重型肝炎肝移植手术患者围手术期凝血功能的观察及护理

目的 探讨重型肝炎肝移植手术患者围手术期凝血功能的观察及护理措施.方法 研究对象为2009年7月至2010年8月收治的32例因重型肝炎行肝移植手术的患者,观察术前、术中、新肝期、术后72 h的凝血功能,探讨有效护理措施.结果 PT值及APTT值术中逐渐升高,新肝期为最高峰,术后72h降为正常;AT值术中逐渐下降,新肝期为最低值,术后72 h升为正常;新肝期3项指标水平与其他时间点比较差异均有统计学意义.结论 肝移植手术患者实施有效围手术期凝血功能监护有重要临床意义,值得推广应用.     

重型肝炎和肝癌肝硬化患者肝移植围手术期肾功能的变化

目的 观察重型肝炎及肝癌肝硬化患者原位肝移植围手术期肾功能变化,评价肝移植术对该类患者肾功能的影响。方法 选择30例术前血肌酐（SCr）、尿素氮（BUN）正常的终末期肝病、行背驮式原位肝移植术患者,手术过程中均未采用体外静-静脉转流。按原发病不同分为重型肝炎组（15例）和肝癌肝硬化组（肝癌组15例）,分别于术前（麻醉后）、无肝前20min、无肝30min、新肝60min、术毕不同时间点取桡动脉血,测定β2-微球蛋白（β2-MG）值,并记录血流动力学变化;分别于术前、新肝60min、术毕留取新鲜尿液,测定尿β2-MG及尿N-乙酰-β-D-葡萄糖苷酶（NAG）值。记录两组患者术前、术后24h、术后1周的SCr、BUN值以及术后肝移植相关性肾功能衰竭（肾衰）的发生情况。结果1术前重型肝炎组有7例血β2-MG、12例尿β2-MG、14例尿NAG值均高于正常参考值;而肝癌组仅有3例血β2-MG、3例尿β2-MG、7例尿NAG值高于正常参考值;两组各时间点血β2-MG异常率比较差异均无显著性（P均〉0.05）;重型肝炎组术前尿β2-MG及NAG异常率明显高于肝癌组（P〈0.01和P〈0.05）。2术中两组血β2-MG值与术前比较变化不大,变化趋势两时间点间比较差异均无显著性;两组新肝期60min及术毕尿β2-MG及NAG均较术前呈增高趋势,但差异无显著性（P均〉0.05）,而重型肝炎组各时间点尿NAG值明显高于肝癌组（P〈0.05或P〈0.01）。3重型肝炎组肝移植相关性肾衰发生率为46.7%,而肝癌组无一例发生（P〈0.01）。结论 重型肝炎患者较肝癌肝硬化患者肝移植术后早期易发生急性肾衰,围手术期应注意肾功能保护。     

背驮式肝移植17例围手术期的处理

同种异体原位肝移植是治疗急性肝功能衰竭和终末期肝病最有效的方法.在肝移植的各种术式中,背驮式原位肝移植（PBLT）有其独特的优点.由于保留了受的肝后下腔静脉,因而具有术中血流动力学稳定,术后恢复较快的优点.我院于2000-08～2004-11开展背驮式肝移植17例,围手术期处理体会如下.     

肝移植患者围手术期护理体会

肝移植手术作为治疗终末期肝病的唯一有效手段,在国内正在广泛开展.尽管移植在技术上已不断进步成熟,但由于晚期肝病患者严重的病生理变化、麻醉手术所致的血流动力学改变以及术后免疫抑制剂的应用等诸多因素的影响,使手术仍极具风险,尤其是术后并发症的发生,是导致移植失败的重要因素[1].因此围手术期的观察和护理显得尤为重要,在做好术前评估的基础上,加强术后管理,可有效提高肝移植患者的存活率和生存质量.我院2002年5月～2011年12月开展肝移植手术100例,现将护理体会报告如下.     

肝移植围手术期电解质酸碱平衡紊乱处理体会

肝移植围手术期电解质酸碱平衡紊乱十分常见,对其治疗和处理具有重要的临床意义。我院自2002年5月至2005年12月施行异体原位肝移植术23例,现就其围手术期电解质酸碱平衡紊乱情况及处理体会报告如下。     

肝移植术围手术期的护理体会

肝移植手术是较为复杂的手术,它代表了一个医院、一个地区、一个国家的整体医疗水平。肝移植手术的围手术期护理已经从原来的患者进手术室至出手术室这一范围扩展到从患者决定手术至患     

肝移植围手术期整体护理的体会

肝移植手术复杂、时间长、出血量多；患者为终末期肝病，全身情况差；术后需长期应用免疫抑制剂，这些特点对围手术期护理提出了更高的要求。我院1998——2004年共进行肝移植4例次，现将肝移植围手术期整体护理体会报告如下。     

