原位肝移植术的麻醉管理

Anesthetic management of adult patients under orthotopic liver transplantation

目的 研究原位肝移植术病人围手术期的麻醉管理。方法 对 45例原位肝移植术病人 ,在围手术期采用全身麻醉或全身麻醉复合硬膜外阻滞 ;术中加强监测血液动力学、出血量、呼吸功能、血气、生化、凝血功能、体温、尿量及血糖 ;无肝期采用体外静脉转流。根据成人原位肝移植术无肝前期、无肝期、新肝期的特点 ,给予相应的麻醉处理。结果 (1) 1例因大量出血死亡。术中 2 9例输血 2 0 0 0～ 40 0 0ml,7例输血 40 0 0～ 6 0 0 0ml,8例输血大于 6 0 0 0ml;(2 )无肝期应用体外静脉转流能使术中血液动力学趋于稳定 ;(3)本组病人除大出血外 ,手术各期无明显酸碱紊乱 ;(4 )围术期电解质主要表现为低钙 ;(5 )术中体温变化大 ;(6 )凝血功能有一定程度紊乱 ,需补充凝血因子、适当使用止血药以及鱼精蛋白中和肝素 ;(7)围术期血糖偏高 ,新肝期血糖逐渐下降。结论 肝移植各期的麻醉管理和监测非常重要 ,无肝期采用体外静脉转流 ,有助于循环稳定。

Objective To study the perioperative changes of and anesthetic management for patient under orthotopic liver transplantation (OLT). Methods General anesthesia or general anesthesia combined with epidural block anesthesia was conducted. During the anhepatic phase, extracorporeal veno venous bypass (EVVB) was used. Hemodynamics, respiratory function, blood gas, blood biochemistry, coagulation function, body temperature, blood glucose, urinary output and bleeding output were monitored during the operation. According to the characteristics of pre anhepatic phase, anhepatic phase and neohepatic phases, corresponding anesthetic management measures were supplied. Results (1) Forty four patients tolerated the operation. One patient died of massive blood loss intraoperatively. 2 000～4 000 ml of blood was transfused to 29 patients, 4 000～6 000 ml to 7 patients and more than 6 000 ml to 8 patients. (2) During the anhepatic phase hemodynamics in 44 patients remained stable. However, in the fifteen minutes′ primary stages of anhepatic phase and in neohepatic phase, transient circulatory instability occurred. Blood volume expansion was applied immediately and succeeded to correct the instability. (3) No patient, except one with massive blood loss showed obvious acid base disturbance occurred during OLT. (4)The main electrolytic change during perioperative phase was hypocalcemia. (5) During the operation a marked change in body temperature took place. (6) Disturbance of coagulation function to a certain degree occurred. (7) The blood glucose level was higher than normal during OLT, and gradually decreased during the neohepatic phase. Conclusions Attention should be paid to the anesthetic management and monitoring during different phases of OLT. Appropriate treatment helps to keep the blood gas, blood biochemistry and coagulation function remain normal and stable. Use of EVVB during anhepatic phase can be helpful to keep hemodynamics stable and prevent obvious acidosis and hyperkalemia. Supplementation of coagulation factors, and proper use of hemostatic drugs and protamine to neutralize heparin were needed. Anti rejection drugs were necessary during OLT.