CAJ | 학술논문

目的分析晚期肝病患者非静脉转流原位肝移手术不同阶段体、肺循环的变化并探讨维持无肝期血流动力学的措施. 方法收集68例肝移植患者手术前(麻醉诱导后)、无肝期前、无肝期5 min、无肝期30 min、新肝期5 min、新肝期30 min、新肝期60 min、术毕、术后12h及24h各时间点中心静脉压(CVP)、心率(HR)、平均动脉压(MABP)、平均肺动脉压(MPAP)、肺动脉楔压(PAWP)、心脏指数(CI)、体循环阻力(SVR)、肺循环阻力(PVR)等数据,并根据无肝期CVP将患者分为3组:A组(CVP<4 mm Hg),B组(4 mm Hg≤CVP≤6 mm Hg),C组(CVP>6 mm Hg),分析比较3组患者手术各时期及术后血流动力学指标变化,以及血管活性药多巴胺、去甲肾上腺素、肾上腺素用量及尿量. 结果肝移植手术不同阶段,患者体、肺循环发生不同变化,与无肝期前相比,无肝期HR增快,CVP、MABP、PVP、CI、PAWP降低,SVR、PVR增高,P<0.05,具有显著性差异,表现为循环血容量降低,体循环及肺血管阻力增高;新肝期早期(新肝期5、30 min)HR减慢,CVP、PAWP、MPAP、PVR、SVR增高(P<0.05),新肝期开始,MABP降低、升高波动大,5 min后升高并趋于稳定.3组间比较,B组患者各时期血体、肺循环指标波动最小,术中血管活性药用量最少,与A、C组比较,差异有统计学意义(P＜0.05). 结论原位肝移植术中患者体、肺循环剧烈变化主要发生在无肝期及新肝早期,无肝期血流动力学的恰当维持尤为重要,适量补充血容量并复合应用多巴胺、去甲肾上腺素、肾上腺素等血管活性药,维持CVP4～6 mm Hg、MABP≥60 mm Hg、PAWP、SVR、PVR正常范围,有利于患者新肝期及术后血流动力学的稳定.
목적 분석만기간병환자비정맥전류원위간이수술불동계단체、폐순배적변화병탐토유지무간기혈류동역학적조시. 방법수집68례간이식환자수술전(마취유도후)、무간기전、무간기5 min、무간기30 min、신간기5 min、신간기30 min、신간기60 min、술필、술후12h급24h각시간점중심정맥압(CVP)、심솔(HR)、평균동맥압(MABP)、평균폐동맥압(MPAP)、폐동맥설압(PAWP)、심장지수(CI)、체순배조력(SVR)、폐순배조력(PVR)등수거,병근거무간기CVP장환자분위3조:A조(CVP<4 mm Hg),B조(4 mm Hg≤CVP≤6 mm Hg),C조(CVP>6 mm Hg),분석비교3조환자수술각시기급술후혈류동역학지표변화,이급혈관활성약다파알、거갑신상선소、신상선소용량급뇨량. 결과간이식수술불동계단,환자체、폐순배발생불동변화,여무간기전상비,무간기HR증쾌,CVP、MABP、PVP、CI、PAWP강저,SVR、PVR증고,P<0.05,구유현저성차이,표현위순배혈용량강저,체순배급폐혈관조력증고;신간기조기(신간기5、30 min)HR감만,CVP、PAWP、MPAP、PVR、SVR증고(P<0.05),신간기개시,MABP강저、승고파동대,5 min후승고병추우은정.3조간비교,B조환자각시기혈체、폐순배지표파동최소,술중혈관활성약용량최소,여A、C조비교,차이유통계학의의(P＜0.05). 결론원위간이식술중환자체、폐순배극렬변화주요발생재무간기급신간조기,무간기혈류동역학적흡당유지우위중요,괄량보충혈용량병복합응용다파알、거갑신상선소、신상선소등혈관활성약,유지CVP4～6 mm Hg、MABP≥60 mm Hg、PAWP、SVR、PVR정상범위,유리우환자신간기급술후혈류동역학적은정.
Objective To study the changes and management of systemic and pulmonary hemodynamics during anhepatic period in patients undergoing orthotopic liver transplantation without veno-venous bypass.Methods Sixty-eight patients with end-stage liver disease undergoing orthotopic liver transplantation were enrolled in this research. Monitoring and recoding CVP, MAP, CI, HR, MPAP, PAWP PVR, SVR at different time points: preincision, before anhepatic, 5, 30 min of anhepatic, 5, 30, 60 min of neohepatic,ending of operation, 12 h and 24 h after operation. All the patients were divided into three groups according CVP during anhepatic period: group A(CVP <4 mmHg) ,group B(4 mm Hg≤CVP≤6 mmHg) ,group C (CVP>6 mmHg). Besides, calculating the concentration of dopamine, norepinephrine ,epinephrine and the volume of urine during of operation. Results There were different changes during different operation periods. During anhepatic period, HR, PVR and SVR increased, while CVP, CI, MAP, PAP, PAWP decreased(P<0.05). At early neohepatic period, HR decreased and CVP,PAWP, MPAP,CI,PVR SVR increased ,At the beginning of neohepatic period, MAP dacreased or increased quickly, and became steadily after 5 min. Among the three groups, the changes of hemodynamics in group B was slightest,and the concentration of dopamine, norepinephrine and epinephrine was smallest (P< 0.05 ). Conclusions The systemic and pulmonary emodynamics fluctuated sharply during anhepatic and early neohepatic period. It is important and useful to manage CVP 4 -6 mmHg, MABP ≥ 60 mmHg by infusing liquid and vasoconstrictors,such as dopamine, norepinephrine or epinephrine during anhepatic period.