Risk Factors for Inadvertent Hypothermia During Adult Living-Donor Liver Transplantation

Background

Hypothermia (core temperature <35°C) causes multiple physiologic disturbances, including coagulopathy and cardiac dysfunction. Patients undergoing liver transplantation are at risk of inadvertent hypothermia and might be more vulnerable to its adverse effects. We sought to identify the factors contributing to hypothermia during living-donor liver transplantation (LDLT), which have not yet been studied in depth.

Methods

Medical records of 134 recipients who underwent adult-to-adult LDLT were reviewed. Core temperature at the following time points were taken: anesthetic induction, skin incision, start and end of the anhepatic phase, and hourly after hepatic reperfusion.

Results

Of 134 recipients, 29 (21.6%) developed hypothermia during surgery. Four independent risk factors for hypothermia were identified: small body weight–to–body surface area ratio, acute hepatic failure, high Model for End-Stage Liver Disease (MELD) score, and low graft-to-recipient weight ratio. The amount of core temperature drop was positively correlated with the number of involved risk factors. Each risk factor had a respective contribution according to the operative phases: body weight–to–body surface area ratio and the MELD score for the preanhepatic phase, acute deterioration of hepatic failure for the anhepatic phase, and graft-to-recipient weight ratio was for the postreperfusion phase.

Conclusions

Hypothermia was independently associated with the recipient's morphometric characteristics, emergency of end-stage liver disease, MELD score, and graft volume. These factors showed a cumulative effect, and the role of each factor was different according to the operative phase. These results should aid in the development of an optimal thermal strategy during LDLT.     

肌松药在肝移植围术期的应用

终末期肝病导致全身脏器受累,使肌肉松弛药药代和药效方面发生复杂改变。肝移植病人应用肌松药,除了要考虑减少肝脏负担外,尚需注意神经肌肉阻滞恢复的困难。以主要经肝脏清除的非去极化肌松药的药效学来评价移植肝功能的早期恢复值得研究。     

非转流肝移植术中的体温保护

目的观察非转流同种异体原位肝移植术中体温保护的效果。方法对18例非转流肝移植术患者术中采用体表覆盖预热后的毛毯、手术床铺变温水毯、加温输注液体、温盐水冲洗腹腔等措施,维持患者体温。结果麻醉后、无肝前期、无肝期、新肝期及出手术室时的最低食管温度分别为(36.6±0.2)、(36.4±0.4)、(35.2±1.1)、(35.7±0.6)及(36.4±0.6)℃。术中发生体温过低(体温低于36.0℃)11例;1例最低体温为33.2℃,发生在无肝期。发生室性早搏4例,仅1例发生室性早搏时体温过低,均未经特殊处理而恢复,无心跳骤停发生。结论非转流肝移植术中极易发生体温过低,使用积极的体温保护措施可减少体温过低的发生率、减轻发生低体温的程度。     

Novel Approaches to Preventing Ischemia-Reperfusion Injury During Liver Transplantation

Ischemia-reperfusion injury (IRI) results in profound allograft damage during liver transplantation. The process of IRI results in adenosine triphosphatase (ATP) depletion, the production of reactive oxygen species, and progressive tissue destruction. This injury process is accelerated on reperfusion in the recipient. Over the last decade an increasing body of literature has identified a complex interplay of molecular and cellular pathways responsible for causing IRI. This article summarizes recent developments, drawing on preclinical and clinical studies, focusing on how the detrimental effects of IRI can be prevented in liver transplantation. We present a balanced overview on how machine preservation technologies, the coagulation system, antioxidants, cytoprotective agents, cytokines, preservation solutions, and the innate and adaptive immune system can be targeted to prevent IRI in liver transplantation.     

围术期低体温的研究进展

一、正常的体温调节 体温调节系统是由感受传入、中枢控制和传出效应互相联系而组成的一个反馈系统^[1-2]。温度感受器分布于全身许多部位,冷感受器通过A-delta纤维传送信号,而热感受器通过C纤维传送信号。在体温自主调节中,皮肤、腹腔和胸腔、脊髓、下丘脑和大脑其他部位传入信号各约占20％,而在行为调节中,主要依赖皮肤温度^[1,2,3]。     

围术期低体温的研究进展

围术期低体温是手术过程中一种常见的并发症,对机体会产生许多不良的影响。随着手术室环境的改进和麻醉要求的提高,围术期保温也成为关注热点之一。本文就围术期低体温近年来国内外现状与研究进展进行以下综述。     

围术期低体温护理的研究进展

综述了导致围术期低体温的原因,低体温对机体产生的影响.针对性地采取围术期低体温的综合护理措施等研究进展.     

