肝移植患者术中胸腔内血容量监测的临床价值

目的 通过PiCCO监测仪对肝移植患者术中各个阶段胸腔内血容量(ITBV)进行监测,了解其变化规律,分析其与漂浮导管监测的血流动力学参数的相关关系,进一步探讨PiCCO监测仪在肝移植术中的应用价值.方法 24例因终末期肝病行原位肝移植的患者,术中除常规监测外,右侧颈内静脉置入7.5 F六腔漂浮导管,监测连续心输出量指数(CCI)等血流动力学参数;同时进行左侧肱动脉穿刺并置入5 F热稀释导管,连接到PiCCO监测仪,监测ITBV、血管外肺水(EVLW)、脉搏连续心输出量指数(PCCI)等参数.分别于术前、无肝前期末、无肝期30 min、新肝期60 min、新肝期120 min和手术结束时记录上述各项血流动力学指标.结果 (1)PCCI的变化趋势与CCI是一致的,无肝期明显下降,新肝期上升,直到手术结束仍维持高动力循环状态,而且PCCI与CCI相关性良好(r=0.815,P＜0.01).(2)ITBV术前即高于正常值,无肝期降低明显,新肝期迅速回升,此后整个新肝期直到手术结束时,ITBV与术前比较差异无统计学意义.(3)ITBV与CCI相关性良好(r=0.655,P＜0.05).而中心静脉压(CVP)、肺动脉阻塞压(PAOP)与CCI无明显相关性.(4)EVLW术前也明显高于正常值,术中虽有逐渐增加的趋势,但与术前比较差异无统计学意义(P＞0.05),EVLW与ITBV呈显著正相关(r=0.480,P＜0.05).结论 与CVP、PAOP相比,通过PiCCO监测仪获得的ITBV是反映肝移植患者术中心脏前负荷的可靠指标,而且肝移植患者术前以及手术结束时ITBV常高于正常值,因此肝移植围手术期应注意防止循环血容量过度超负荷.

The clinical value of intrathoracic blood volume during the perioperative period of liver transplantation

Objective To investigate the changes of intrathoracic blood volume (ITBV) monitored by pulse indicator continuous cardiac output (PiCCO) during the perioperative period of liver transplantation and analyse the relationship of hemodynamic parameter between it and floating catheter,further explore the clinical value of PiCCO. Methods Twenty-four consecutive patients with end-stage liver disease undergoing orthotopic liver transplantation (OLT) were studied. After anesthesia induction,a pulmonary artery catheter was inserted via a 7.5 F introducer into the fight internal jugular vein for continuous cardiac output index (CCI) measurement. In all patients a 5 F fiberoptic catheter with a thermistor was placed in the brachial artery and connected to the PiCCO system. Extravascular lung water (EVLW),ITBV,and pulse continuous cardiac output index (PCCI) were monitored. After induction of anesthesia and achievement of stable hemodynamic and respiratory conditions,recordings of the baseline values of hemodynamic data,ITBV and EVLW were determined. The patients were studied during the anhepatic stage and 60,120 min after reperfusion of the graft. Final measurements of all the values were determined immediately after operation.Results PCCI correlated with CCI significantly (r=0.815,P＜0.01 ). Baseline values of ITBV increased compared to normal values and indicated adequate hydration. During the anhepatic stage,ITBV tended to decrease,whereas reperfusion led to a statistically increase-compared with anhepatic values-in ITBV,which remained statistically unchanged to baseline values during the rest of the study period. During the liver transplantation,ITBV correlated with CCI significantly (r=0.655,P＜0.05 ). EVLW was positive correlation with ITBV (r=0.480,P＜0.05). Conclusions ITBV seems to be a more reliable predictor of cardiac preload. Baseline values of ITBV and ITBV in the end of operation often increase compare with normal values. So proper perioperative fluid management is one of the most important aspects governing hemodynamic function in the patients with liver transplantation.