction during piggback orthotopic liver transplantation.