门静脉性肺动脉高压症患者肝移植术的麻醉管理

Anesthetic management of patients with portopulmonary hypertension during liver transplantation

目的探讨门静脉性肺动脉高压(portopulmonary hypertension,PPHTN)患者肝移植术麻醉的特殊性。方法 PPHTN组15例(男7例、女8例),入选标准:肝硬化合并门静脉高压,平均肺动脉压(MPAP)>25 mm Hg,肺动脉阻塞压(PAOP)<15 mm Hg;对照组15例(男7例、女8例),入选标准:肝硬化排除肺动脉高压。采集2组无肝前期置入Swan-Ganz导管时(T1)、无肝期门静脉阻断5 min(T2)、无肝期门静脉阻断30 min(T3)、新肝期门静脉开放5 min(T4)、新肝期门静脉开放60 min(T5)和术毕(T6)的心率(HR)、平均动脉压(MAP)、MPAP、右心房压(RAP)、PAOP、外周血管阻力指数(SVRI)、肺血管阻力指数(PVRI)、心脏指数(CI)、右心室射血分数(RVEF)、每搏指数(SVI)、右心室舒展末期容积指数(RVEDVI)。结果 T1时PPHTN组MPAP、RAP、PAOP、PVRI明显高于对照组;RVEF和SVI明显低于对照组(P<0.05)。与T1比较:T2时2组HR、SVRI明显升高,MAP、MPAP、RAP、PAOP、PVRI、CI、RVEF、SVI和RVEDVI明显降低(P<0.05);T4时2组MPAP、PVRI明显升高,MAP、CI、RVEF和SVI明显降低(P<0.05);T5、T6时2组SVRI明显降低,CI明显升高,PPHTN组MPAP、PVRI、RVEDVI明显升高,RVEF明显降低(P<0.05)。结论 PPHTN患者与非PPHTN患者相比较,肝移植术中新肝期肺动脉高压及心功能抑制时间更长。麻醉的关键是维持右心功能,减轻右心负荷,纠正可逆性的肺动脉高压因素,减少新肝期再灌注对机体的影响,选择适宜的患者,采用合适的手术方式也同样重要。

Objective To investigate the unique features of anesthesia in liver transplantation patients with porto- pulmonary hypertension（PPHTN）. Methods There were 15 liver cirrhosis patients（ 7 male, 8 female） with mean pulmo- nary artery pressure （MPAP）〉 25 mmHg and pulmonary artery occlusion pressure （PAOP） 〈15 mmHg in the PPHTN group, 15 liver cirrhosis patients（7 male, 8 female） without PPHTN in the control group. Heart rate, mean arterial pres- sure （MAP）, MPAP, right atrial rressure （RAP）, PAOP, systemic venous resistance index （SVRI）, pulmonary vascular resis- tance index （PVRI）, cardiac index （CI）, right ventricular ejection fraction （RVEF）, stroke volume index （SVI）, and right ventricular end diastolic volume index （RVEDVI） in pre-anhepatic phase（T1）, anhepatic phase 5 min（T2）, anhepatic phase 30 min（T3）, neohepatic phase 5 min（T4）, neohepatic phase 60 min（T5）,and at the end of operation（T6） were all recorded. Re- suits At T1, MPAP, RAP, PAOP and PVRI were significantly higher in PPHTN group than in the control group, and RVEF and SVI in PPHTN group were significantly lower than in the control group（P 〈 0.05）. Compared with %, HR and SVRI significantly increased （P 〈 0.05）, MAP, MPAP, RAP, PAOP, PVRI, CI, EF, SVI and RVEDVI significantly de- creased（P 〈 0.05 ） in the 2 groups at T2. Compared with Tl, MPAP and PVRI significantly increased（P 〈 0.05）, MAP, CI, RVEF, and SVI significantly decreased（P 〈 0.05）in the 2 groups at T4. Compared with T1, SVRI significantly decreased, and CI significantly increased in both groups at T5 and T6（P 〈 0.05）. MPAP, PVRI, and RVEDVI increased, and EF sig- nificantly decreased in the PPHTN group （P 〈 0.05）. Conclusion The duration of pulmonary hypertension and cardiac suppression in the patients with PPHTN are longer than non-PPHTN patients during neohepatic phase. The key to success- ful anesthesia is to alleviate the right heart load, to correct the reversible factors of pulmonary hypertension, and to reduce the effect of reperfusion on the transplanted liver. Choosing appropriate patients and surgical intervention are also impor- tant.