不采用体外静脉-静脉转流技术的经典原位肝移植术

目的　评价在成人经典原位肝移植术中不采用体外静脉 静脉转流技术的结果和可行性。　方法　对 4 3例采用体外静脉转流技术的原位肝移植和 15例不采用体外静脉转流技术的经典原位肝移植进行了对比分析。　结果　在采用和不采用体外静脉转流技术的 2组患者中 ,术后 3d血肌酐值和肛门排气时间差异无显著性。不采用体外静脉转流技术的患者组 ,手术时间 (5 6± 1 4 )h ,术中出血量 (42 0 0± 85 0 )ml,术中输血量 (480 0± 92 0 )ml,ICU停留时间 6 3d ,均低于或短于采用体外静脉转流技术的患者组。　结论　原位肝移植术中不采用体外静脉 静脉转流技术在大多数成人肝移植中是安全而又可行的 ,并且可以缩短手术时间 ,减少术中出血量和输血量 ,缩短ICU停留时间     

血液保护在肝移植中的应用

目的研究血液保护在肝移植术中的应用。方法38例患者接受非转流经典原位肝移植,术中采取减少出血和凝血功能保护等血液保护措施,分别统计切肝期、无肝期及新肝期(简称“三期”)的液体出入量及成分输血;经中心静脉采血,分别测定诱导后、切肝期1h、无肝期15min、新肝期1h时肌酐(Cr)、血红蛋白、白蛋白水平,测量中心静脉压及Sonoclot数据。结果患者术中输全血总量为(816±86.3)ml,输红细胞总量为(962±55.3)ml,有2例未输血;切肝期、无肝期及新肝期均维持一定尿量;三期的中心静脉压均比诱导后低(P<0.05),而血红蛋白及白蛋白与诱导后比较,差异无统计学意义,血肌酐在新肝期明显升高(P<0.05);Sonoclot指标中,激活全血凝固时间在切肝期、无肝期及新肝期均延长(P<0.05),无肝期及新肝期Clot率下降,血小板功能减退(P<0.05)。结论肝移植患者的血液保护应采取综合措施,切肝期应行凝血功能保护,无肝期应补充凝血成分,而新肝期在补充凝血成分的同时须注意尽早恢复新肝功能。     

原位肝移植术中体外静脉转流的改进

目的探讨同种原位肝移植术中先行转流,再游离肝脏这一技术改进的可行性及优越性.方法回顾性分析近3年来连续施行的46例原位肝移植术,前期23例(前期组)按经典式方法先游离肝脏后转流,后期23例(后期组)先转流再游离肝脏,分析比较两组转流时间、无肝期长短、失血量等指标以及术后恢复过程、并发症及预后等.结果前期组和后期组的转流时间分别为(99.78±21.6)min及(96.32±22.25)min,无肝期时间分别为(100.00±21.19)min及(102.00±24.31)min(P＞0.05),而术中失血量则为(5 096±4 243)ml及(1 726±1 125)ml,(P＜0.01).术后前期组发生并发症26例次,死亡3例,后期组发生并发症13例次,无死亡.结论先转流后游离肝脏,不增加转流时间及无肝期时间,但能显著减少术中出血量,有助于术后恢复及减少并发症,特别适用于终末期肝硬化患者及肝癌患者的肝移植术.     

急性等容血液稀释用于心血管外科血液保护的效果

目的 比较急性等容血液稀释(ANH)联合术中血液回收与单纯术中血液回收用于心血管外科血液保护的临床效果。方法 将术前血红蛋白Hb≥130g/L的心血管外科成年病人140例随机分成两组:A+C组,ANH联合术中血液回收(ANH量 8～12ml/kg,n=70);C组,术中单纯血液回收(n=70)。分别记录两组病人术前及术后24h血红蛋白(Hb)、血球压积(HCT)、血小板(PLT);回收血量;体外循环(CPB)总转流时间;术后24h引流量;全血用量;血浆用量;悬浮红细胞用量;冷沉淀用量;血小板用量和总住院时间。结果 两组病人一般情况无显著差异,术前各实验室指标无显著差异;A+C组术中血液回收量(581.8±28.2)ml少于C组(785.4±43.8)ml,有显著差异(P<0.001);A+C组术后24hHb(122.2±18.8)g/l高于C组(112.3±15.6)g/l,有显著差异(P<0.01),HCT(35.2±5.5)高于C组(33.2±4.5),亦有显著差异(P<0.05);A+C组全血用量(81.7±23.0)ml少于C组(217.4±35.7)ml,有显著差异(P<0.01)A+C组有15例,C组有6例未输异体血;两组间CPB时间、总住院时间及其它血制品用量无显著差异。结论ANH联合术中血液回收比较术中单纯血液回收用于心血管外科血液保护可减少异体血需要及用量,值得推广。     

