公民心死亡器官捐献肝移植

目的 总结公民心死亡器官捐献肝移植的临床经验.方法 回顾性分析2006年7月至2011年5月广州军区广州总医院施行的20例公民心死亡器官捐献肝移植供受者的临床资料.脑心双死亡器官捐献(DBCD)供者通过体外膜肺氧合技术(ECMO)避免热缺血,M-Ⅲ供者不采用ECMO,待心跳停止5 min后实施肝脏获取手术.受者均采用原位肝移植术,其中17例行胆管端端吻合,3例行胆肠吻合.所有受者获定期随访.采用Kaplan-Meier法绘制生存曲线.结果 20例供者中M-Ⅲ占10％( 2/20),DBCD占90％ (18/20).20例受者均顺利完成手术,平均手术时间、无肝期、术中出血量和术后ICU时间分别为(6.2±2.7)h、(54±13) min、(2305±1311)ml和(44±35)h.全组无手术死亡,术后肝功能恢复满意,无原发性肝脏无功能或移植肝功能恢复延迟;术后1个月内1例受者因脓毒血症死亡,1例因肺部感染死亡,其余18例受者长期生存,最长生存时间为58个月.结论 公民心死亡器官捐献是现阶段我国可以应用的供肝获取方法,其中以DBCD为主要类型;建立科学的心死亡器官捐献肝移植流程,合理使用ECMO等保护供肝质量措施,对我国公民死亡器官捐献工作有着积极的作用.     

采用心脏死亡供者无偿捐献的供肝进行原位肝移植七例观察

目的 观察利用可控的心脏死亡供者捐献的肝脏对受者进行原位肝移植的预后.方法 利用7例心脏死亡供者捐献的供肝对终末期肝硬化患者进行原位肝脏移植术,并对术前和术后的随访数据进行分析,探讨受者采用此种类型供肝移植后的预后情况.结果 7例受者中,除1例于术后第9天死于上消化道出血外,其余6例受者均长期存活,随访时间均大于12个月,中位随访时间为15.7个月,预后均较好.结论 采用符合荷兰马斯特里赫特(Maastricht)分类第Ⅲ型的心脏死亡供者捐献的肝脏对终末期肝硬化患者进行原位肝移植,预后较好.     

超声在脑-心双死亡器官捐献供肝体外膜肺氧合模式中的应用价值研究

目的评价超声在体外膜肺氧合(ECMO)保护脑-心双死亡器官捐献(DBCD)供肝中的应用价值。方法选取2006年4月至2014年11月广州军区广州总医院收治的符合供肝要求的40例脑死亡或不可逆脑损伤患者作为研究对象。分别在ECMO运转前、运转后5 min、停转即刻,记录超声监测的供肝肝动脉流量(QHA)、门静脉流量(QPV)及ECMO导致的肝动脉ECMO流量(VE)。在相应时刻监测供体血液总胆红素(TB)、丙氨酸转氨酶(ALT)、乳酸的变化;随访肝移植受者术后3个月内移植肝恢复情况。结果 ECMO转机时间平均为(1.0±0.2)h。使用ECMO运转前后QHA、QPV间差异均无统计学意义(均为P0.05)。在使用ECMO运转前后肝功能指标比较差异均无统计学意义(均为P0.05)。术后3个月内不同时间点对移植肝进行超声评估,及对肝功能TB、ALT等进行检测,结果显示40例受者移植肝功能均恢复良好。结论通过超声监测QHA,选择最优ECMO流量灌注,能保护DBCD供肝,避免灌注损伤及灌注不足。     

公民逝世后器官捐献供肝移植胆道并发症的预防经验

目的总结公民逝世后器官捐献供肝移植的胆道并发症预防经验。方法回顾性分析2008年10月至2016年12月中山大学附属中山医院88例公民逝世后器官捐献肝移植病例的临床资料。结果 88例均符合中国标准三类捐献(即脑-心双死亡标准器官捐献)。所有病例按标准获取流程成功完成肝脏捐献,88例受者均顺利植入供肝,胆道重建多采用胆管端端吻合,供者胆管尽可能短,吻合时保持微张力。未出现原发性移植肝无功能、排斥反应。1例患者出现胆漏经引流3周后自愈,2例患者出现胆道狭窄并发症,经置入胆道支架后缓解。结论加强获取器官管理,采用规范的获取供肝流程,充分利用体外膜肺氧合(ECMO),尽量缩短热、冷缺血时间,注意胆道重建技巧,有助于减少胆道并发症发生率,公民逝世后器官捐献供肝移植可以取得满意的临床效果。     

