CAJ | 학술논문

目的观察以氧供（DO2）为导向的血流动力学管理模式在不同程度肝功能损害患者非转流经典原位肝移植手术过程中机体氧代谢变化。方法选择接受经典非转流肝移植术患者50例，按Pugh-Child评分法分为A级（A组，12例）、B级（B组，18例）、C级（C组，20例）。左桡动脉置管后常规麻醉诱导，经右颈内静脉放置Swan-Ganz导管。术中维持心排血指数（CI）＞50 ml/（s·m2），平均动脉压（MAP）≥60 mm Hg（1 mm Hg＝0.133 kPa）。分别在麻醉后手术前（T1），无肝期前10分钟（T2），无肝期30分钟（T3），新肝期30分钟（T4）及术毕（T5），采集桡动脉血和肺动脉的混合静脉血监测和计算以上各时点的动脉血氧饱和度（SaO2）、动脉血氧分压（PaO2）、混合静脉血氧饱和度（SvO2）、CI、DO2、氧耗（VO2）及氧摄取率（ERO2）。结果3组患者在T3时VO2、SvO2和DO2均明显低于T1时（P＜0.05或P＜0.01）。3组VO2在T4时上升，明显高于T3时（均P＜0.05），T5时恢复至T1时水平。B、C组的ERO2在T3时均明显高于T1时（均P＜0.05）。T3时B、C组的SvO2和DO2低于A组（均P＜0.05），ERO2则明显高于A组（均P＜0.05）。术后住院天数A、B、C组依次递增。结论以DO2为导向的血流动力学管理模式，对不同程度肝功能损害患者肝移植术中机体氧代谢整体变化趋势一致，均以无肝期异常最为严重。Pugh-Child分级B级和C级患者DO2和ERO2变化较A级患者更为剧烈。
목적관찰이양공（DO2）위도향적혈류동역학관리모식재불동정도간공능손해환자비전류경전원위간이식수술과정중궤체양대사변화。방법선택접수경전비전류간이식술환자50례，안Pugh-Child평분법분위A급（A조，12례）、B급（B조，18례）、C급（C조，20례）。좌뇨동맥치관후상규마취유도，경우경내정맥방치Swan-Ganz도관。술중유지심배혈지수（CI）＞50 ml/（s·m2），평균동맥압（MAP）≥60 mm Hg（1 mm Hg＝0.133 kPa）。분별재마취후수술전（T1），무간기전10분종（T2），무간기30분종（T3），신간기30분종（T4）급술필（T5），채집뇨동맥혈화폐동맥적혼합정맥혈감측화계산이상각시점적동맥혈양포화도（SaO2）、동맥혈양분압（PaO2）、혼합정맥혈양포화도（SvO2）、CI、DO2、양모（VO2）급양섭취솔（ERO2）。결과3조환자재T3시VO2、SvO2화DO2균명현저우T1시（P＜0.05혹P＜0.01）。3조VO2재T4시상승，명현고우T3시（균P＜0.05），T5시회복지T1시수평。B、C조적ERO2재T3시균명현고우T1시（균P＜0.05）。T3시B、C조적SvO2화DO2저우A조（균P＜0.05），ERO2칙명현고우A조（균P＜0.05）。술후주원천수A、B、C조의차체증。결론이DO2위도향적혈류동역학관리모식，대불동정도간공능손해환자간이식술중궤체양대사정체변화추세일치，균이무간기이상최위엄중。Pugh-Child분급B급화C급환자DO2화ERO2변화교A급환자경위극렬。
Objective To investigate the effects of oxygen delivery(DO2)-directed hemodynamic management on oxygen metabolism during orthotropic liver transplantation(OLT)without veno-venous bypass in the patients with different degrees of hepatic insufficiency. Methods 50 patients scheduled non veno-venous bypass OLT were divided into 3 groups according to the Pugh-Child scores ,class A(group A,12 patients),class B(group B,18 patients),class C(group C,20 patients). Left radial artery was cannulated before induction of anesthesia, then Swan-Ganz catheter was inserted in the pulmonary artery via right internal jugular vein. Cardiac index(CI)was maintained more than 50 ml/(s·m2)and mean arterial pressure more than 60 mm Hg(1 mm Hg=0.133 kPa)in all patients. Arterial partial pressure of oxygen(PaO2),mixed venous saturation(SvO2),CI,DO2,oxygen consumption (VO2)and oxygen extract rate(ERO2)were measured or calculated after anesthesia and before surgical incision(T1, baseline),at 10 minutes before anhepatic phase(T2),30 minutes after onset of anhepatic phase(T3),30 minutes after neohepatic phase(T4)and the end of surgical procedure(T5). Results In the three groups,VO2,SvO2, and DO2 during T3 showed substantial decrease in comparison with T1(P<0.05 or P<0.01),then VO2 markedly increased during T4 in comparison with T3(all P<0.05),which recovered to T1 up to the end of T5. ERO2 increased significantly during the T3 in comparison with T1 in group B and C(both P<0.05). Moreover,there were significant differences among three groups during T3,which mainly manifested the SvO2 and DO2 were much lower in group B and C than in group A, while ERO2 was much higher in group B and C than group A(all P<0.05). The length of hospital stay was increased sequentially from group A to group C. Conclusions The tendency of the whole changes in oxygen metabolism of the patients with different degrees hepatic insufficiency during OLT is consistent during DO2-directed management patterns of hemodynamics,and abnormality of oxygen metabolism occurs more severely in anhepatic phase. The changes of DO2 and ERO2 in patients with Pugh-Child scores Class B and C were more serious than Class A.