婴幼儿亲属活体肝移植术中受者生理内环境的变化及处理

Intraoperative changes of internal environment in infants undergoing living related liver transplantation

目的观察婴幼儿亲属活体肝移植受者术中生理内环境的变化规律，并探讨相应的处理措施。方法25例肝移植婴幼儿受者中，男性12例，女性13例，年龄（3．4±4．6）个月（2～11个月），体重（6．8±1．3）kg（3．1～8．8kg）。肝移植术中定时经桡动脉采血监测血气、血生化及凝血功能，对酸碱平衡、电解质、血糖、乳酸等指标的变化进行分析，检测时点分别为麻醉后手术开始前（术前）、门静脉阻断前5min（无肝期前）、门静脉开放前5min（无肝期）、门静脉开放后5min（新肝期I）、门静脉开放后30min（新肝期1I）及术毕。针对术中各阶段的不同特点和具体情况给予相应处理。结果术中患儿生理内环境出现较大波动。与术前相比，Na^＋浓度于术中各阶段均无显著变化；pH值和K^＋浓度于无肝期前及无肝期时均无显著变化（P〉0．05），pH值于新肝期I时出现显著下降（P〈0．01）并于术毕时恢复至术前水平，K^＋浓度于新肝期I时显著下降，并持续至术毕（P〈0．01）；Ca^2＋浓度于无肝期前至新肝期Ⅱ时均出现下降，但术毕时恢复至术前水平，其中无肝期前和新肝期Ⅱ时的Ca^2＋浓度显著低于术前水平（P〈0．05）；血糖于无肝期前至新肝期Ⅱ时出现显著升高（P〈O．05），虽在术毕时有所降低，但仍显著高于术前水平（P〈0．05）；乳酸于无肝期前至新肝期Ⅱ时出现显著升高（P〈0．01），术毕时恢复至术前水平；剩余碱值于无肝期前显著降低，并持续降低至新肝期II（P〈0．05），术毕时恢复至术前水平。25例患儿均顺利完成手术，除术后在重症监护病房死亡2例外，其余均顺利回到病房。结论婴幼儿亲属活体肝移植术中受者血液酸碱平衡、电解质、乳酸、血糖等生理内环境指标变化复杂，且独具特点并相互关联；术中应根据监测结果，针对手术不同阶段的不同指标适时加强监测和调控。

Objective To investigate intraoperative changes of internal environment in infants undergoing living related liver transplantation （LRLT）, and to explore appropriate treatment measures. Methods Twenty-five infants undergoing LRLT were retrospectively studied, including 12 males, 13 females, with age of （3. 4 ± 4. 6） months （ranging from 2-11 months）, weight of （6. 8 ± 1.3） kg （ranging from 3. 1-8. 8 kg）. Arterial blood samples were collected before the operation, at preanhepatic phase （5 rain before cross-clamping）, at anhepatic phase （5 rain before opening inferior vena cava）, 5 and 30 min after the opening inferior vena cava respectively, and at the completion of the surgery the pH value, bases excess （BE）, the levels of sodium, potassium, calcium, glucose and lactate were determined. Results There were large fluctuations to the internal environment during operation. Compared with the preoperative values, the intraoperative concentrations of Na^＋ had no significant changel The pH value and blood level of K^＋ had no significant change at pre-anhepatic phase and anhepatic phase （P〉0. 05）, the pH value was decreased at anhepatic phase I （P〈0. 01 ） and returned to the preoperative level at the end of the operation, and the blood level of K^＋ decreased at anhepatic phase and lasted till the completion of the surgery （P〈0. 01）. The blood level of Ca^2＋ was decreased at pre-anhepatic phase and neohepatic phase II （P〈0. 05）, and recovered at the end of the operation. Blood glucose concentration was increased significantly at preanhepatic phase to neohepatic II , and still kept at the higher level until the end of operation. The lactate concentrations were increased significantly at pre-anhepatic phase to neohepatic II （P〈0. 01 ）, and recovered at the end of operation. The BE was decreased at pre-anhepatic phase to neohepatic 11 （P〈0. 05）, and recovered at the end of the operation. Conclusion There are significant disruptions which are unique and inter-related to the internal environment parameters in infants during the operation of LRLT. Monitoring and accurate intraoperative managements for different physiological status at different phases are critical for the success of LRLT in infants.