含乳酸晶体液对肝移植术中病人动脉血乳酸浓度的影响

Effect of lactated crystalloid solution on arterial blood lactate concentration during orthotopic liver transplantation

目的探讨三种不同晶体液输入对非转流原位肝移植术中病人动脉血乳酸和酸碱平衡的影响。方法全麻下非转流经典原位肝移植术中病人90例,男78例,女12例,年龄16-67岁,体重45-87kg,随机分为3组,术中分别静脉输入乳酸林格氏液(LR组)、生理盐水(NS组)和醋酸林格氏液(PA组)。术中胶体液和血液制品的输入根据血压(BP)、中心静脉压(CVP)和血红蛋白等进行调节。于麻醉前、门静脉阻断时、无肝期30min、门静脉开放前即刻和下腔静脉开放后5min、30min、手术结束时采动脉血测pH、剩余碱(BE)和乳酸(LA)。结果三组晶体、胶体液和血液制品输入量差异无统计学意义(P>0．05)。与麻醉前相比,三组pH于无肝期前均下降并持续至术毕(P<0．05),BE在无肝期30 min明显下降(P<0．05),LA浓度自无肝期前开始升高并持续至术毕,新肝开放后升高尤为显著,约相当于麻醉前3倍水平(P<0．01)。各时点三组间上述各指标差异无统计学意义。结论非转流原位肝移植术中输入乳酸林格氏液,对动脉血LA升高的趋势无显著影响。

Objective To compare the effects of three different crystalloid solutions on arterial blood lactate concentration and acid-base balance during orthotopic liver transplantation （OLT） without veno-venous bypass. Methods Ninety ASA Ⅱ-Ⅳ patients with end-stage liver disease of both sexes （78 males, 12 females） aged 16-67 yrs weighing 45-87 kg undergoing OLT were randomly allocated to one of 3 groups （ n = 30 each） ： group Ⅰ received normal saline （NS）; group Ⅱ received lactated Ringer＇s solution （LR） and group IlI acetated Ringer＇s solution （Plasma A, Baxter） （PA）. The crystalloid was infused at a rate of 6-8 ml·kg^-1·h^-1. Colloid, albumin, RBC and whole blood were infused based on BP, CVP and Hb concentration. The arterial pH, BE and lactate concentration were measured before anesthesia （To baseline）, before cross-clamping of the portal vein （T1） at 30 min and the end of anhepatic phase （T2, T3 ）, 5 and 30 min after unclamping of the portal vein （T4, T5 ） and at the end of surgery （T6）. Results There was no significant difference in the amount of crystalloid, colloid and blood products infused during operation among the 3 groups. Arterial pH decreased significantly at T1 （ immediately before anhepatic phase） as compared to the baseline value at To and the low pH was maintained until the end of operation. BE was significantly decreased during anhepatic phase （at T2 and T3 ）. The blood lactate was increasing during operation and was 3 times that of baseline value at the end of operation. However there was no significant difference in arterial pH, BE and lactate concentration among the 3 groups. Conclusion In OLT without venovenous bypass, blood lactate increases progressively but the lactated Ringer＇s solution does not have any effect on the blood lactate concentration.