中老年肝移植围手术期的临床分析

Clinical analysis of liver transplantation perioperatively in the aged patients over sixty years of age

目的探讨中老年患者肝移植术前基本资料的特点及术中血流动力学和肾功能的变化。方法 2003年4月至2011年12月施行成年非转流腔静脉成形肝移植术202例,年龄≥60岁24例为中老年组,余178例为成年组。均采用静吸复合全麻,观察术中不同时期血流动力学指标及肾功能指标,回顾性分析两组术前基本资料。结果中老年组患者术前合并糖尿病和高血压的比例高于成年组,术前血清胆红素总量、凝血酶原时间和肝肾综合征的比例低于成年组,差异有统计学意义(P<0.05)。两组患者在无肝期中心静脉压(CVP)、平均动脉压(MAP)、肺动脉嵌压(PAWP)均较麻醉前明显下降,而心率(HR)明显加快,在新肝期5、30 min CVP、PAWP、HR较术前明显增高,新肝期5 min MAP明显下降,差异有统计学意义(P<0.05)。在无肝期30 min中老年组CVP明显低于成年组;而HR则明显高于成年组,MAP则在新肝期5 min和30 min低于成年组,差异有统计学意义(P<0.05)。两组患者在新肝期1h和术毕肌酐(Cr)明显高于术前,差异有统计学意义(P<0.05)。结论中老年肝移植患者器官功能退行性改变且可能合并各种并发症,但术前筛选严格,基本情况较好,虽术中血流动力学复杂,但术中加强监护和管理,能平稳地度过围手术期。

Objective To investigate the clinical characteristics of pre-operation and changes in hemodynamics and renal function during operation of liver transplantation in the aged patients over sixty years of age. Methods Retrospective analysis was conduct on 202 consecutive adult patients undergoing the suprahepatic venacavaplasty in liver transplantation. The elder group consisted of patients over 60 years （ n = 24） and adult group consisted of patients under 60 years of age （n = 178）. General anesthesia with tracheal intubed was conducted in all patients. Hemodynamics and renal function （BUN and Cr） were monitored during operation, and clinical characteristics of pre-operation were reviewed retrospectively. Results The data from Analysis revealed that the elder group had lower serum total bilirubin and shorter prothrombin than that in the adult group （ P 〈 0.05 ）. The incidence rates of hypertension and diabetes in per-operation were higher significantly in the elder group （ P 〈 0.05 ）. The incidence rate of hepatic renal syndrome in per-operation was lower significantly in the elder group （P 〈 0.05）. In all patients, the values of CVP, MAP, PAWP were decreased significantly compared with preoperative values at anhepatic phase （ P 〈 0.05 ）, heart rates were increased from preanhepatic phase to end of operation （P 〈 0.05 ）. The values of CVP, PAWP and HR were increased at 5 min and 30 min of neohepatic phase ,and the values of MAP were decreased at 5min of neohepatic phase （P 〈 0.05 ）. Compared the elder group with the adult group, the values of CVP were lower and heart rates were higher at 30min of anhe- patic phase in the elder group （P 〈 0.05 ）, the values of MAP were lower significantly at 5 min and 30 min of neohepatic phase in the elder group （P 〈 0.05 ）. The values of Cr in all patients were increased significantly at the 1 h of anhepatic phase and the end of operation （P 〈 0.05）. Conclusion The retrograde function and coexisting complication of organ are present in the aged patients receiving liver transplantation, and the hemodynamics are complicated during the operation, the operations were smoothly accomplished under carefully screening low-risk elderly patients and accordingly intensified and managed monitor during operation.