成人活体肝移植供肝切取术麻醉管理的研究

The anesthesia management in adult-to-adult living-donor liver transplantation

目的探讨成人间活体肝移植(A￣ALDLT)供体供肝切取术的麻醉管理安全措施。方法前瞻性研究2007年5月至2008年9月在中山大学附属第三医院肝移植中心实施A￣ALDLT供体供肝切取术的18例患者的麻醉管理措施。所有患者均签署知情同意书,符合医学伦理学规定。术中采取控制性低中心静脉压、维持循环系统的稳定、全程回输自体血液、全身应用小剂量肝素、保护肝、肾功能等麻醉管理措施。观察供体手术时间、出血量、尿量、输液量及围手术期是否顺利等情况;将手术过程分为麻醉后手术前(手术前),切肝1、2、3 h,关腹前5个时间点,监测患者心率(HR)、收缩压(SBP)、舒张压(DBP)、中心静脉压(CVP)等生命体征;监测红细胞压积(HCT)、活化凝血时间(ACT)变化;观察术前和术后1、3、7及14 d的丙氨酸转氨酶(ALT)、白蛋白(ALB)、总胆红素(TB)及血清肌酐(Scr)等生化指标变化。术中各时间点SBP、DBP、HR、CVP、HCT、ACT、ALT、ALB、TB、Scr指标变化用单因素方差分析,各时间点组间比较用Student￣Newman￣Keuls(q)检验。结果 18例供体均顺利渡过围手术期,手术时间(526±106)min,出血量(842±285)ml,尿量(1 558±442)ml,回输自体血液(417±84)ml。手术过程中检测HR、血压(BP)无明显变化。与手术前相比,切肝1、2、3 h的CVP明显降低,差异有统计学意义(均为P<0.05)。回输自体血液后,关腹前HCT为0.33±0.03,略有下降,但仍在正常范围内。应用小剂量肝素5 min后ACT值明显升高,用鱼精蛋白中和后ACT恢复至术前水平。术后肝功能下降,2周后基本恢复正常;肾功能无明显变化。供体均痊愈出院。结论活体肝移植供体肝叶切取术中采用控制性低中心静脉压,维持循环系统的稳定,全程回输自体血液,全身应用小剂量肝素,保护肝、肾功能等麻醉管理措施,可保障供体安全。

Objective To evaluate the effect of anesthesia managements in the donor＇s operation of adult-to-adult living-donor liver transplantation （A-ALDLT）. Methods Anesthesia managerents in hepatectomy of 18 A-ALDLT donors from liver transplant center in the Third Affiliated Hospital of Sun Yat-sen University from May 2007 to September 2008, were analyzed prospectively. Local ethical committee approval had been received and that the informed consent of all participating subjects was obtained. Application of controlled low central venous pressure （CVP）, stablization of circulation, blood auto- transfusion, low dose systematic heparinization and hepatorenal function protection were used in the 18 donors. The operation time, blood loss, urine volume, transfusion volume and the operative procedures were observed and recored. The operation was devided into 5 time points, after anesthesia and before operation, 1, 2, 3 h after hepatectomy, before abdomen-closing. Heart rate（HR）, systolic blood pressure（SBP）, diastolic blood pressure（DBP）, CVP, hematocrit（HCT） as well as activated clotting time（ACT） were monitored. The levels of alanine aminotrausferase（ALT）, albumin（ALB）, total bilirubin（TB） and serum ereatinine（Scr） were measured preoperation and 1,3,7,14 days postoperaion. One-way anova was applied to analyze the SBP, DBP, HR, CVP, HCT, ACT, ALT, ALB, TB, Ser of every time point. Student-Newman-Keuls statistical method was applied to analyze the group comparison. Results All donors recovered smoothly. The average operation time was （526±106）min and the blood loss was （842±285）ml. The average urine volume was （1 558±442）ml. The auto-transfusion blood was （417±84）ml. The HR, blood pressure（BP） were stable during the operation. The CVP dropped markedly 1, 2 and 3 h after hepateetomy, compared with preoperation. There was significant differenee （P〈0.05）. The average HCT was 0.33±0.03 after blood autotransfusion but before abdominal closure, which mildly decreased but still within the normal range. The ACT increased markedly 5 minutes later after low dose heparinization and recovered to baseline level after the application of protamine. Mild liver function damage was observed after operation and recovered to normal 2 weeks later. The renal function remained unchanged. All the donors recovered smoothly and discharged. Conclusions In the donor＇s operation of A-ALDLT, anesthesia management including controlled low CVP, stabilization of circulation, blood autotransfusion, low dose heparinization and hepatorenal function protection are very important for donor safety.