1例全内脏反位肝移植患者围术期护理

对1例全内脏反位行肝移植患者实施整体护理,结果恢复良好,肝功能明显好转,术后29 d出院.提出术前予以周密准备及心理支持,术后对呼吸及循环系统和排斥反应的严密监护以及早期预防感染是保证手术成功的关键.     

1例全内脏反位肝移植患者围术期护理

对1例全内脏反位行肝移植患者实施整体护理，结果恢复良好，肝功能明显好转，术后29d出院。提出术前予以周密准备及心理支持．术后对呼吸及循环系统和排斥反应的严密监护以及早期预防感染是保证手术成功的关键。     

Perioperative Predictors for Refractory Hyperglycemia During the Neohepatic Phase of Liver Transplantation

BackgroundHyperglycemia in the neohepatic phase of liver transplantation (LT) tends to decrease toward completion of the surgical procedure. Refractory hyperglycemia in the neohepatic phase (RH) is influenced by multiple perioperative factors and may be connected to posttransplant outcomes. We attempted to demonstrate the relationship of RH to posttransplant outcomes and to establish a predictive model for RH in living donor liver transplantation (LDLT).MethodsPerioperative data of 211 patients who underwent LDLT from 2009 and 2012 were reviewed, including declines in the blood glucose levels during the neohepatic phase. Perioperative variables including the posttransplant model for end-stage liver disease (MELD) score until day 30 were compared between patients with normal declines in blood glucose and patients with RH. Selected variables after intergroup comparisons were examined by means of multivariate logistic regression to establish a predictive model for RH occurrence.ResultsThe mean blood glucose decline was 22.3 ± 31.5 mg/dL during the neohepatic phase, and 84 of 203 patients (41.4%) had no decline in blood glucose. In intergroup comparisons, preoperative factors associated with RH included sex, Child-Pugh-Turcotte class, MELD score, emergency, liver enzymes, and graft-to-recipient weight ratio. During surgery, surgical time, serum lactate, and arterial pH were associated with RH. After surgery, the RH group showed slower recovery of the MELD score (15.2 versus 11.9 days) and higher MELD scores until day 10 (P < .05). After the multivariate analysis, recipient sex, emergency, surgical time (≤9 h), and the final intraoperative serum lactate level (≥5.0 mmol/L) were included in the predictive model for RH.ConclusionsRH was associated with delayed functional recovery of the liver graft in LT. Recipient sex, emergency, surgical time, and the final intraoperative serum lactate level were identified as predictors of RH. Close monitoring of intraoperative blood glucose in LDLT may be an early prognostic indicator.     

围手术期轻度低温对细胞免疫功能的影响

围手术期轻度低温对机体的免疫系统会产生许多不利影响 ,本文主要综述轻度低温对机体细胞免疫功能的影响 ,其通过对机体淋巴细胞、吞噬细胞、自然杀伤细胞及细胞因子等产生不同程度的抑制作用 ,从而抑制机体的细胞免疫功能 ,影响患者术后的恢复。     

Effects of Mild Perioperative Hypothermia on Cellular Immune Responses

Background: Unintentional perioperative hypothermia is a common complication of anesthesia and surgery associated with adverse effects on several systems, including impaired wound healing and more frequent wound infections. Mild hypothermia affects various immune functions. In the current study, the authors sought to determine whether immune alterations in the perioperative period might be induced, at least in part, by impaired thermoregulation during this period.

Methods: Sixty patients undergoing abdominal surgery were randomly assigned to two thermal care groups: routine care or forced-air warming. The patients' anesthetic care was standardized. Venous blood samples were collected 90 min before induction of anesthesia and immediately, 24 h, and 48 h after surgery. White cells were separated and frozen. Peripheral blood mononuclear cells were used to test cytokine production (interleukins [IL] -1 [small beta, Greek], -2, and -6; tumor necrosis factor-[small alpha, Greek] [TNF-[small alpha, Greek]), mitogens-induced proliferation, and natural killer NK cell cytotoxicity. Plasma cortisol levels were also determined.

