原位肝移植术中肺氧合功能的变化

Changes in pulmonary gas exchange and intrapulmonary shunt during orthotopic liver transplantation.

目的 研究体外静脉 静脉转流下原位肝移植 (OLT)围术期肺氧合功能及肺内分流的改变。方法 11例晚期肝病行OLT手术的病人采用异氟醚吸入复合连续硬膜外麻醉 ,无肝期使用体外静脉 静脉转流。放置Swan Ganz导管连续监测心输出量 (CO) ,测定肺氧合功能及肺内分流率。分别于手术开始、无肝前期 12 0min、无肝期 30min、6 0min、新肝期 5min、6 0min及术毕抽取桡动脉和肺动脉血作血气分析 ,根据公式计算肺泡 动脉氧分压差 (A aDO2 )、肺内分流率 (Qs Qt)、氧供指数(DO2 I)和氧耗指数 (VO2 I)。结果 手术开始FiO2 10 0 %时 ,A aDO2 与Qs Qt高于正常值 ,分别为2 88± 134mmHg和 2 6 %± 11%。与手术开始相比 ,无肝前期 12 0min各指标无显著性差异 ;无肝期PaO2 增高 ,A aDO2 与VO2 I降低 (P <0 0 5 ;新肝期CI、DO2 I明显增加 (P <0 0 1,Qs Qt在新肝早期明显增加 (P <0 0 5。与无肝期 6 0min相比 ,新肝期 5minPaO2 降低 (P <0 0 5 ,PaCO2 和A aDO2 增高(P <0 0 1;CI、DO2 I和VO2 I无显著变化。结论 OLT术前和术中有明显的肺氧合功能障碍。

Objective To evaluate the changes of pulmonary gas exchange and intrapulmonary shunt during orthotopic liver transplantation (OLT) Methods Eleven ASA Ⅲ Ⅳ patients (male 8, female 3) with end stage liver diseases were studied Age ranged from 17 67 yr Anesthesia was induced with midazolam 0 1 mg·kg -1 , fentanyl 5μg·kg -1 and pipecuronium 0 1 mg·kg -1 and maintained with isoflurane inhalation and intermittent iv boluses of fentanyl and pipecuronium combined with epidural anesthesia (T 8 9 ) The patients were mechanically ventilated with 100% O 2 during operation After induction of anesthesia Swan Ganz catheter was inserted via right internal jugular or subclavian vein Cardiac output (CO),mixed venous oxygen saturation and core venous temperature were continuously monitored with continuous cardiac output monitor (Baxter,Vigilance) ECG, CVP, SpO 2 and P ET CO 2 were also continuously monitored during operation Radial artery was cannulated for continuous direct blood pressure monitoring Arterial and mixed venous blood samples were taken at the beginning of operation, 120 min during preanhepatic stage, 30 and 60 min during anhepatic stage, 5 and 60 min during neohepatic stage and at the end of operation Alveolar arterial oxygen partial pressure difference (A aDO 2) , intrapulmonary shunt (Qs/Qt) , oxygen delivery index (DO 2I) and oxygen consumption (VO 2 I ) were calculated During operation body temperature was maintained above 35 5℃ Veno venous bypass (VVB) was performed during anhepatic stage Results At the beginning of operation, when FiO 2 was 100%, PaO 2 was only (376±141) mmHg, A aDO 2 and Qs/Qt were all higher than normal values There were no significant changes in all parameters 120 min during preanhepatic stage as compared with those at the beginning of operation PaO 2 increased and A aDO 2 and VO 2I decreased significantly during anhepatic stage Qs/Qt, A aDO 2 and PaCO 2 increased and PaO 2 decreased significantly, but there were no significant changes in cardiac index, DO 2I and VO 2I during early neohepatic stage Cardiac index, DO 2I and VO 2I increased at 60 min during neohepatic stage and at the end of operation Conclusions There are severe changes of pulmonary gas exchange during OLT