肝移植手术出血特点及对移植后呼吸功能恢复的影响

背景:肝移植手术容易导致致命性大出血,如何评估肝移植手术过程的出血、止血、凝血功能以及使用怎样的止血措旌解决凝血问题,目前还没有常规止血指导方案.呼吸功能监测和呼吸道管理是肝移植后首先遇到的重要问题,因此呼吸机治疗和呼吸系统并发症的处理在ICU期间显得尤为重要.目的:回顾性分析肝移植手术中的出血特点以及出血/输血量对移植后呼吸功能恢复的影响.设计、时间及地点:回顾性病例分析,于2001-02/2006-09在中山大学附属第二医院肝胆外科完成.对象:资料完整的成人肝移植患者48例.根据病因将患者分为4组,单纯肝硬化组8例,肝硬化合并肝癌组32例,单纯肝癌不合并肝硬化组5例,急性炎症组3例.以出血量大于5 000 mL为界将患者分为2组,大量失血组9例,小量失血组39例.方法:了解不同病因患者移植手术中出血量对术后呼吸功能恢复的影响.回顾性分析手术各时期的出血量,包括切肝期,无肝期和新肝期,对各期的出血量进行统计分析,了解在肝移植手术过程中不同病因的患者手术不同时期出血的特点.主要观察指标:患者手术各时期的出血量.大量失血组及小量失血组手术后呼吸功能等恢复情况,围手术期并发症、死亡率.结果:病肝切除阶段是主要的出血时间段,以广泛渗血为主要特点.不同病因患者手术出血量明显不同,出血量最多为肝癌合并肝硬化、其他依次为肝硬化、急性重症肝炎及无肝硬化肝癌(P<0.05).出血量较大(>5 000 mL)明显影响患者移植后呼吸功能的恢复,并且造成较高的围手术期并发症发生率及死亡率(P<0.05).结论:在肝移植手术中,尤其是对肝癌合并肝硬化实施肝移植手术,控制切肝时间相广泛渗血是手术中主要的防止出血手段;大量出血、输血可能造成患者移植后呼吸功能恢复延迟,并且造成较高的呼吸系统并发症发生率及死亡率.

Bleeding features of patients undergoing liver transplantation and its impact on respiratory function recovery

BACKGROUND:Liver transplantation surgery may cause massive hemorrhage or even induce death.How to evaluate bleeding,hemostasis,and blood coagulation and how to solve blood coagulation remain still unclear.Respiratory function monitoring and respiratory tract management are initial difficulties following liver transplantation.Therefore,respirator therapy and disposal of respiratory system complication are remarkably necessary during intensive care.OBJECTIVE:To retrospectively investigate the effects of bleeding features,bleeding/blood-transfusion volume on respiratory function recovery following liver transplantation.DESIGN,TIME AND SETTING:A retrospective case analysis was performed at Department of Hepatobiliary Surgery,the Second Hospital affiliated to Sun Yat-sen University from February 2001 to September 2006.PARTICIPANTS:A total of 48 adults undergoing liver transplantation were randomly divided into four groups:hepatic cirrhosis group(n=8),hepatic cirrhosis+liver cancer group(n=32),liver cancer group(n=5),and acute inflammation group(n=3).Based on bleeding volume,patients were divided into massive hemorrhage group(n=9)and tiny bleeding group(n=39).METHODS:The effect of bleeding volume on respiratory function recovery was investigated in each group following liver transplantation surgery.Bleeding volume was statistically analyzed during liver dissection phase,anhepatic phase,and neohepatic phase so as to understand the bleed features in different phases of liver transplantation surgery.MAIN OUTCOME MEASURES:Bleeding volume in different surgical phases,respiratory function recovery in massive hemorrhage and tiny bleeding groups,complications in perioperative phase,and death rate.RESULTS:Bleeding mainly occurred in liver dissection phase,showing a wide capillary hemorrhage.The bleeding volume was different in the four groups,i.e.,the bleeding volume was the highest in the hepatic cirrhosis+liver cancer group,and then in hepatic cirrhosis,acute inflammation,and liver cancer groups(P＜0.05).Massive hemorrhage(＞5 000 mL)might affect respiratory function recovery following liver transplantation or even increase incidences of perioperative complications and death (P＜0.05).CONCLUSION:To control wide capillary hemorrhage in the liver dissection phase is a major method to avoid from massive hemorrhage in patients with hepatic cirrhosis+liver cancer during liver transplantation surgery.Both massive hemorrhage and blood transfusion may delay respiratory function recovery and increase incidence of respiratory system complication and death.