原位肝移植术中应用羟乙基淀粉对患者预后的影响

Effects of fluid therapy with hydroxyethyl starch in 361 patients undergoing orthotopic liver transplantation

目的:观察术中输注贺斯和万汶对原位肝移植术后转归的影响。方法:361例ASAⅡ～Ⅳ级晚期肝病患者分成非重症肝炎组(Ⅰ组)和重症肝炎组(Ⅱ组),同时根据患者输注不同胶体液分为贺斯亚组(Ⅰh组,Ⅱh组)和万汶亚组(Ⅰv组,Ⅱv组)。分别纪录各组患者术前,术毕,术后3、7和14d血浆白蛋白、血糖、肌酐、尿量和凝血酶原时间(PT);记录患者术中心跳骤停、术后14d内感染、肺水肿等并发症和血液透析、死亡等情况的病例数。结果:Ⅱ组术中心跳骤停、术后感染、肺水肿和14d内病死率均显著高于Ⅰ组(P<0.01)。Ⅱ组肌酐、尿量、PT水平与Ⅰ组比较均分别在不同时段差异有显著性(P<0.01或P<0.05);Ⅱh组从术毕以后血糖指标显著高于Ⅰh组(P<0.01或P<0.05)。Ⅰ组中,Ⅰh组肌酐水平、PT从术毕至术后3d均显著高于Ⅰv组(P<0.01);从术毕至术后7d,Ⅰh组尿量显著低于Ⅰv组(P<0.01)。Ⅱ组中,Ⅱh组肌酐水平从术毕至术后3d显著高于Ⅱv组(P<0.01);Ⅱh组PT水平术毕时高于Ⅱv组(P<0.01);Ⅱh组血糖从术毕至术后7d,显著高于Ⅱv组(P<0.01)。结论:在白蛋白和血浆等的联合配伍下,贺斯和万汶在原位肝移植术中均能提供良好的液体治疗,万汶对原位肝移植患者的肾脏保护和凝血机制更有利,并可能对重症肝炎患者术后的血糖控制有益。

Objective To observe the effects of two different hydroxyethyl starch 200/0,5 （HES） and 130/0.4 （voluven） on orthotopie liver transplantation （OLT）. Methods 361 ASA Ⅱ-Ⅳ patients with end-stage liver disease undergoing OLT were divided into non-fulminant hepatic failure （non-FHF） group （ I ） and fulminant hepatic failure （FHF） group （ Ⅱ ） and then assigned to receive either HES 200/0.5 or voluven. Blood levels of albumin （Alb）, glucose （Glu） and ereatinine （Cr）, urine volume （UV）, and PT were documented preoperatively, on completion of surgery, and at postoperative days 3, 7, and 14; so were the cases of intraoperative cardiac arrest, postoperative infection within 14 days, pulmonary edema, dialysis requirement, and death. Results The cases of intraoperative cardiac arrest, postoperative infection, pulmonary edema, dialysis requirement, and death were significantly greater in group Ⅱ than in group Ⅰ （P 〈 0.01）. There were significant differences in Cr levels, UV, and PT between group Ⅱ and group Ⅰ at different time points（P 〈 0.01 or P 〈 0.05）. Postoperative Glu levels in group Ⅱ with HES 200/0.5 were markedly higher than those in group Ⅰ with HES 200/0.5 （P 〈 0.01 or P 〈 0.05）. In group Ⅰ , Cr levels and PT were notably higher in the patients receiving HES 200/0.5 than those receiving voluven from completion of surgery to postoperative day 3 （P 〈 0.01 ）, while UV was lower from completion of surgery to postoperative day 7 （P 〈 0.01 ）. In group Ⅱ , Cr levels were obviously higher in the patients receiving HES 200/0.5 than those receiving voluven from completion of operation to postoperative day 3 （P 〈 0.01 ）, so was PT at the end of surgery （P 〈 0.01 ） and were Glu levels from completion of surgery to postoperative day 7 （P 〈 0.01 ）. Conclusions In combination with Alb and blood plasma, either HES 200/0.5 or voluven is an effective fluid therapy during OLT. Voluven is more beneficial for those with poorer renal or coagulation function and for the postoperative glucose control.