公民逝世后器官捐献供肝移植62例临床分析

目的分析公民逝世后器官捐献供肝移植的流程方法及疗效,为公民逝世后器官捐献供肝移植提供一定借鉴。 方法回顾性分析中山大学附属中山医院2008年10月至2015年12月完成62例公民逝世后器官捐献肝移植病例的临床资料。 结果62例均符合《中国心脏死亡器官捐献工作指南》三类捐献标准（脑-心双死亡标准器官捐献,DBCD）。所有病例按标准成功完成了肝脏捐献及获取流程,其中15例使用体外膜肺氧合技术（ECMO）维持至器官获取。供肝热缺血时间0~30（16.2±6.5）min,冷缺血时间190~680（347±39）min。62例受体均顺利植入供肝,未出现原发性移植肝无功能、排斥反应。1例围手术期死于多发动脉血栓形成,1例发生胆漏经引流后自愈,2例发生胆道狭窄并发症,经胆道支架置入后缓解;肿瘤复发转移死亡3例。 结论通过合理流程充分利用ECMO,加强获取器官管理,缩短热冷缺血时间,公民逝世后器官捐献供肝移植可以获得较满意的临床效果。     

体外膜肺氧合用于脑心双死亡供者器官获取的流程和方法

目的 总结体外膜肺氧合(ECMO)用于脑心双死亡供者(DBCD)器官获取的流程和方法.方法 回顾分析2009年1月至2012年12月完成的39例DBCD器官捐赠.39例供者中,男性30例,女性9例,年龄(28.1±10.2)岁,体质量指数为(21.3±2.5)kg/m2;原发病为重型脑外伤29例,脑血管意外8例,以及缺血缺氧性脑病2例.评估供者危险指数为1.27±0.28.39例供者在捐赠器官过程中均使用了ECMO支持.结果 ECMO使用时间为(161±77)min.ECMO起始流量为(3.14±0.24) L/min,平衡流量为(1.76±0.58)L/min,复灌流量为(3.10±0.48) L/min.供者器官热缺血时间均为0 min.供者评估时、ECMO使用前、器官获取前供者胆红素总量、丙氨酸转氨酶均无显著性差异,但获取前血清肌酐水平显著升高,尿量显著减少.共获取38个肝脏,78个肾脏,分别实施了37例肝移植、64例肾移植.1个肝脏因合并乙型肝炎病毒表面抗原阳性未匹配到合适受者而未使用,14个肾脏因肾功能不全、肾结石未使用.结论 供者家属和伦理委员会对使用ECMO没有争议,ECMO辅助DBCD器官获取可避免热缺血损伤,获得更满意的移植效果.     

中国Ⅲ类和Ⅰ类心脏死亡供体在肝移植应用中的近期效果

目的 总结中国Ⅲ类和Ⅰ类心脏死亡供体在肝移植应用中的近期效果.方法 回顾性分析2011年9月-2014年6月在广东佛山市第一人民医院完成的中国Ⅰ类心脏死亡捐献供体(DBD组)和Ⅲ类心脏死亡捐献供体(DBCD组)肝移植的临床资料.结果 DBD组和DBCD组分别有12例和21例受体,两组术前供、受体年龄、原发病、肝功能指标ALT、TBIL、ALB、供肝冷缺血时间、受体MELD评分无明显差异,两组术中出血量、输血量、手术时间、无肝期差异无统计学意义,P＞0.05;DBD组和DBCD组术后中位随访时间分别为8.8个月和20个月,两组肝移植受体和移植物累积生存率均为100％,术后ICU住院时间、术后肝功能恢复时间、术后住院时间、早期并发症、急性排斥反应发病率差异均无统计学意义,P＞0.05.结论 中国Ⅲ类心脏死亡供体(DBCD)肝移植能取得与中国Ⅰ类心脏死亡供体(DBD)肝移植一样的近期效果,详细的供体评估、规范的供体器官获取流程、缩短冷供肝缺血时间、保护供肝胆管周围微血管网、加强围手术期的管理和长期随访是提高中国Ⅲ类心脏死亡供体肝移植受体生存率的关键.     

心脏死亡器官捐献获取流程探讨

目的总结并进一步探讨心脏死亡器官捐献(DCD)获取流程的初步经验。方法回顾性分析2009年7月至2012年1月期间广州军区总医院28例DCD者的临床资料、供体入选标准及器官获取流程。结果 28例DCD供体均成功实施了器官捐献,其中MaastrichtⅢ类3例(10.7%),MaastrichtⅣ类1例(3.6%),脑-心双死亡捐献(DBCD)供体24例(85.7%)。3例MaastrichtⅢ类供体实施了标准DCD器官获取流程(简称DCD流程),1例MaastrichtⅣ类供体采用DBCD器官获取流程(简称DBCD流程)非体外膜肺氧合(ECMO)模式,24例DBCD采用了DBCD流程ECMO模式。供体器官热缺血时间:DBCD为0 min,MaastrichtⅣ类为18 min,MaastrichtⅢ类平均25 min(22～28 min)。本组共获取了28个肝脏、40个肾脏、2个心脏,分别成功用于肝移植、肾移植和心脏移植。结论我国DCD器官获取可分为DCD流程和DBCD流程,后者又分为ECMO模式和非ECMO模式。ECMO模式可避免器官热缺血损伤且没有伦理学争议,对我国公民DCD器官有着十分重要的作用。     

