重症肝炎肝移植术患者的麻醉管理

Perioperative anesthetic management for fuiminant hepatic failure patients receiving liver transplantation

目的:总结重症肝炎患者行肝移植术的麻醉管理经验。方法:回顾性分析2006年1月至2007年1月48例重症肝炎行肝移植术患者的临床麻醉资料,总结麻醉管理经验。采用全身麻醉,术中根据血流动力学监测结果调整肾上腺素、去氧肾上腺素用量;分别与术前、门静脉阻断前5 min、无肝期30 min、开放血流前5 min、新肝期5 min、新肝30 min和60 min时抽取桡动脉血作血气电解质分析,测定凝血功能,根据结果调整用药维持电解质及凝血功能稳态。结果:48例肝移植患者麻醉成功,无术中死亡,术中平均出血量(5 219±478)ml。术前轻度碱中毒、低K^+、低Na^+、低Cl^-。与术前相比,pH、BE、HCO_3^-无肝期30 min明显降低,新肝期60 min回升;K^+无肝期30 min明显升高,新肝60 min逐渐下降;无肝期Ca^(2+)明显降低(P<0.05)。术前凝血酶原时间(PT)明显长于正常值(P<0.05),经治疗后好转,在新肝期前后5 min内PT再次延长;纤维蛋白原定量(FIB)较术前明显降低(P<0.05),至术毕时逐渐恢复。全组患者在无肝期心输出量(CO)、平均动脉压(MAP)迅速下降,其余各点血流动力学基本平稳。结论:重肝患者肝移植术前常合并内环境紊乱,必须随时监测患者血流动力学、血气及凝血功能的相关指标,并根据监测结果随时调整用药以维持内环境稳定。

Objective： To summarize our experience in perioperative anesthetic management for {ulminant hepatic failure （FHF） patients receiving liver transplantation. Methods：The clinical anesthetic data of 48 FHF patients receiving orthotopic liver transplantations （OLT） from January 2006 to January 2007 were retrospectively analyzed,and the anesthetic management experience was summarized. General anesthesia was applied; the hemodynamics was monitored during the operation and doses of adrenaline and phenylephrine were adjusted according to the monitoring results. Blood samples were obtained before operation, before anheptic,30 min after anhepatic phase, 5 min before neohepatic phase,and 5 min, 30 min and 60 min after neohepatic phase for blood gas and electrolyte analysis and for determination of coagulation function; the drugs were subsequently adjusted according to analysis results. Results： All the 48 patient underwent successful anesthetic management and there was no death during opearation. The average blood loss during operation was （5 219±478） ml. Mild alkalosis, hypokalemia, hyponatrium, and hypocalcemia were present before operations, pH, BE and HCO3^- were obviously reduced 30 min after anhepatic phase and increased 60 min after neohepatic phase. Kalemia was obviously increased 30 min following anhepatic phase and began to increase 60 min following neohepatic phase. Calium concentration was decreased at the end of preanhepatic phase （P〈0.05）. Prothrombin time （PT） before operation was significantly longer than the norm （P〈0.05） and tended to recover after treatment; however,it prolonged again 5 min before and after neohepatic phase. The fibrinogen （FIB） level was significantly decreased compared with that before operation （P〈0.05） and gradually recovered at the end of the operation. There was no rapid decrease in the cardiac output or mean aterial pressure at anhepatic phase, and the hemodynamics was stable at other phases. Conclusion： FHF patients are often complicated with disorders in the inner environment; their hemodynamics,blood gas and coagulation functions should be monitored perioperatively,and drugs should be adusted accordingly to maintain the stability of the inner environment.