原位肝移植麻醉中不同阶段血流动力学特点及处理方法

Characteristics of Hemodynamics at Different Phases in Orthotopic Liver Transplantation and Anesthetic Management

目的：探讨原位肝移植麻醉中不同阶段血流动力学变化的特点及麻醉处理方法。方法：选择2011年1月～2012年6月期间在我院接受背驼式原位肝移植术的终末期肝病患者32例，采用气管内静吸复合全麻。监测心输出量（CO）、心脏指数（CI）、中心静脉压（CVP）、平均动脉压（MAP）等血流动力学参数变化，同时查血气监测内环境各项指标。结果：血流动力学变化显示，在无肝期CO、CI、CVP、MAP均较术前明显下降（P〈0．01）；新肝植入初期CVP较术前明显升高（P〈0．01）、而MAP、CO、CI下降（P〈0．01）；血气监测显示，无肝后期表现为pH值轻度降低，血清Ca2＋、K＋降低，碱剩余（BE）、乳酸含量增高；新肝植入初期表现为pH值降低明显，血清K＋、BE、乳酸含量增高，血清Ca2＋降低，经综合处理，均可纠正电解质紊乱和酸碱失衡。结论：血流动力学改变主要发生于无肝后期和新肝植入初期。肝移植麻醉不同阶段采用不同原则管理循环、及时处理内环境紊乱，可保持肝移植麻醉的循环平稳。

Objective：To explore the characteristics of hemodynamics at different phases in orthotopic liver transplantation and anesthetic management. Methods：During the periods from January 2011 to June 2012, thirty-two patients with the chronic end-stage liver disease underwent orthotopic liver transplantation were enrolled in our hospital. All patients were anesthetized under combined intravenous-inhalational anesthesia. The hemodynamic parameters including cardiac output （CO）, cardiac index （CI）, central venous pressure （CVP） and mean systemic arterial pressure （MAP） were monitored. The artery blood gas parameters were also measured. Results： Compared with those parameters before operation, CO, CI, CVP and MAP decreased significantly at anhepatic stage （P〈 0.01）, but CVP increased while CO, CI and MAP decreased significantly at the early phase ofneohepatic stage （P〈0.01）. The blood gas analysis results indicated that serum pH value decreased slightly. Serum potassium and calcium decreased and base excess and lactate increased at later phase ofanhepatic stage. With this correspondence, serum pH value decreased apparently. Serum potassium, base excess and lactate increased further and serum calcium decreased further at neohepatic stage （P〈0.01）. After comprehensive treatment, electrolyte disturbance and acid-base imbalance were rectified at the end of operation.Conclusion：Hemodynamics changes occurred at later phase of anhepatic stage and early phase of neohepatic stage. Different anesthetic managements were used at hepatectomy, anhepatic and neohepatic stage, electrolyte disturbance and acid-base imbalance should be rectified timely. The comprehensive anesthetic management protects the steady hemodynamics in orthotopic liver transplantation.