复杂肝脏损伤急救与围手术期监护处理  

Perioperative intensive care and first aid treatment of complex hepatic injuries

作　　者：都定元[1] 高劲谋[1] 林曦[1] 杨俊[1] 印伟[1] 李昌华[1] 胡平[1] 田显阳[1] 赵兴吉[1] 

机构地区：[1]重庆市急救医疗中心,重庆市创伤研究所,400014

出　　处：《中华创伤杂志》2002年第10期592-595,共4页Chinese Journal of Trauma

基　　金：重庆市卫生局科研基金资助项目 (99-2 0 48)

摘　　要：目的　探讨复杂肝脏损伤 (CHI)临床救治的措施。　方法　回顾性分析我院 1988年1月～ 2 0 0 2年 3月救治的 99例CHI[美国创伤外科医师学会器官损伤定级 (AAST -OIS)Ⅳ、Ⅴ级 ]病例资料。治疗手段主要包括术前、术中积极液体复苏和补充足量血液 ,迅速手术控制出血 ,Pring le手法肝门阻断下清创性肝切除术 ,肝切开直视下缝扎损伤的血管与胆管 ,明胶海绵大网膜填塞 ,选择性肝动脉结扎 ,肝周纱垫填塞 ,全肝血流阻断下肝后腔静脉或主肝静脉 (RHVC MHV)修补术 ,选择性肝动脉造影与栓塞术 ;术后严密监测生命体征 ,及时纠正血流动力学不稳定、酸中毒、凝血功能异常 ,及时处理合并伤及胸腹部并发症。　结果　CHI 99例 (Ⅳ级 6 1例 ,Ⅴ级 38例 ) ,总生存率 6 5 .7% (6 5 99) ,Ⅳ级生存率 83.6 % (5 1 6 1) ,Ⅴ级 36 .8% (14 38)。　结论　术中迅速探明肝脏损伤程度 ,正确选择相应术式是成功的关键 ;加强围手术期监护复苏与术后并发症处理 。Objective To assess the clinical experience with aggressive approach to the management of complex hepatic injuries (CHI). Methods The patients sustaining CHI (AAST OIS Grades Ⅳ andⅤ of liver trauma) from January 1988 to March 2002 were retrospectively studied. Complex surgical techniques including immediate surgery for initial control of bleeding by bimanual compression of the injury over several lap pads, portal triad occlusion by Pringle method, hypovolemia and acidosis correction with fluid resuscitation and transfusion, elective hepatotomy with direct suture ligation, resectional debridement, anatomical resection, hepatic artery ligation, hepatic packs with absorbable gelatin sponge and omentum, perihepatic packing with gauze pads, direct repair of retohepatic vena cava or main hepatic vessel (RHVC/MHV) under total hepatic vascular occlusion, and hepatic angiography and angioembolization. Postoperative management included intensive care, resuscitation and stabilization of hemodynamic status, acidosis and coagulopathy correction, and treatment of complicated polytrauma and postoperative complications in the chest and the abdomen. Results Of 99 patients, there were 61 cases of Grade Ⅳ and 38 GradeⅤ with an overall survival rate of 65.7% (65/99). Survival rate by injury grade was 83.6% (51/61) for Grade Ⅳ and 36.8 % (14/38) for Grade Ⅴ ( P <0.01). Conclusions Early injury recognition, vascular isolation and choice of procedure accordingly are key to a successful surgical outcome. Enhancement of perioperative intensive care, resuscitation and treatment of postoperative complications are of a key significance to improve survival rate for CHI patients.

关 键 词：复杂肝脏损伤 急救 围手术期 血流动力学 并发症 

分 类 号：R657.3[医药卫生—外科学]