不同肝移植术式围手术期液体管理对术后肺部并发症发生的影响

Effects of perioperative fluid management on pulmonary complication in patients undergoing different liver transplantion procedures

目的评价不同经典原位肝移植术式及围手术期液体管理对术后肺部并发症发生的影响。方法回顾性分析南京军区福州总医院从2003年4月至2007年3月行经典原位肝移植手术的终末期肝病患者107例,单因素分析兼多因素Logistic回归分析患者术前(MELD评分,腹水状况,供肝冷缺血时间)、术中(手术方式,输液总量,晶体液体量,胶体液体量,输血液制品总量,白蛋白使用量,手术时间,无肝期时间)和术后(前3天每天的液体出入量)等情况与肝移植术后肺部并发症发生率的相关性。结果统计MELD评分≤15分和>15分且<25分病例,标准经典原位肝移植组和改良经典原位肝移植组的肺部并发症发生率有显著差异。改良经典原位肝移植组比标准经典原位肝移植组术中输液总量>10L的患者(P=0.020)和术后前3天至少有2天的液体平衡≤-300mL的患者均减少(P=0.023)。肝移植术中输液总量>10L(P=0.023)和输血液制品总量>4L(P=0.032)是术后发生肺部并发症的危险因素,而采用改良经典原位肝移植(P=0.006)和术后前3天至少有2天的液体平衡≤-300mL(P=0.040)则是保护因素。结论改良经典原位肝移植术和术后前3天至少有2天的液体平衡≤-300mL,能够显著降低术后的肺部并发症发生率。

Objective: To evaluate the effects of perioperative fluid therapy on pulmonary complication after standard classic liver transplantation and modified classic liver transplantation and the risk factors of the treatment. Method: A total of 107 patients receiving liver transplantation for end-stage liver disease between April 2003 and March 2007 were analyzed retrospectively in our hospital. We used mono-factorial and multivariate logistic regression analysis to investigate the relationship between pulmonary complication and the following variables: the pre-operative Meld score, ascites condition and cold ischemia time (CIT) of donor liver ; intraoperation-2 types of liver transplantation, total amount of the infusion, liquid volume of the crystal, liquid volume of the colloidal, total transfusion of blood products, the use of albumin, operation time, the time of anhepatic period; daily volume of net fluid retention in the first 3 days after surgery. We compared the standard classic liver transplantation group and the modified classic liver transplantation group. Results: Significant difference in pulmonary complication was found between the standard classic liver transplantation and the modified classic liver transplantation patients in the situation of Meld score ≤15 points and 15-25points. Compared to the patient with standard procedures, those with modified procedures had a reduced total amount of the intraoperative infusion (P=0.020) and larger number of patients whose fluid balance ≤-300 ml for no less than 2 days in the first 3 days after operation (P=0.023). The total amount of the intraoperative infusion>10L(P=0.023) and total intraoperative transfusion of blood products>4L(P=0.032) were the risk factors of pulmonary complication, while the modified classic liver transplantation(P=0.006)and fluid balance ≤ -300 ml for no less than 2 days in the first 3 days after operation were the protective factors. Conclusion: The modified classic liver transplantation and maintaining fluid balance at ≤-300 ml for no less than 2 days in the first 3 days after operation could significantly reduce the incidence of pulmonary complication after surgery.