重型肝炎肝移植围术期血流动力学变化及监测意义
罗晨芳 黑子清 罗刚健 黎尚荣 马武华 池信锦【摘要】 目的 探讨重型肝炎患者肝移植围术期血流动力学的变化。方法 10例重型肝炎患者行原位肝移植术。麻醉诱导后经右颈内静脉放入肺动脉导管，左桡动脉放置动脉导管，通过换能器连接HP多功能监测仪及Edwards持续心排监测仪，持续监测心排血量(CO)、平均动脉压(MAP)等血流动力学参数，记录体循环阻力(SVR)、肺循环阻力(PVR)、心脏指数(CI)、每搏指数(SI)等相关指标。结果 ①术中心率(HR)增快，MAP在无肝早期和新肝早期均降低；中心静脉压(CVP)变化显著，在无肝期明显下降，新肝早期急剧增高，新肝60 min后逐渐下降；平均肺动脉压(MPAP)的变化与平均肺动脉楔压(PAWP)的变化一致，均在无肝期显著下降，新肝早期急剧增高。②SVR在手术开始前处于较低水平，无肝期开始后进行性升高，新肝期开始时较无肝期明显下降；PVR在新肝期变化最明显，早期显著升高后逐渐降至术前水平。③左室作功指数(LVSWI)在无肝期显著下降，新肝期1 min继续下降后逐渐升高；右室作功指数(RVSWI)在无肝期显著下降，新肝期逐渐升高。④CO及CI始终处于高水平，无肝期较无肝前期明显下降，新肝期逐渐升高至较术前更高水平。结论重型肝炎患者原位肝移植围术期血流动力学的变化以无肝期和新肝期最显著，但CO一直处于高输出状态。SVR变化复杂，受血压、血容量、血管活性药物等多种因素影响。围术期监测血流动力学可指导加强麻醉管理，对预防和控制心功能不全、低血容量具有重要意义。
【关键词】 肝炎，重型； 肝移植； 血流动力学
Significance of hemodynamic changes and monitoring value of patients with severe hepatitis during perioperative orthotopic liver transplantation
LUO Chen-fang, HEI Zi-qing, LUO Gang-jian, LI Shang-rong, MA Wu-hua, CHI Xin-jin.
Department of Anesthesiology, Third Affiliated Hospital, Sun Yet-sen University, Guangzhou 510630, Guangdong, China
【Abstract】 OBJECTIVE：To observe the hemodynamic changes of the patients with severe hepatitis during orthotopic liver transplantation (OLT). METHODS：Ten patients with severe hepatitis received liver transplantation. The pulmonary artery catheter was inserted into right jugular vein and an arterial line was put in the left radial artery. Hemodynamics parameters including cardic output (CO), arterial blood pressure (ABP), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), cardiac index(CI) at different time points were observed. RESULTS：During the operation, HR was increased, and ABP was significantly decreased at the beginning of anhepatic period and neohepatic period. Central venous pressure (CVP) was significantly decreased during anhepatic period and profoundly increased in the early neohepatic phase, then declined to normal range progressively. Pulmonary capillary wedge pressure (PCWP) changed in accordance with the variation of pulmonary arterial pressure (PAP). Both of them were significantly decreased during anhepatic period and profoundly increased in the early neohepatic phase. SVR was at a lower level before operation, and gradually increased during anhepatic period, then significantly declined at the beginning of anhepatic period. PVR had the most marked changes during the neohepatic period, gradually decreased to the preoperation level after significant elevation at the early neohepatic phase. Left ventricular stroke work index (LVSWI) was profoundly declined from the beginning of anhepatic period to the 1 minute after neohepatic phase, then progressively increased. Right ventricular stroke work index (RVSWI) was significantly decreased during anhepatic period, then progressively increased during neohepatic period. CO and CI maintained at a higer level, significantly declined during anhepatic period compared with pre- anhepatic period and gradually increased to a higher level than perioperation. CONCULSION: Remarkable changes in hemodynamics of patients with severe hepatitis during liver transplantation are found especially at the early phase of anhepatic and neohepatic, while CO maintained at a higher level, together with a complicated changes in SVRI. Monitoring hemodynamics during perioperation has its value to prevent and manage cardiac insufficiency and low blood volume. ......
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