Results: Patients in the normothermia group maintained normal body core temperature, whereas temperature decreased by approximately 1 [degree sign]C in the hypothermia group. Mitogenic responses were suppressed in cells from patients in the hypothermia but not in the normothermia group 24 and 48 h after surgery. Proinflammatory cytokine (IL-1 [small beta, Greek], IL-6, TNF-[small alpha, Greek]) production increased in both groups, although the production of IL-1 [small beta, Greek] was significantly higher in the normothermia group 24 h after surgery. Production of IL-2 was suppressed in the hypothermia but not in the normothermia group at 24 h.     

Liver Transplant From Unexpected Donation After Circulatory Determination of Death Donors: A Challenge in Perioperative Management

Unexpected donation after circulatory determination of death (uDCD) liver transplantation is a complex procedure, in particular when it comes to perioperative recipient management. However, very little has been published to date regarding intraoperative and immediate postoperative care in this setting. Herein, we compare perioperative events in uDCD liver recipients with those of a matched group of donation after brain death liver recipients. We demonstrate that the former group of recipients suffers significantly greater hemodynamic instability and derangements in coagulation following graft reperfusion. Based on our experience, we recommend a proactive recipient management strategy in uDCD liver transplantation that involves early use of vasopressor support; maintaining adequate intraoperative levels of red cells, platelets, and fibrinogen; and routinely administering tranexamic acid before graft reperfusion.     

肝癌肝移植的围手术期抗癌治疗及效果评价

肝细胞癌是我国最常见的恶性肿瘤之一。由于我国乙肝病毒携带者基数大,肝炎肝硬变患者众多,肝癌的发病率较高,我国每年新发病例数占全世界50%以上,而且还有不断上升的趋势[1]。肝移植是治疗原发性肝癌的有效途径,通     

Entecavir Combined With Short-term Hepatitis B Immunoglobulin in Preventing Hepatitis B Virus Recurrence in Liver Transplant Recipients

BackgroundThe combination of nucleoside analogs and long-term hepatitis B immunoglobulin (HBIG) is considered to be the standard regimen for preventing hepatitis B virus (HBV) recurrence after liver transplant (LT). However, long-term use of HBIG causes many adverse effects. The aim of this study was to evaluate the effect of nucleoside analogs entecavir combined with short-term HBIG in preventing HBV recurrence after LT.MethodsThis retrospective study assessed the effect a combination of entecavir and short-term HBIG in prophylaxis of HBV recurrence among 56 LT recipients who had undergone the procedure because of HBV-associated liver disease at our center between December 2017 and December 2021. All patients received entecavir treatment combined with HBIG for the prevention of hepatitis B recurrence, and HBIG treatment was withdrawn within 1 month. The patients were followed up to determine levels of hepatitis B surface antigen, antibody to hepatitis B surface antigen (HBsAb), and HBV-DNA and the recurrence rate of HBV.ResultsOnly 1 patient appeared positive for hepatitis B surface antigen at 2 months post-LT. The overall HBV recurrence rate was 1.8%. The HBsAb titers of all patients gradually decreased over time, with a median of 376.6 IU/L at 1 month post-LT and a median of 13.47 IU/L at 12 months post-LT. During the follow-up period, the HBsAb titer of the preoperative HBV-DNA–positive patients remained at a lower level than that of HBV-DNA–negative patients.ConclusionsEntecavir combined with short-term HBIG can exert a good effect for the prevention of HBV reinfection post-LT.     

肝移植围手术期的管理

随着肝移植手术例数的逐年增加 ,手术技术日趋成熟 ,肝移植受者围手术期的治疗水平已成为肝移植手术成功的关键。尤其是一些合并肝外重要器官损害的终末期肝病患者 ,如合并肝肾综合征、肝性脑病、肝肺综合征、大量腹水、自发性细菌性腹膜炎等。如何在围手术期对这些并发症进行处理是目前肝移植医师较为关心的方面。一、合并肝肾综合征 (ＨＲＳ)受者围手术期处理ＨＲＳ是终末期肝硬化的常见并发症 ,其发生率约为 60 %～ 80 % ,肝移植是ＨＲＳ最根本的治疗途径。但合并有ＨＲＳ的肝移植受者术后死亡率较一般患者明显升高 ,最主要的死亡原因是…