肝移植术中应用连续静脉-静脉血液透析滤过的麻醉管理

Anesthetic management of continuous veno-venous hemodiafiltration applied in liver transplantation

目的总结肝移植术中应用手术床旁连续静脉-静脉血液透析滤过(continuous veno-venous hemodiafiltration,CVVHDF)替代治疗的麻醉管理经验。方法回顾性分析2005年至2012年期间在首都医科大学附属北京佑安医院接受肝移植且术中应用CVVHDF替代治疗肝衰竭合并急性肾衰竭的8例患者的临床资料。记录患者术中血流动力学指标、出血量、尿量、补液量、CVVHDF替代治疗时间及手术情况等。测定CVVHDF替代治疗前后血尿素氮(BUN)、血清肌酐(Scr)及血清总胆红素等,计算内生肌酐清除率(Ccr)。术后2周观察转归。计量数据以均数±标准差或中位数(四分位数间距)表示。治疗前后两组Scr、Ccr、BUN和血清总胆红素比较采用独立样本t检验。结果 CVVHDF治疗时间(415±197)min,脱水量为50～200ml/h。手术期间总尿量116(60,437)ml,尿量0.18(0.07,0.78)ml/(kg·h)。出血量3950(2200,5225)ml,补液量8837(7690,10012)ml。CVVHDF替代治疗后,Scr和BUN有下降趋势,Ccr有所升高,但差异无统计学意义(均为P<0.05)。与CVVHDF替代治疗前相比,治疗后的血清总胆红素下降31%,差异有统计学意义(t=2.356,P<0.05)。2例患者分别于CVVHDF替代治疗2d及6d后,肾功能逐渐恢复;2例死亡,分别死于多器官功能衰竭和原发性移植物失功所致肾衰竭;4例术后继续CVVHDF替代治疗及综合支持治疗。结论对于肝衰竭合并急性肾衰的肝移植手术患者,应用CVVHDF替代治疗,有助于平稳渡过手术期,减轻肾功能损害,提高生存率。

Objective To summarize the experience in anesthetic management of continuous venovenous hemodiafiltration （CVVHDF） applied in liver transplantation. Methods Clinical data of 8 cases, who developed hepatic failure and acute renal failure and applied CVVHDF treatment during liver transplantation in Affiliated Beijing You＇an Hospital of Capital Medical University from 2005 to 2012, were retrospectively analyzed. Hemodynamic indexes, blood loss, urine volume, fluid infusion, time of CVVHDF treatment and the surgical situation were recorded. Some indicators were measured before and after CVVHDF alternative treatment, including blood urea nitrogen （BUN）, serum ereatinine （Scr） and serum total bilirubin. And endogenous creatinine clearance rate （Ccr） was calculated. The outcome was observed at 2 weeks after operation. Mean （standard deviation ） or median （interquartile range ） was used in measurement data. Independent sample t test was used in comparison of Scr, Ccr, BUN and serum total bilirubin in two groups before and after treatment. Results The time of CVVHDF treatment was （415 ± 197） min. The dehydration volume was 50-200 ml/h. The total urine volume during operation was 116 （60, 437） ml, and 0. 18 （0. 07, 0. 78） ml/ （kg· h）. The bleeding volume was 3 950 （2 200, 5 225） ml and fluid infusion volume was 8 837（7 690, 10 012）ml. After CVVHDF treatment, the levels of Scr and BUN decreased, and Ccr increased. But there was no significant difference in them. Compared with that before CVVHDF treatment, serum total bilirubin decreased by 31% after treatment and with significant difference （ t = 2. 356, P 〈 0. 05）. Renal function in 2 cases recovered at 2 d and 6 d after treatment. Two cases died of multiple organ failure and renal failure caused by primary graft failure. The other 4 cases continued with CVVHDF and comprehensive support treatment after operation. Conclusions For liver transplant patients with hepatic failure and acute renal failure, CVVHDF treatment can contribute to successful surgery, dimishing renal function damage and improving survival rate.