原位肝移植术无肝期体肺循环的变化及维持

Changes and management of systemic and pulmonary hemodynamics during anhepatic period in patients undergoing OLT

目的分析晚期肝病患者非静脉转流原位肝移手术不同阶段体、肺循环的变化并探讨维持无肝期血流动力学的措施。方法收集68例肝移植患者手术前（麻醉诱导后）、无肝期前、无肝期5min、无肝期30min、新肝期5min、新肝期30min、新肝期60min、术毕、术后12h及24h各时间点中心静脉压（CVP）、心率（HR）、平均动脉压（MABP）、平均肺动脉压（MPAP）、肺动脉楔压（PAwP）、心脏指数（CI）、体循环阻力（SVR）、肺循环阻力（PVR）等数据，并根据无肝期CVP将患者分为3组：A组（CVP〈4mmHg），B组（4mmHg≤CVP≤6mmHg），C组（CVP〉6mmHg），分析比较3组患者手术各时期及术后血流动力学指标变化，以及血管活性药多巴胺、去甲肾上腺素、肾上腺素用量及尿量。结果肝移植手术不同阶段，患者体、肺循环发生不同变化，与无肝期前相比，无肝期HR增快，CVP、MABP、PVP、CI、PAWP降低，SVR、PVR增高，P〈0．05，具有显著性差异，表现为循环血容量降低，体循环及肺血管阻力增高；新肝期早期（新肝期5、30min）HR减慢，CVP、PAWP、MPAP、PVR、SVR增高（P〈0．05），新肝期开始，MABP降低、升高波动大，5min后升高并趋于稳定。3组间比较，B组患者各时期血体、肺循环指标波动最小，术中血管活性药用量最少，与A、C组比较，差异有统计学意义（P〈0．05）。结论原位肝移植术中患者体、肺循环剧烈变化主要发生在无肝期及新肝早期，无肝期血流动力学的恰当维持尤为重要，适量补充血容量并复合应用多巴胺、去甲肾上腺素、肾上腺素等血管活性药，维持CVP4～6mmHg、MABP≥60mmHg、PAWP、SVR、PVR正常范围，有利于患者新肝期及术后血流动力学的稳定。

Objective To study the changes and management of systemic and pulmonary hemodynamics during anhepatic period in patients undergoing orthotopic liver transplantation without veno-venous bypass. Methods Sixty-eight patients with end-stage liver disease undergoing orthotopic liver transplantation were enrolled in this research. Monitoring and recoding CVP, MAP, CI, HR, MPAP, PAWP PVR, SVR at different time points ： preincision, before anhepatic, 5, 30 rain of anhepatic, 5, 30, 60 min of neohepatic, ending of operation, 12 h and 24 h after operation. All the patients were divided into three groups according CVP during anhepatic period： group A（ CVP 〈4 mmHg） ,group B（4 mm Hg≤CVP≤6 mmHg） ,group C （CVP 〉 6 mmHg）. Besides, calculating the concentration of dopamine, norepinephrine ,epinephrine and the volume of urine during of operation. Results There were different changes during different operation periods. During anhepatic period, HR, PVR and SVR increased, while CVP, CI, MAP, PAP, PAWP decreased （P 〈 0.05）. At early neohepatic period, HR decreased and CVP, PAWP, MPAP, CI, PVR SVR in- creased ,At the beginning of neohepatic period, MAP dacreased or increased quickly, and became steadily after 5 min. Among the three groups, the changes of hemodynamics in group B was slightest, and the concentration of dopamine, norepinephrine and epinephrine was smallest （ P 〈 0.05）. Conclusions The sys- temic and pulmonary emodynamics fluctuated sharply during anhepatie and early neohepatic period. It is important and useful to manage CVP 4 -6 mmHg, MABP≥ 60 mmHg by infusing liquid and vasoconstrictors, such as dopamine, norepinephrine or epinephrine during anhepatic period.