肝移植围手术期护理

肝移植是临床治疗各种终末期肝病的最有效的治疗方法,但因该手术过程复杂、创伤大、并发症多、费用多,且术后需要终生服用免疫抑制剂等,护理难度很大。由于术式的不断改进以及免疫抑制剂的不断更新,以及临床对肝移植护理经验的不断积累和完善,肝移植成功率和存活率越来越高,肝移植术逐渐被广大患者和家属所接受。我院自2004年8月~2005年1月共成功施行3例同种异体改良背驮式原位肝移植和1例经典原位肝移植术。由于术前精心准备和术后特别护理,病人术后均恢复良好,未出现与护理相关的并发症。现报道如下。1临床资料4例病人均为男性,年龄37~65…     

肝移植围手术期护理

肝移植是临床治疗各种终末期肝病的最有效的治疗方法,但因该手术过程复杂、创伤大、并发症多、费用多,且术后需要终生服用免疫抑制剂等,护理难度很大.由于术式的不断改进以及免疫抑制剂的不断更新,以及临床对肝移植护理经验的不断积累和完善,肝移植成功率和存活率越来越高,肝移植术逐渐被广大患者和家属所接受.我院自2004年8月～2005年1月共成功施行3例同种异体改良背驮式原位肝移植和1例经典原位肝移植术.由于术前精心准备和术后特别护理,病人术后均恢复良好,未出现与护理相关的并发症.现报道如下.     

肝移植患者围手术期心理护理体会

随着医学模式的转变和护理技术的发展,运用护理心理学的理论和技术开展心理护理,改善护患关系以提高护理质量,已被医护人员所接受和认同。随着肝移植数量的增加,一系列伦理学和社会学问题将会出现在人们面前,一些心理学和精神病学的问题也随之增多。肝移植患者的心理因素和家属的支持与其预后密切相关。肝移植患者出现的一系列心理、精神问题也需要专门的指导和治疗。因此,肝移植患者移植前的心理准备及移植后的心理康复就显得更为重要。     

Perioperative management of liver transplantation patients

Perioperative care involves many disciplines, each of which contributes in important ways. Changes in liver-transplantation care during the last 40 years can be attributed to the accumulation of improvements, discoveries, and technologic improvements across different disciplines. Here we review some of the articles that were published during the last year that relate to these advances.     

Clinical management of patients with recurrent viral hepatitis after liver transplantation

Liver transplantation is indicated in end-stage chronic viral liver disease, but unless adequate prophylaxis is administered, the patient will in most cases develop recurrent hepatitis B (HBV) and C (HCV) virus infection. Today, patients receiving prophylaxis using nucleoside analogue drugs with or without specific immune globulin drugs in connection with orthotopic liver transplantation for HBV related cirrhosis, present low risk of relapse and high 5–10 year survival rates. Lamivudine was the first drug used in the prophylactic treatment, but this drug has increasingly been combined with or replaced by adefovir due to the low genetic barrier, which causes viral resistance. Most patients develop viral recurrence after orthotopic liver transplantation for HCV related cirrhosis, and in an elevated number of cases, cirrhosis and hepatic insufficiency set in after a few years. Prophylaxis before transplantation and pre-emptive treatment using interferon and ribavirin present numerous side effects resulting in reduction of doses and suspension of therapy, with consequently low sustained virological remission rates and risk of rejection.The treatment is better tolerated by patients with histologically confirmed chronic disease, but also in these patients virological remission rates are low. This pathology requires new therapeutic protocols and/or new drugs in order to obtain better compliance and better responses.     

肾移植患者围术期麻醉管理:40例资料回顾

背景:从肾移植患者围术期血生化检测结果可以看到,一些酸碱指标及生化指标的变化可能与血液稀释有关。目的:通过监测肾移植患者围术期血流动力学的变化以及电解质、血生化的改变,麻醉药物使用情况,探讨肾移植患者理想的麻醉管理方法。方法:分析40例肾移植患者麻醉前、肾动脉血流开放前、血流开放后10min、手术结束时(T4)各时点平均动脉压、中心静脉压、心率、电解质、血糖和血气参数的变化。结果与结论:与肾移植患者麻醉前比较,血流开放后10min平均动脉压、中心静脉压、pH、HCO3-、BE显著降低(P<0.01),K+和葡萄糖明显增加(P<0.01)。与肾动脉血流开放前比较,血流开放后10min平均动脉压、葡萄糖、pH、HCO3-、BE明显降低而心率明显增高(P<0.05)。说明充分的移植前准备,合理的麻醉药物选择,以及围术期的循环、呼吸及水电解质酸碱平衡的维持是肾移植术全身麻醉成功的关键。     

Living related liver transplantation for acute fulminant hepatitis B: experience from two possible hyper-acute cases