婴幼儿亲属活体部分供肝肝移植中的供、受者安全性分析

目的 探讨婴幼儿亲属活体部分供肝肝移植中的供、受者的安全性.方法 2006年9月至2009年11月,行婴幼儿亲属活体部分供肝肝移植者8例,受者原发病均为先天性胆道闭锁.供者术前常规行三维CT观察和计算全肝及肝叶(段)体积及形状,磁共振胰胆管造影术(MRCP)了解胆道情况.根据婴幼儿受者腹腔容积切取合适肝叶(段)行肝移植术.受者术后给予抗排斥反应和预防感染等治疗;供者术后给予保肝和抑酸治疗.分析供、受者术前、术中及术后情况.结果 8对供、受者手术均获成功.6例供肝为左外侧叶,1例为S3肝段,1例为减体积S3肝段,供肝重量为(235.9±53.6)g(148～302 g),供肝重量与受者体重比(GW/RW)为(2.65±0.48)%(2.11%～3.36%).对供、受者随访3～40个月(中位数18个月),8例供者均存活,发生并发症2例(25%).8例受者中,死亡1例(12.5%),其他受者发生并发症13例次.结论 术前对供、受者行精确评估,切取合适供肝行肝移植术,术中精细操作,术后精心治疗可最大程度保证供、受者的安全.     

DBCD供体状态与器官移植受者术后器官功能恢复的相关性分析

目的探讨脑-心双死亡器官捐献(DBCD)供体状态与其肝、肾移植受者术后器官功能恢复的相关性。方法回顾性分析2011年8月至2013年11月四川省人民医院器官移植中心的12例DBCD供体评估资料及器官保护措施,以及由其提供器官的12例肝移植、22例肾移植受者术后恢复的各项指标。将供体各项指标分别与其肝移植、肾移植受者术后恢复指标进行相关性分析。结果肝移植受者术后发生肝脏原发无功能(PNF)1例(1/12,8%),肾移植受者术后发生移植物功能延迟恢复(DGF)11例(11/22,50%)。经统计学分析,供体入住重症监护室(ICU)时间、肝功能、维持收缩压、凝血功能、血糖、电解质(血Na+、K+)等指标,与其肝、肾移植受者术后器官功能恢复的相关性均有统计学意义(均为P﹤0.05)。年龄、脑死亡原因、维持舒张压、活化部分凝血活酶时间(APTT)、动脉血p H值与其相应肝移植受者术后恢复存在相关性。总胆红素、白细胞计数与其相应肾移植受者术后恢复存在相关性。结论 DBCD供体是适合我国国情的器官移植供体。DBCD肝移植受者术后PNF发生率较低,肾移植受者术后DGF发生率较高。根据影响因素有针对性地进行供体评估和器官保护工作,有助于提高DBCD的肝、肾移植效果。     

Brain death

Summary Following the research of Giessen Neurosurgery on primary and secondary lesions of the hypothalamo-pituitary system and the brainstem over a period of more than 30 years, cerebral failure and death does not represent a uniform syndrome but consists of several, well characterized syndromes of irreversible hypothalamo-pituitary, mesencephalic and bulbar failure. The specific syndromes are described in detail. The diagnosis is based on establishing complete irreversible damage of specific vital basal functions such as hypothalamo-pituitary transmission, water-and electrolyte metabolism, temperature regulation, circulation and respiration. The common feature of all types is the irreversible break-down of the complex central neurogenous and/or neurohumoral regulatory system. The permanent and irreversible loss of central regulation and modulation means at the same time the complete cessation of the specific human cortical function, the death of the whole brain. Only in bulbar failure with primary irreversible cessation of respiration artificial respiration can maintain the autonomous functions of the heart for a limited time. It is indicated when organ explantation is to be considered. Complete and irreversible isolated loss of cortical function abolishes the normal human life, but does not mean death of the remaining vegetating human being.Presented at the meeting of the Working Group of the Pontificia Academia Scientiarum on The artificial prolongation of life and the exact determination of the moment of death, Vatican City, October 19–21, 1985.Dedicated to Prof. Dr. Jean Brihaye at the occasion of his 65th anniversary.     