小体积肝移植和辅助性原位小体积肝移植治疗猪急性肝功能衰竭的近期疗效观察

目的观察小体积肝移植和辅助性原位小体积肝移植治疗猪急性肝功能衰竭的近期疗效。方法急性肝功能衰竭猪随机分为3组接受肝移植治疗:A组行全肝移植(n=5);B组行小体积肝移植(n=5);C组行辅助性原位小体积肝移植(n=5)。各组动物开腹后即刻、切脾后即刻和再灌注后30 min分别监测门静脉压力,并观察术后生化指标变化、病理改变和1周生存率。结果A、B和C三组的移植肝重量与受体体重之比分别为(2．44±0．30)％、(0．76±0．02)％和(0．75±0．03)％。再灌注后30 min,B组移植肝门静脉压力显著高于其它两组(A:B:C=13．3:17．5:12．2 cmH2O, P<0．01),C组原肝门静脉压力显著高于移植肝门静脉压力(14．3:12．2 cmH2O,P<0．05)。A组和C组术后第2天起血清天冬氨酸转氨酶、总胆红素、凝血酶原时间、乳酸和血氨水平明显下降,术后第7天基本恢复至正常水平。B组术后上述生化指标一直维持在较高的水平,术后第2～4天明显高于其它两组(P<0．01)。A组、B组和C组1周生存率分别为100％、20％和80％,B组明显低于其它两组(P<0．05)。结论辅助性原位小体积肝移植治疗急性肝功能衰竭近期疗效优于小体积肝移植,术中不必干预原肝门静脉。     

广州地区手术中应用血液回收机成本-效益分析

目的总结手术中应用血液回收机节约用血的效果及成本-效益。方法641例手术患者按回收血量不同分为四组:A组,≤1000ml;B组,1001~1500ml;C组,1501~2000ml;D组,>2000ml,分析使用血液回收机的成本-效益。结果四组共收集自体血435695ml,平均每例693ml。A组回收血量占输血总量的百分比及未输异体血的几率均显著高于B、C、D组(P<0.01);B、C、D组输异体血量均显著高于A组(P<0.01)。按高价血(658.8元/U)计算:应用血液回收机与输异体血费用相等时需收集自体血477ml。A组98例(15.3%)成本>效益,其余543例(84.7%)成本≤效益。按低价血(240元/U)计算:应用血液回收机与输异体血费用相等时需收集自体血1150ml。A、B组共496例(77.4%)成本>效益,B、C、D组共145例(22.6%)成本≤效益。结论术中应用血液回收机回收自体血在一定程度上能缓解血源紧缺,可减少输异体血的诸多并发症,但使用时应注意成本-效益问题。     

猪原位肝移植术中体外静脉转流途径的实验研究

目的　探讨猪原位肝移植手术中体外静脉转流的应用及不同转流途径对血流动力学的影响。方法　选择50只健康家猪按体重接近原则配对分为供体组与受体组进行 2 5例原位肝移植手术 ,受体组无肝期采用不同体外静脉转流途径 ,其中A组 (1 6只 )经门静脉插管 ,B组 (9只 )经脾静脉插管。术中连续监测A、B两组动物的血流动力学变化。结果　术后 2 4h ,A组存活 1 4只 ,B组 9只全部存活。A组血流动力学在无肝期开始及结束时均出现明显波动 ,平均动脉压和中心静脉压下降 ,心率上升 ;B组在整个无肝期内血流动力学保持平稳 ,两组间比较差异有显著性意义 (P<0 .0 5)。结论　猪原位肝移植术中应用体外静脉转流 ,有利于维持血流动力学稳定 ,而经脾静脉插管转流较经门静脉插管转流具有更大的优越性     