Fulminant hepatic failure, which is represented by fulminant hepatitis, is fatal in most cases unless prompt liver transplantation is performed. Even if liver transplantation is performed, irreversible neurological damage is often complicated. In this case report, we describe two cases of fulminant hepatitis induced by acute hepatitis B virus infection, both of which were successfully rescued by living related liver transplantation without significant complications. The case 1 was a 45-year-old Japanese male. He complained general malaise and anorexia. His local physician diagnosed him as acute hepatitis B, and referred to our hospital. Due to severe coagulopathy, plasma exchange was performed 3 times. However, his hepatic coma progressed rapidly along with rapid decrease of both his direct/indirect bilirubin (D/T) ratio and serum blood urea nitrogen (BUN) levels. Living related liver transplantation was performed under the diagnosis of acute fulminant hepatitis B. The case 2 was a 34-year-old Japanese male. His complaints were fever and skin rush. He was referred to our hospital under the diagnosis of acute hepatitis B. On the second day after admission, he developed grade II hepatic coma, which deteriorated into grade III in spite of intensive therapy including plasma exchange. He also demonstrated rapid decrease of both D/T ratio and serum BUN level. Living related liver transplantation was performed on the next day. Both cases recovered without any evidence of neurological sequelae. In general, it is extremely difficult to rescue fulminant hepatitis by conservative treatments, particularly in cases with rapid progression. Although emergency liver transplantation may be an only option to rescue in such a case, living related liver transplantation has an advantage in view of urgent organ donation over cadeveric transplantation.     

Atracurium infusions in patients with fulminant hepatic failure awaiting liver transplantation

Objective: To determine the pharmacokinetics and pharmacodynamics of the neuromoscular blocking agent atracurium besylate in patients with fulminant hepatic failure (FHF).Design: Open study of patients receiving atracurium infusions to facilitate mechanical ventilation.Setting: Intensive care unit in a tertiary referral university teaching hospital.Patients: Ten encephalopathic patients with FHF reuiring mechanical ventilation while awaiting orthotopic liver transplantation. Three patients died before transplantation could be performed, three died after transplantation, and four survived following successful transplantation.Methods: Plasma, urine and dialysate fluid were analysed for atracurium and its metabolites using HPLC. Neuromuscular blockade was measured using transcutmeous ulnar nerve stimulation and an accelerometer. Electroencephalography and liver function tests were performed daily.Results: Patients received atracurium infusions for a period ranging from 38 to 217 h. Six patients required continuous arteriovenous haemodiafiltration (CAVHD) to replace renal function. Atracurium mean steady state clearence was 8.6 ml/min/kg, and train-of-four recovery ratio, to 75% took 63 min (range 32–108). Laudanosine clearance was markedly reduced in the non-survivors; the half-life was 38.5 hrs compared with 5.3 h in the 4 patients who underwent successful transplantation. Laudanosine accumulation could be observed in all patients before transplantation, but kinetics returned to normal after successful transplantation. The highest laudanosine level recorded was 6,860 ng/ml. There was no evidence of adverse central neurological effects attributable to laudanosine. CAVHD did not contribute significantly to clearance of atracurium or its metabolites.Conclusions: Atracurium kinetics and dynamics are nearnormal even in patients with fulminant hepatic failure and renal failure; laudanosine accumulation will occur, but this is not associated with measurable central neurological effects. Implantation of a functioning liver graft results in clearance of laudanosine, which seems to be independent of renal function. Atracurium is an appropriate choice for producing neuromuscular blockade for periods of several days in patients with fulminant hepatic failure and renal impairment.     

Atracurium infusions in patients with fulminant hepatic failure awaiting liver transplantation

Objective: To determine the pharmacokinetics and pharmacodynamics of the neuromoscular blocking agent atracurium besylate in patients with fulminant hepatic failure (FHF). Design: Open study of patients receiving atracurium infusions to facilitate mechanical ventilation.     

肺移植围术期处理

肺移植术（LTX）是治疗终末期肺疾病的一种有益选择。由于我国供体肺紧缺以及大量终末期肺疾病患者没能及时进行肺移植评估,导致这些患者需要在重症医学科（ICU）内行生命支持的同时进行LTX等待及评估;而且这些患者的术后并发症也较多。这样ICU医生对肺移植受体围术期评估和支持能力面临着巨大的挑战。本文就在ICU内LTX受体的围术期管理,包括术前评估,术后并发症以及体外膜氧合（ECMO）技术的应用,根据国外的文献结合本中心的经验进行综述。     

小儿活体肝移植的围手术期护理

目的 总结小儿活体肝移植围手术期的护理经验.方法 对2006年6月-2007年1月施行的小儿活体原位部分肝移植手术,进行充分的术前评估,精心的术前准备,耐心细致的术后护理,密切监测受体病情及各种生化指标的动态变化,有效预防各种并发症的发生.结果 5例患儿手术均成功,1例72 h发生移植肝无功能死亡,1例术后4个月发生急性排斥反应死亡,其余3例均健康存活,无并发症发生.结论 小儿活体肝移植手术风险大、并发症多、护理难度大.充分的术前准备,先进的监护技术和细致的术后病情观察及护理对小儿活体肝移植至关重要.