19例原位肝移植术中凝血弹性图变化及与ACT相关性的临床研究

The changes in thrombelastograph (TEG) and correlation between TEG and ACT during orthotopic liver transplantation

目的 探讨国人原位肝移植术中凝血弹性图 (TEG)的变化及其与激活全血凝块形成时间 (ACT)的相关性。方法 19例病人分为急性肝衰组 (8例 )与肝肿瘤组 (11例 ) ,接受原位肝移植术 ,无肝期采用体外静脉～静脉转流。两组病人分别于术前、无肝前 (手术开始后 12 0min ,Ⅰ +12 0 )、无肝后 30min(Ⅱ +30 )、新肝前 5min(Ⅲ 5 )、新肝后 5min(Ⅲ +5 )、30min(Ⅲ +30 )、6 0min(Ⅲ +6 0 )、12 0min (Ⅲ +12 0 ) ,8个时间点 ,分别观察硅燥土激活的全血TEG及ACT的变化。 19例病人中有 6例于新肝后 5min同时观察肝素酶修正后的TEG与非肝素酶修正后的TEG及ACT的变化。结果 肝衰组TEG值 (r、r +k、alpha角或α、MA)的变化主要在Ⅱ +30min、Ⅲ 5min、Ⅲ +5min ,肝肿瘤组TEG值 (r、r+k、α、MA)的变化均在新肝后 5min、30min、6 0min。与术前值相比 ,两组TEG值的表现为r与r+k延长 ,α与MA减小 (P <0 0 5、0 0 1)。相关研究表明 ,两组r +k与ACT均呈正相关 (r分别为 0 74 3及 0 6 34,P <0 0 1)。其中 6例于新肝后 5min ,有肝素酶与无肝素酶的全血TEG值差异亦显著 (P <0 0 1) ,后者经静注鱼精蛋白 5 0～ 75mg后 ,两组TEG值差异无统计学意义 (P >0 0 5 )。

Objective To determine the changes in TEG and correlation between TEG and ACT during orthotopic liver transplantation(OLT) in Chinese Methods 19 patients with end stage liver disease undergoing OLT were studied They are composed of two groups: acute hepatic failure group (n=8) and liver neoplasm group(n=11) Anesthesia was induced with propofol 1 5 2 0mg/kg, fentanyl 3 5μg/kg and vecuronium 0 1mg/kg and maintained with isoflurane or desflurane inhalation combined with continuous infusion of propofol at 2 4mg·kg -1 ·h -1 The operation was divided into three phases: Ⅰ preanhepatic phase, Ⅱ anhepatic phase, and Ⅲ postreperfusion phase (after liver graft) Veno venous bypass was performed during anhepatic phase Arterial blood samples were drawn from an existing arterial line for determination of celite activated TEG and ACT at 8 intervals: before operation, preanhepatic phase (120min after operation was started Ⅰ+120), 30min after liver was removed (Ⅱ+30), 5min before reperfusion (Ⅲ 5) and 5min (Ⅲ+5), 30min (Ⅲ+30), 60min (Ⅲ+60) and 120min(Ⅲ+120) after reperfusion In 6 patients among the 19 patients heparinase celite TEG was measured 5min after reperfusion(Ⅲ+5) in addition to celite TEG If there was significant differences in traces between the two TEG measurements, an iv bolus of 50 70mg protamine was given and the heparinase celite TEG was repeated The measured variables included the r (reaction) time, representing the rate of initial fibrin formation, k(coagulation) time, alpha angles(α) reflecting fibrin platelet interaction, MA(maximal amplitude) indicating qualitative platelet function and percent fibrinolysis at 60min Results In hepatic failure group changes in TEG occurred at Ⅱ+30, Ⅲ 5, and Ⅲ+5 while in liver neoplasm group changes in TEG were found at Ⅲ+5, Ⅲ+30, Ⅲ+60 as compared with preoperative value r and r+k times increased and α and MA decreased in the two groups There was positive correlation between r+k time and ACT in two groups At Ⅲ+5 there were significant differences in TEG(r, r+k, α and MA) values between celite and heparin celite TEG (P<0 01) After an iv bolus of 50 75mg protamine the differences were not significant Conclusions During OLT coagulation disorder occurs mainly at anhepatic and early reperfusion phase A positive correlation exists between TEG(r+k) and ACT Heparinase celite TEG discloses the presence of residual of heparin and the need for protamine