新入职护士死亡教育需求状况及影响因素分析

目的 了解新入职护士死亡教育需求状况并分析其影响因素,为医院管理者对新入职护士开展死亡教育培训提供参考.方法 以便利抽样法于2021年7～8月选取河北省11所医院的387名新入职护士,采用一般资料调查表、死亡教育需求量表、死亡态度描绘量表及死亡焦虑量表进行调查.结果 新入职护士死亡教育需求总分为171.76±40.83...     

Brain stem death

The concept of brain and brain stem death developed from the observation of apnoeic comatose patients. In the UK, the diagnosis of brain stem death is made by clinically testing brain stem function once specific preconditions have been met. The exact definition of brain death and some details regarding the tests required to make this diagnosis vary across the globe. However, the majority of tests carried out are similar to those in the UK. In this review we define brain stem death and the clinical tests used to confirm it. The use of ancillary testing can have a role in patients where clinical tests are not possible and this is also discussed.     

Permanent brain arrest as the sole criterion of death in systemic circulatory arrest

Historically, there has been a tendency to think that there are two types of death: circulatory and neurological. Holding onto this tendency is making it harder to navigate emerging resuscitative technologies, such as extracorporeal membrane oxygenation and the recent well-publicised experiment that demonstrated the possibility of restoring cellular function to some brain neurons 4 h after normothermic circulatory arrest (decapitation) in pigs. Attempts have been made to respond to these difficulties by proposing a unified brain-based criterion for human death, which we call ‘permanent brain arrest’. The clinical characteristics of permanent brain arrest are the permanent loss of capacity for consciousness and permanent loss of all brainstem functions, including the capacity to breathe. These losses could arise from a primary brain injury or as a result of systemic circulatory arrest. We argue that permanent brain arrest is the true and sole criterion for the death of human beings and show that this is already implicit in the circulatory-respiratory criterion itself. We argue that accepting the concept of permanent cessation of brain function in patients with systemic permanent circulatory arrest will help us better navigate the medical advances and new technologies of the future whilst continuing to provide sound medical criteria for the determination of death.     

Brain stem death

The concept of brain and brain stem death developed from the observation of apnoeic comatose patients. In the UK, the diagnosis of brain stem death is made by clinically testing brain stem function once specific pre-conditions have been met. The exact definition of brain death and some details regarding the tests required to make this diagnosis vary across the globe. However, the majority of tests carried out are similar to those in the UK. In this review we define brain stem death and the clinical tests used to confirm it. The use of ancillary testing can have a role in patients where clinical tests are not possible and this is also discussed.     

Traumatic death in urban children

Trauma has remained one of the leading causes of death in children in spite of improved medical care. A review of 911 pediatric trauma deaths which occurred over a 5 yr period in an urban setting revealed that almost 50% of these children died before receiving medical care. A significant improvement of the trauma mortality can thus only be accomplished by reducing the number of “DOAs”. We therefore analyzed the cause and type of injury and its relationship to age, sex, race, seasonal occurrence, and sociological circumstances. The following four categories are merely part of the overall material developed in this review. Even with improved medical care of trauma patients the overall pediatric trauma mortality cannot be significantly reduced unless the number of DOAs is decreased through prevention. Educational and family assistance programs can be designed for specific problem areas to reach identified susceptible groups through existing channels such as day care centers, schools, or welfare agencies. Statistical data, such as presented here (but not previously available) are essential to analyze the particular problems of specific geographic and sociologic areas. Since the vast majority of pediatric trauma deaths fall within the interest sphere of the pediatric surgeon, our active participation in accident prevention is essential to achieve a significant reduction of pediatric trauma mortalities.     

肾移植受者移植肾带功能死亡与失功能死亡原因比较

目的 分析肾移植受者移植肾带功能死亡与失功能死亡原因.方法 回顾分析我院2001年至2010年期间死亡的207例肾移植受者资料.将其分为移植肾带功能死亡组(102例)和失功能死亡组(105例),对两组死亡原因进行比较分析.结果 所有受者的死亡原因依次为感染(31.9％)、心血管疾病(21.3％)、肝功能衰竭(15.9％...     

Medical and legal considerations of brain death

Brain death was first defined in 1968, and since then laws on determining death have been implemented in all countries with active organ transplantation programs. As a prerequisite, the aetiology of brain death has to be known, and all reversible causes of coma have to be excluded. The regulations for the diagnosis of brain death are most commonly given by the national medical associations, and they vary between countries. Thus, the guidelines given in the medical textbooks are not universally applicable. The diagnosis is based on clinical examination, but confirmatory tests, such as angiography or EEG, are allowed on most occasions. Brain death is followed by cardiovascular and hormonal changes, which have implications in the management of a potential organ donor. Spinal reflexes are preserved, and motor and haemodynamic responses are frequently observed in brain dead patients.