非体外静脉-静脉转流下原位肝移植术临床麻醉管理探讨

Observation of the Clinical Anaesthesia in Patients Who Undergo Orthotopic Liver Transplantion without Extracorporeal Veno-Venous Bypass

目的 探讨非体外静脉 静脉转流下原位肝移植术的麻醉处理。方法 采用气管内插管静吸复合全身麻醉 ,术中监测血流动力学、呼吸功能、血气、生化、尿量及出血量等。根据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 13例肝移植病人手术均成功完成 ,手术较一般手术出血多 ,快速输血 ,给予多巴胺和肾上腺素维持血压 ,术中呼吸、循环维持满意 ;②术中出血 (44 5 0± 2 6 40 )ml,尿量 (45 0± 2 5 6 )ml,手术时间 (370± 110 )min ,无肝时间 (86± 2 6 )min ;③与麻醉前相比 ,血压在腔静脉阻断和开放即刻下降 (P <0 .0 1) ;CVP在腔静脉阻断时降低 (P <0 .0 1) ,腔静脉开放后 5min内增高 (P <0 .0 1) ,心率在无肝期和新肝期增快 (P <0 .0 1) ;④与麻醉前比较 ,无肝期和新肝期K+ 浓度和TCO2 下降 (P <0 .0 5 ) ;无肝期至手术结束时红细胞压积、pH和HCO3 -1值均下降 (P <0 .0 5 ) ;PCO2 无肝期下降、新肝期升高 (P <0 .0 5 ) ;BE新肝期和术毕均下降 (P <0 .0 5 )。结论 非体外静脉 静脉转流下病人原位肝移植围术期循环、酸碱平衡及电解质变化剧烈 ,积极预防性对症治疗是麻醉管理的关键。

Objective To observe the clinical anaesthesia in patients who undergo orthotopic liver transplantion without extracorporeal veno-venous bypass.Methods All the patients were given general anaesthesia via venis and gas.During operations hemodynamics,respiratory function,blood gas,biochemistry,urine volume,bleeding volume were observed.According to the different steps of orthotopic liver transplantion,corresponding measures were taken.Results (1)Thirteen patients had undergone orthotopic liver transplantion without extracorporeal veno-venous bypass succesfully,although they all had moderate bleeding with stable vital signs because of a rapid blood transfusion.(2)bleeding volume:(4 450±2 640)ml,urine volume:(450±256)ml,operation time:(370±110)min,time of anhepatic phase:(86±26)min.(3)compared with the blood pressure before anaesthesia it declined at the time of the blocking and opening of cava(P<0.01);CVP decreased at the time of the blocking of cava(P<0.01)and increased in 5 min afterthe opening of cava(P<0.01);heart rate increased during the anhepatic phase and neohepatic phase(P<0.01).(4)k + and TCO 2 decreased during the anhepatic phase and neohepatic phase compared with that before anaesthesia;PCV,PH and HCO 2 -1 decreased from anhepatic phase to the end of operations(P< 0.05);PCO 2 decreased during anhepatic phase and increased during neohepatic phase(P<0.05);BE decreased from neohepatic phase to the end of operations(P<0.05).Conclusion The circulation,acid-base balance and electrolure of patients who undergo orthotopic liver transplantion without extracorporeal veno-venous bypass varies greatly during perioperation,and active prophylactic treatment is the key of anaesthesia.