采用Swan—Ganz导管评价肝硬化患者肝移植术前心功能的状态

Evaluation of cardiac function of patients with fiver cirrhosis before orthotopic fiver transplantation using Swan-Ganz catheter

目的采用Swan—Ganz导管评价肝硬化患者肝移植术前心功能的状态。方法择期拟行原位肝移植术患者60例，年龄45。64岁，ASAⅡ-Ⅳ级，按术前肝功能状态分为2组：肝硬化代偿组（C组，n=28）和肝硬化失代偿组（H组，n=32）。静脉注射眯达唑仑、异丙酚、维库溴铵和芬太尼麻醉诱导，气管插管后行机械通气，维持PETCO2 30—45mmHg；吸入异氟醚，间断静脉注射芬太尼，静脉输注维库溴铵维持麻醉。常规监测HR，麻醉诱导后桡动脉穿刺置管，监测MAP；右侧颈内静脉置入Swan-Ganz漂浮导管，监测心输出量（CO）、心指数（CI）、右室射血分数（RVEF）、平均肺动脉压（MPAP）、肺动脉楔压（PAWP）、右房压（RAP）、右心室舒张末期容积（RVEDV）、右心室收缩末期容积（RVESV）和心搏指数（SVI），计算右室每搏功指数（RVSWI）、左室每搏功指数（LVSWI）、体循环血管阻力（SVR）和肺循环血管阻力（PVR）。结果与C组比较，H组HR、MAP、RAP和RVEF差异无统计学意义（P〉0．05），CO、CI、SVI、MPAP、PAWP、RVEDV、RVESV、RVSWI和LVSWI升高，SVR和PVR降低（P〈0．05）。结论原位肝移植术前肝硬化失代偿患者处于高排低阻状态，肺动脉压升高，心脏收缩功能和舒张功能降低，应加强心脏功能的保护。

Objective To evaluate the cardiac function of the patients with liver cirrhosis before orthotopic liver transplantation （OLT） using Swan-Ganz catheter. Methods Sixty ASA II- IV patients aged 45-64 yr with liver cirrhosis scheduled for OLT without veno-venous bypass were allocated into 2 groups according to preoperative liver function： compensated group （group C, n = 28） and decompensated group （group H, n = 32）. Anesthesia was induced with midazolam 3-5 mg, fentanyl 0.15-0.2 mg, propofol 1 mg/kg and vecuronium 0.1 mg/kg and maintained with 0.5%-3.0% isoflurane, fentanyl 0.05-0.10 mg and vecuronium 4 mg/h. The patients were mechanically ventilated after tracheal intubation, and Prr CO2 was maintained at 30-45 mm Hg. Radial artery was cannulated and Swan-Ganz catheter was placed via right internal jugular vein for monitoring of mean arterial pressure （MAP）, cardiac output （CO）, cardiac index （CI）, right ventricular ejection fraction （RVEF）, mean pulmonary arterial pressure （MPAP）, pulmonary arterial wedge pressure （ PAWP）, right atrial pressure （RAP）, right ventricular end-diastolic volmne （RVEDV）, right ventricular end-systolic volume （RVESV）and stroke volume index （SVI）. Right and left ventricular stroke work index （RVSWI, LVSWI） and systolic and pulmonary vascular resistance （SVR, PVR） were calculated.Results CO, CI, SVI,MPAP, PAWP, RVEDV, RVESV, RVSWI and LVSWI were significantly elevated in group H as compared with group C indicating hyper-hemodynamic state. The SVR and PVR were significantly decreased in group H. There was no significant difference in HR, MAP, RAP and RVEF between the two groups. Conclusion The patients with decompensated liver function before OLT are in a hyper-hemodynamic state. More attention should be paid to perioperative myocardial protection.