肝性脑病肝移植患者围手术期的监测  

Perioperative monitoring of adult patients with hepatic encephalopathy under orthotopic liver transplatation

作　　者：马武华[1] 黑子清[1] 刘德昭[1] 关健强[1] 甘小亮[1] 黎尚荣[1] 罗刚健[1] 

机构地区：[1]中山大学器官移植研究中心中山大学附三院麻醉科

出　　处：《中华器官移植杂志》2005年第12期735-738,共4页Chinese Journal of Organ Transplantation

基　　金：广东省科技计划资助项目(2004B35001005)

摘　　要：目的对肝性脑病行原位肝移植患者围手术期的监测指标进行探讨。方法选取2003年10月至2004年8月间终末期肝病合并肝性脑病患者18例,患者肝移植术中行气管内全身麻醉,麻醉诱导给予异丙酚、芬太尼和维库溴胺,尽量不给或减量给予咪唑安定。患者均采用背驮式肝移植术。监测围手术期血流动力学、呼吸功能、血酸碱平衡和生化情况、凝血功能、体温和肝肾功能。给予脱水,维持满意的尿量,补充凝血物质和给予抗炎性药物治疗。结果(1)14例肝性脑病患者肝移植后存活,4例死于多器官功能衰竭。(2)围手术期主要表现为酸中毒,低Na+、低K+和低Ca2+。(3)患者围手术期心率明显升高,术前心输出量均明显高于正常,患者血流动力学指标在无肝期均明显降低。(4)术毕时查血清丙氨酸转氨酶、天冬氨酸转氨酶、尿素氮和血肌酐明显升高。结论肝性脑病行肝移植患者围手术期的严格监测非常重要,应尽量选用对肝肾功能影响小的药物,不用或少用苯二氮芯卓类药物,纠正低Na+、低K+和低Ca2+,及时改善凝血功能和补充血容量,重点保护肾功能和防治脑水肿。Objective To evaluate the perioperative monitoring of adult patients with hepatic encephalopathy under orthotopic liver transplatation （OLT）. Methods Combined intravenous and inhalational general anesthesia was used for 18 patients with hepatic encephalopathy from October 2003 to August 2004. Rapid-sequence induction was performed. Propofol, 1 to 1.5 mg/kg, and fentanyl, 4μg/kg, were used. Norcuron, 0.1 mg/kg, was added to facilitate tracheal intubation. All patients were subjected to piggyback liver transplantation. Hemodynamics, respiratory, blood gas, blood biochemistry, coagulation function, body temperature, liver and kidney functions, urine output, and bleeding output were monitored during operation. According to the situations of patients, platelet, cryoprecipitate, fibrinogen, coagulation factors and ulinastatin were administrated. Results Eighteen patients tolerated the operation. Only 4 patients died of multiple organ dysfunction syndrome after operation. The survival rate reached was up to 77.8%. The main blood gas change during perioperative phase was metabolic acidosis and hyposodium, hypokaleamia, hypocalcium The main hemodynamics change during operation was that HR was increased significantly, and CO was higher than normal value before operation, and CO, CVP, SPAP and DPAP decreased significantly in anhepatic stage. Compared with those before operation, ALT, AST, BUN and Cr were increased significantly in neohepatic stage. Conclusions It is very important to pay more attention to these patients with hepatic encephalopathy during different stages of OLT. Drugs not affecting the function of liver and kidney should be selected. Benzodiazepine should be avoided. Supplementation of coagulation factors, CRBC and electrolyte was necessary. The key point is to protect renal function, maintain enough urine output and treat brain edema.

关 键 词：肝性脑病 肝移植 监测 生理学 

分 类 号：R657.3[医药卫生—外科学] R747.9[医药卫生—临床医学]