自体血回输对病人血浆肝素含量的影响

目的　观察自体血回输对病人血浆中肝素含量的影响 ,探讨肝素在血液回收时的应用。方法　自体血液回输组 (n =32 )与异体输血组 (n =30 )骨科、脑科择期手术病人 ,男女各半 ,年龄 18～ 48岁 ,术前肝、肾、凝血功能均正常 ,无其他血液系统疾病。自体回输血量及异体输血量均超过 10 0 0ml。采用凝固法测定血浆中肝素含量 ;ACT Ⅱ型测定仪测定血中活化凝血时间 (ACT)。结果肝素含量 :自体血液回输组 ,术前、输血前、输血后 2小时肝素含量分别为 (0 6 5± 0 2 7)、(0 6 8±0 2 0 )和 (0 72± 0 19)U/ml;异体输血组分别为 (0 6 3± 0 2 4)、(0 6 7± 0 2 8)和 (0 6 9± 0 2 0 )U/ml。两组间均无显著差异 (P >0 0 5 )。ACT :自体血回输组三个不同时间分别为 (86 10± 2 0 5 4)、(133 5 0± 2 9 6 5 )和 (95 0 5± 2 9 71)秒 ;异体输血组分别为 (88 42± 18 37)、(131 70± 2 7 36 )和(92 86± 14 35 )秒。两组ACT值输血前均明显长于术前 (P <0 0 5 ) ,术前与输血后 2小时无显著差异 (P >0 0 5 )。结论　自体血液回输组与异体输血组术前、输血前、输血后 2小时肝素含量无显著差异。自体血回输中使用肝素抗凝适量 ,安全可行     

原位肝移植术中自体血液回收与回输

我院 1999年 2月～ 2 0 0 0年 6月行同种异体原位肝移植手术 14例 ,其中12例术中应用自体血回收 ,取得良好效果 ,现报道如下。资料与方法一般资料　 12例原位肝移植手术患者 ,男 8例 ,女 4例 ,平均年龄 11～ 5 7(4 2 4± 14 5 )岁 ,平均体重 2 1～ 74(5 7 3± 15 )ｋｇ ,术前ＡＳＡⅢ～Ⅳ级。麻醉及监测方法　均用静吸复合全身麻醉 ,无肝期采用体外静脉 静脉转流。术中监测桡动脉压、ＣＶＰ、ＥＣＧ、血气、电解质、血红蛋白、白蛋白、血小板及纤维蛋白原。血液回收　手术切皮开始启动全自动血液回收系统 (美国Ｍｅｄｔｒｏｎｉｃ产Ｃｅｌ…     

对行肝脏移植手术的肝肾综合征病人麻醉处理的探讨

目的　通过观察合并肝肾综合征(HRS)病人行肝脏移植术中应用体外静脉静脉(V-V)转流与非转流以及连续输注多巴胺等处理对围术期肾功能的影响,探讨HRS病人肝移植术中的肾功能保护方法。方法　30例合并肝肾综合征病人随机分为A(n =15 )、B(n =15 ) 2组,气管插管全麻下行肝脏移植术。术中加强血流动力学、尿量、体温等监测,术中各时期及术后2 4h测定血浆尿素氮(Bun)、血肌酐(Cr)水平。其中A组建立V-V转流,B组则不采用V-V转流。2组均通过适当的扩容和连续推注小剂量多巴胺等血管活性药维持血液动力学的稳定,并给予连续输注速尿(furosemide)和三甘氨酰基赖氨酸加压素(Terlipressin)等措施保护或改善肾功能。结果　A组术中血液动力学基本稳定。B组于无肝期HR明显加快,CVP、MPAP、PC WP有明显降低(P <0.0 5 ) ;新肝期期间,2组病人CVP、MPAP、PCWP水平均有明显的升高(P <0.0 5 ) ;手术平均时间、无肝期平均时间、多巴胺、速尿和Terlipressin平均用量等差异均无显著性(P >00 0 5 )。A组病人Terlipressin平均用量6. 80±0 .95mg ,B组病人Terlipressin平均用量(6 75±1 0 5 )mg。A、B两组尿量、Bun、Cr水平在无肝期前的各时期差异无统计学意义(P >0.0 5 ) ,但随后各时期中,A组均优于B组(P <0 .0 5 )。结论　无肝期     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.