肝肾联合移植围术期电风暴的识别与救治  

Diagnosis and treatment of perioperative electrical storm in combined liver and kidney transplantation

作　　者：陈莉萍[1] 刘磊[1] 张晓琳[1] 石炳毅[1] 

机构地区：[1]解放军309医院器官移植中心,100091

出　　处：《解放军医学杂志》2012年第5期505-507,共3页Medical Journal of Chinese People's Liberation Army

摘　　要：目的分析肝肾联合移植术后患者并发电风暴的临床特征,揭示此类急症在器官移植围术期的危险性及诊疗措施。方法解放军309医院器官移植中心2009年3月收治1例肝肾联合移植患者,对其围术期并发电风暴的诊治体会进行分析并查阅文献。患者术前诊断为"肝功能衰竭、尿毒症",心脏超声提示"左房、右心轻度增大,二尖瓣、三尖瓣轻度反流",左室射血分数62%,既往无心律失常病史。患者术中及术后24h内室性心动过速(室速)或室性纤维性颤动(室颤),利多卡因效果不佳,需较大剂量升压药维持血压。换用盐酸艾司洛尔联合胺碘酮静脉持续泵入,并根据血压和心律调节用量。结果患者术后第2天发生3次室扑,每次立即给予盐酸艾司洛尔100mg弹丸式静脉推注后恢复窦性心律,术后第3天起未再出现心律失常。患者术后4d停用盐酸艾司洛尔,术后2周停用胺碘酮,术后42d出院,生命体征稳定,移植物功能正常。结论肝肾联合移植围术期交感神经系统过度兴奋是引起心室电风暴的重要因素。重视β-受体阻断剂在治疗中的积极作用,维持机体内环境稳定,改善脏器功能,是器官移植围术期电风暴的重要治疗措施。[Objective] Objective To analyze the clinical characteristics of a case of a combined liver and kidney transplantation complicated by electrical storm （ES）, and to determine the risks, diagnosis, and treatment of perioperative ES. Methods In March 2009, one patient underwent combined liver and kidney transplantation in the Organ Transplant Center of the 309 Hospital of Chinese People＇s Liberation Army. The diagnosis and treatment of complicated ES during the perioperative period was analyzed. The patient was diagnosed to have liver failure and uremia before the operation. Echocardiography showed that the left atrium and the right side of the heart were slightly hypertrophic, with minimal mitral and tricuspid valve regurgitation, and 62% left ventricular ejection fraction. The patient had no history of arrhythmia. The patient developed intraoperative ventricular tachycardia and ventricular fibrillation, and also during the first postoperative 24-hour. As lidocaine failed to provide an adequate response, a large dose of vasopressor was given to maintain the blood pressure. The patient ultimately received continuous injection of esmolol combined with amiodarone, with the dose adjusted according to the blood pressure and heart rate. Results During the second postoperative day, the patient developed three instances of ventricular flutter. Consequently, a 100 mg bolus of esmolol was administrated immediately to restore sinus rhythm. The patient responded almost immediately with resolution of the ventricular flutter, and no arrhythmia occurred on the third postoperative day. Esmolol and amiodarone were discontinued on the fourth day and two weeks after operation, and the patient was discharged 42 days after the operation. The vital signs and transplant functions were found to be normal. Conclusions Sympathetic overdrive is the main factor underlying ES during the perioperative period of the combined liver and kidney transplantation. The consideration for using a beta-blocker to terminate the sympathetic overdrive,

关 键 词：肝移植 肾移植 手术期间 心律失常 

分 类 号：R541.7[医药卫生—心血管疾病]