经肺温度稀释法在肝及其与肾、胰、十二指肠联合移植围术期的应用研究

Application of transpulmonary thermodilution method in patients undergoing liver or liver plus other organs transplantation

目的:观察经肺温度稀释法(PiCCO技术)在肝及其与肾、胰、十二指肠联合移植手术围术期的应用情况,并与改良式肺动脉漂浮导管(CCO导管)比较反映心脏前负荷参数的有效性。方法:对2例实施肝移植,1例实施肝脏、胰腺、十二指肠移植术,1例实施肝肾联合移植术的患者进行研究,4例患者均为男性,年龄42～48岁,ASAⅢ～Ⅳ级。无PiCCO及CCO导管置入禁忌证。静脉注射咪唑安定、异丙酚、芬太尼、维库溴胺后经鼻气管插管。于麻醉诱导前、气管插管后、切皮、无肝前期、无肝期、新肝前期、新肝期、术毕及术后血流动力学发生变化时,通过温度稀释法同时测定PiCCO与CCO系列参数。结果:共测得数据135组,其中全心舒张末期容积指数(GEDI)与每搏量指数正相关(r=0.77,P<0.001),肺动脉阻塞压与GEDI相关(r=0.44,P<0.05),中心静脉压与GEDI不相关(r=0.24,P>0.05);两种方法心输出量指数结果对比差异无统计学意义(P>0.05)。SVI与GEDI之间Pearson相关系数为r=0.77(P<0.001)。结论:在上腹部单或多器官移植围术期应用PiCCO技术可准确测量心输出量,其所测量的全心舒张末期容积与胸腔内血容积较CVP更能反映心脏前负荷变化。

Objective To investigate the application of transpulmonary thermodilution method during the peri-operation of simultaneous orthotopic liver and heterotopic pancreas-duodenum transplantations, and compare the efficiency in monitoring the preload of heart with improved Swan-Ganz CCO-SvO2 method. Methods Four male patients （age： 42 -48, ASA Ⅲ-Ⅳ） were involved in the study： 2 had liver transplantation, 1 had liver and pancreas-duodenum transplantations and 1 had simultaneous liver and kidney transplantations. All cases did not have any eontraindieations of catheter implantation for PiCCO and CCO. Each patient had tracheal intubation via noses after venous administration of midazolam, propofol, fentanyl and pipeeuronium. The parameters of PiCCO and CCO had been monitored by thermodilution before induction of anesthesia, after tracheal intubation, when the operation started, before and after the old liver removed, before and after the new liver implanted, the end of the operation and after operation. Results 135 groups of data had been collected. GEDI and SVI were positively related （ r=0.77, P 〈 0. 001）; PAOP and GEDI were related（ r = 0. 44, P 〈 0. 05）, CVP and GEDI were non-related（ r = 0. 24, P 〉 0. 05） ; there was no statistic difference of CI monitored by two different methods （ P 〉 0. 05） . The Pearson correlation coefficient between SVI and GEDI was r = 0. 77 （ P 〈 0. 001 ） . Conclusion During the peri-operation of single or multi-organ transplantations in the upper abdomen, the application of PiCCO can accurately monitor the CO, the GEDV and ITBV from PiCCO is more reliable in reflecting the change of heart preload compared with the CVP.