不同肝功能分级患者非转流下原位肝移植术中血流动力学及氧代谢的变化

目的:研究不同肝功能分级患者在非转流原位肝移植手术(orthotopic liver transplantation ,OLT)过程中血流动力学及氧代谢参数的变化趋势.方法:40例肝病患者全麻下行OLT,常规麻醉诱导后放置Swan-Ganz导管监测平均肺动脉压(mean pulmonary artery pressure, mPAP)、中心静脉压(central venous pressure, CVP)、肺毛细血管楔压(pulmonary capillary wedge pressure, PCWP)和心排血量(cardiac output, CO).分别于诱导后30 min(T1)、门静脉阻断即刻(T2)、阻断30 min(T3)、开放10 min和60 min(T4、T5)及术毕(T6)监测血流动力学指标并记录心排血量指数(cardiac index, CI)、每搏指数(stroke volume index, SVI)、外周(system vascular resistance index, SVRI)和肺血管阻力指数(pulmonary vascular resistance index, PVRI);同时在以上各时点取桡动脉及肺动脉血行血气分析并计算氧供(oxygen delivery,DO2)和氧耗(oxygen consumption,VO2).结果:Child C级患者各时点mPAP及T1和T2时的CVP均高于Child A级和B级患者.所有患者门静脉开放后的PCWP均显著高于开放前,其中Child C级PCWP在T1,T2和术毕较Child A级和B级患者高.Child C级患者T1时SVRI和T3时PVRI显著低于Child A级患者.患者术中DO2均超过1 000 mL/min,VO2均低于正常值并于术毕恢复.结论:不同Child分级肝病患者,术中血流动力学呈高排低阻型,术中过高的PCWP和CVP与临床表现不一致.不同肝功能分级患者术中VO2低于正常值,并于术毕恢复正常.

Changes in hemodynamics and oxygen metabolism of different Child-grade patients during orthotopic liver transplantation without veno-venous bypass

OBJECTIVE: To investigate the changes in hemodynamics and oxygen metabolism of different Child-grade patients during orthotopic liver transplantation (OLT) without veno-venous bypass. METHODS: Forty patients with end-stage liver disease undergoing non veno-venous OLT under general anesthesia were enrolled in this research. Swan-Ganz catheter was placed in the pulmonary artery via right internal jugular vein and right radial artery was cannulated to monitor mean pulmonary artery pressure (mPAP) and artery blood pressure (ABP) continuously. Pulmonary capillary wedge pressure (PCWP) and central venous pressure (CVP) were also recorded. Cardiac output (CO) was recorded at several time points, such as, 30 min after induction (T1), when inferior vena cava and portal vein were clamped (T2), 30 min after portal vein was clamped (T3), 10 min after unclamping of portal vein (T4), 60 min after graft reperfusion (T5) and at the end of the operation (T6). Blood samples were taken from radial and pulmonary artery for blood gas analysis and hemodynamic parameters, such as, cardiac index (CI), stroke volume index (SVI), pulmonary vascular resistance index (PVRI), and system vascular resistance index (SVRI); oxygen delivery (DO2) and oxygen consumption (VO2) were also calculated at these time points. RESULTS: (1) The mPAP values were much higher in group C than in group A or B at all time points. CVP was significantly increased at T1 or T2 in group C as compared with those points of Child's B or C. PCWP was increased significantly after unclamping of portal vein in all three groups and was much higher at several points in Child's C than in Child's A or B. The SVRI value of T1 and the PVRI value of T3 were much lower in group C than those points in group A and the value of SVRI/PVRI was less than normal except at T3 point. And blood gas analysis elucidated that PaO2 was higher than 400 mm Hg at any points. (2) Oxygen consumption was significantly decreased during the operation due to less blood supply and was reverted to normal at the end point of the operation in all patients. Oxygen delivery was all at least 1,000 mL/min during OLT and there was no significant difference between different groups or different points. CONCLUSION: The hemodynamic state of high cardiac output with low peripheral resistance deteriorated when patients' Child-grade shifted from A to C. VO2 was less than normal value during OLT until the end point.