肝移植无肝期应用去甲肾上腺素和多巴胺对肾功能影响的比较研究

目的观察肝移植无肝期应用去甲肾上腺素和多巴胺对肾功能的影响。方法将50例晚期肝病患者,ASAⅢ~Ⅳ级,择期行经典OLT手术。随机分为两组,即多巴胺组(A组):25例腔静脉阻断前5min多巴胺5～10μg/(kg·min)持续微泵输注,使收缩压维持在80mmHg以上。对照组(B组)25例腔静脉阻断前5min去甲肾上腺素0.5~1.0μg/(kg·min)持续微泵输注,使收缩压维持在80mmHg以上。记录患者在腔静脉阻断时、阻断后20min、腔静脉开放时、术毕的HR,CVP,PAWP,MAP,UVP,PVR,SVR,CO等血流动力学指标以及尿素氮(BUN),肌酐(Cr)等肾脏功能指标。统计无肝期应用血管活性药的总量和各时间点的尿量。结果A组与B组比较COSVR,MAP-UVP在阻断后20min、腔静脉开放时有显著差异(P<0.05),而在其余时间点无显著差异(P>0.05)。HR,CVP,PAWP和PVR在腔静脉阻断时、阻断后20min、开放时及术闭时指标差异无显著性(P>0.05),无肝期每小时尿量A组与B组差异有显著性(P<0.05)。而A组与B组各时间点肌酐、尿素氮差异均无显著性(P>0.05)。无肝期应用的血管活性药两组比较有明显差异,A组多于B组(P<0.05)。结论肝移植无肝期应用去甲肾上腺素较多巴胺更能维持血流动力学稳定,并且对肾功能有保护作用,至少与多巴胺比较没有毒副作用。     

A retrospective study of fluid therapy for 100 patients of liver transplantation

Objective: To review the evolution of fluid therapy (IOFT) during liver transplantation (LTX) based on clinical experience in our institute over 7 years. Methods: All patient records (n = 130) of LTX from 1996 to 2003 were examined. After excluding patients with co-morbidities 100 cases were found suitable for IOFT analysis. All patients had undergone LTX and follow-up under the same surgical team. Based on IOFT records we tried to identify distinct patterns of practice evolving over 7 years. Intraoperalive hemodynamics (IOHD) and long-term outcome records were examined. Results: Retrospectively, 3 types of IOFT were found. Group A (n= 18, period 1996-1997) received high amounts of crystalloids; group B (n= 24, period 1998-2000) received high amounts of plasma and albumin; and group C (n = 58, period 2001-2003) received lower amounts of albumin and plasma and recommended amounts of 6% hy-droxyethyl starch 200/0. 5 (HES) and high amounts of vasoprcssors. Intraoperatively, group A exhibited the highest levels of central venous and pulmonary artery pressures in the neo-hepatic stage (P<0. 05). Postoperatively, the patients in group C had the shortest time to extubation; the values for group A,B,C were (15.8±11), (17. 3±10. 2) and (7. 98±3. 2) h respectively( P<0. 05). At the end of one-year follow-up, the patients in group C had the lowest mortality (group A, B, C were 27. 78%, 29. 17% and 6. 25% respectively; P<0. 05). Conclusion: In our institute over the years the use of crystalloids, albumin and plasma during IOFT of LTX is gradually replaced to a large extent by HES. The improvements in IOHD and long term outcomes are likely to be related to improved surgical experience of our team. Nevertheless, the shift in IOFT practices might be associated with an beneficial effect on IOHD or long term outcome. Treatment with proper amount of liquid and vasoactive drugs may be a better method of fluid therapy.     

肝移植病人液体治疗策略的回顾性研究

手术病人体液状态的调控是良好麻醉不可或缺的一部分，这对肝移植的手术麻醉尤为重要。我院已安全实施了130例肝移植，全部在非静脉一静脉(V-V)转流下实行。我们的补液策略走过了不同的阶段，从以大量补液到以补大量血浆、蛋白为主，直至目前以适量补液加用血管活性药物。本文选择性回顾研究100例肝移植病人在三种不同补液方式下血液动力学及术后转归的不同，以期为寻找更好的肝移植补液策略提供一些有意义的临床资料。     

猪原位心脏移植模型的建立

为在全麻体外循环下建立猪原位心脏移植的实验模型，选用小型猪进行供体心切取，在全麻体外循环下，切除受体心，进行原位心脏植入。术中进行血液动力学监测。发现移植后心脏全部复跳，辅助循环60min后，均顺利脱离体外循环，血液动力学稳定。表明猪原位心脏移植模型的建立是成功的，为心脏移植的进一步基础及临床研究提供了方便。