经典非转流原位肝移植手术的麻醉管理

Management of anesthesia during orthotopic liver transplantation with classical non-bypass

选择2004-06/2006-08合肥市第一人民医院收治的终末期肝病患者25例,均采用经典非转流原位肝移植手术。①麻醉诱导采用丙泊酚、芬太尼、司可林,血液动力学不稳定者用咪唑安定、氯胺酮、阿曲库铵诱导。麻醉维持用丙泊酚、阿曲库铵泵注、芬太尼间断推注及间断吸入异氟醚。②分别于切皮前、无肝前期、无肝期即刻、无肝期后5,30min和新肝期即刻、新肝期后5,30min以及手术结束时无创或有创连续监测动脉血氧饱和度、中心体温、心率、心电图、呼气末二氧化碳浓度、尿量、动脉压、股静脉压、中心静脉压及平均动脉压,并采血检测血气电解质变化。25例患者肝移植手术期间的麻醉管理平稳。①无肝前期收缩压、舒张压、中心静脉压、平均动脉压均较切皮前下降,经补液维持在正常范围内。②无肝期即刻收缩压、舒张压、中心静脉压、平均动脉压均较切皮前下降(P<0.01),无尿,而心率、股静脉压较切皮前升高(P<0.01),所有患者需血管活性药物维持,新肝期即刻收缩压、舒张压较切皮前下降(P<0.05)。经处理后逆转正常,给予利尿剂后基本改善无尿,此期间股静脉压、中心静脉压、平均动脉压与切皮前差异无显著性意义(P﹥0.05)。③无肝期和新肝期酸碱度、剩余碱、碳酸根离子变化明显(P<0.05),特别是新肝期即刻变化尤为显著。新肝期即刻至新肝期后5min血钾水平均较切皮前升高(P<0.01),血钙水平从新肝期即刻至新肝期后5min均较切皮前下降(P<0.05),处理后效果良好。经典非转流原位肝移植手术成功的麻醉管理在于对患者手术前评估、平稳的麻醉诱导和维持、各手术时期血液动力学和机体稳态以及血管活性药物应用等综合指标的把握。

From June 2004 to August 2006, twenty-five patients with end-stage liver disease received orthotopic liver transplantation surgery using classical non-bypass method in the Hefei First People＇s Hospital. After systemic anesthesia in all of patients was induced using propofol, fentanyl and scoline, but some patients with instable hemodynamics were induced using midazolam, ketamine and atracurium. Anesthesia was maintained by target controlled infusion of propodol and atracurium, fentanyl was given discontinuously, and isoflurane was inhaled discontinuously. Pulse oxygen saturation, core temperature, heart rate, electrokardiogram, end-tidal CO2 pressure, urinary volume, arterial pressure, peripheral venous pressure, central venous pressure （CVP）, mean pulmonary arterial pressure （MPAP） were monitored continuously in a noninvasive or invasive way, which were recorded according to difference time of before incision, preanhepatic, anhepatic momentarily, 5 minutes and 30 minutes after anhepatic, neohepatic, 5 minutes and 30 minutes after neohepatic, and postanhepatic phases. Blood gas and electrolytes were also analyzed. All of 25 patients were succeeded to manage anesthesia during the transplantation. There were slight decreases about systolic blood pressure （SBP）, diastolic blood pressure （DBP）, CVP and MPAP in preanhepatic phase compared with before incision, and they all maintained at a normal level after fluid replacement. The levels of SBP, DBP, CVP and MPVP were markedly lower in anhepatic phase （P 〈 0.01）, accompanied with anuria, while heart rate and peripheral venous pressure were markedly raised compared with before incision （P 〈 0.01）. All patients were in need of vasoactive agents. SBP and DBP were seriously declined in neohepatic phase （P 〈 0.05）. Retroconversion recovered after treatment, and there were no significant differences in the peripheral venous pressure, CVP and MPVP compared with before incision （P 〉 0.05）. Acid-bases indices, such as acidity or alkalinity, base excess and carbonate ion were markedly changed in both anhepatic and neohepatic phases （P 〈 0.05）, especially at immediate neohepatic phase. Compared with before incision, the serum potassium level was increased （P 〈 0.01） whereas serum calcium level was decreased （P 〈 0.05） during the immediate stage to 5 minutes at neohepatic phase. All of above anomaly state was corrected by using vasoactive drugs and diuretic as well as transfusion treatment. Succeed anesthesia management in classical non-bypass orthotopic liver transplantation depends on preoperation evaluation, a steady hemodynamics during anesthesia induction and maintenance, homeostasis and application of vasoactive drugs.