肝移植术中再灌注前经门静脉放血对内环境和心肺功能的影响

The effect of portal vein bloodletting before reperfusion on homeostasis and cardiopulmonary function during orthotopic liver transplantation

目的研究肝移植术中再灌注前放血的临床意义。方法32例肝病患者在静脉及吸入复合全麻下行无转流原位肝移植术，分为再灌注前放血组（经门静脉放血200ml，21例）和对照组（11例）。常规麻醉监测，并放置Swan—Ganz导管监测心输出量，无肝前期、无肝期给予抑肽酶、去甲肾上腺素及多巴胺，维持无肝期平均动脉压〉70mmHg，心输出量指数〉2．5L·min^-1·m^-2。分别于门静脉阻断即刻（T1）、门静脉开放即刻（T2）、新肝期10min（T3）、新肝期30min（T4）采集桡动脉血液测定电解质、血气及炎性细胞因子浓度（肿瘤坏死因子tumor necrosis factor alpha—alpha，TNF-α；白介素6，Interleukin-6，IL-6）。各时间点分别记录心肺功能参数。结果两组患者心律失常发生率（Х^2=1．73，P〉0．05）和死亡率（Х^2=1．12，P〉0．05）没有显著差别；各时间点血钙、血镁浓度均明显低于正常值；两组患者桡动脉血钾、TNF—α、IL-6均无显著变化，再灌注前放血对乳酸的增长没有影响；各时间点肺氧合功能、心功能参数无显著变化，组间无明显差异。新肝期30min，两组患者均表现为乳酸、炎性因子呈增高趋势，外周血管阻力指数（systemic vascular resistance index，SVRI）显著下降。结论再灌注前放血似乎对内环境、心肺功能影响较小。

Objective To investigate the clinical implications of portal vein bloodletting immediately before reperfusion during orthotopic liver transplantation （OLT）. Methods Thirty-two patients with end-stage liver diseases undergoing non veno-venous OLT were divided into bloodletting group （n = 21 ） and control group （n = 11 ）. During anhepatic phase, we maintained mean arterial pressure 〉70 mm Hg,cardiac index 〉 2.5 L·min^-1·m^-2 by infusion, norepinephrine and dopamine. Blood samples were taken at the time when portal vein was clamped（ T1 ）, the time when portal vein was unclamped （ T2 ）, 10 minutes after neohepatic phase （ T3 ）, neohepatic phase 30 minutes （ T4 ） for electrolytes, blood gas and plasma inflammatory cytokines. Hemodynamic and ventilation parameters were also recorded. Results There was no significant difference in mortality （ Х^2 = 1.12, P 〉 0. 05 ） and arrhythmia incidence （Х^2 = 1.73, P 〉 0. 05 ） between the two groups. Serum calcium, magnesium were both significantly lower than normal. After anhepatic phase, potassium, tumor necrosis factor alpha, interleukin-6 in radial artery didn＇t alter significantly; Bloodletting had no effect on lactic acid. There was no significant difference in hemodynamic and ventilation parameters among four time periods. Conclusion Bloodletting seemed to have no effect on changes of internal environment.