摘要
目的:观察肝移植围术期血流动力学以及各种心肌酶的变化,探讨血流动力学变化与心肌损害的关系。方法:选取2004-06/09中山大学第三附属医院拟行原位肝移植术的终末期肝病患者20例,静吸复合全身麻醉下接受原位肝移植术。常规结扎切断肝管、肝左右动脉和门静脉,用肝上下腔静脉阻断钳从前至后夹闭肝上下腔静脉,切除病肝后进行供肝吻合。先吻合腔静脉,腔静脉吻合口为倒三角形,再吻合门静脉,恢复供肝血流,进入新肝期,再依次吻合肝动脉和胆管。分别在术前、无肝前、无肝期30min、新肝期30m in、术毕、术后24h各采中心静脉血3m L,测定心肌酶谱。同时测量围术期心率、心输出量、中心静脉压、平均动脉压。结果:按意向处理分析,实验纳入患者20例,全部进入结果分析。①全部患者术后转归情况:20例患者均成功接受原位肝移植术。手术时间(335.74±74.04)min,无肝期时间(36.37±7.90)m in。术后3例出现心脏衰竭,心脏衰竭患者中有2例最终死亡。其余患者术后均恢复良好。②全部患者肝移植围术期血流动力学的变化:心输出量和中心静脉压在无肝期下降(P<0.01),进入新肝期增高(P<0.01或0.05);平均动脉压在阻断和开放下腔静脉后3min内有一过性下降,应用血管活性药后基本维持稳定;心率在无肝期增快,进入新肝期早期增高,以后逐渐恢复到术前水平。③全部患者肝移植围术期心肌酶谱的变化:与麻醉后术前比较:无肝期30min除肌红蛋白显著增高外(P<0.01),其余各种酶均基本相似(P>0.05);新肝期30m in、术毕的心肌酶谱各值均显著增高(P<0.05或0.01);术后24h除乳酸脱氢酶同工酶无明显变化外(P>0.05),其余各种酶均显著增高(P<0.05或0.01)。与新肝30m in比较:术后24h的谷草转氨酶、乳酸脱氢酶、乳酸脱氢酶同工酶、α-羟丁酸脱氢酶均显著降低(P<0.05),肌酸激酶则显著增高(P<0.05),肌酸激酶同工酶和肌红蛋白基本无变化(P>0.05)。结论:新肝期表现为高血流动力学,而心肌酶普遍增高,术后24h开始恢复,提示开放后血流动力学与心肌损害存在分离现象。
AIM： To observe the changes of periopeative hemodynamics and various myocardial enzymes during orthotopic liver transplantation （OLT）, and investigate the association between hemodynamics and myocardial damage. METHODS： Twenty patients with end disease of hepatism, whowere selected from the Third Affiliated Hospital of Sun Yat-sen University between June and September 2004, were scheduled for OLT under combined general anesthesia. The hepatic duct, left and right hepatic arteries and portal veins were ligated routinely, the superior and inferior vena cavas were clipped to close from front to behind with the interruption claw of vena cava, supplied liver anastomosis was conducted after diseased liver was cut. The cava was anastomosed firstly, and the stoma was shaped as inverted triangle, and then portal veins were anastomosed, the liver blood supply was recovered to enter the new liver period, and then hepatic arteries and bile duct were anastomosed in order. Blood samples were drawn from central vein at preoperative stage, 30 minutes after anhepatic stage, 30 minutes after reperfusion stage, the end of surgery and 24 hour after operation respectively, the myocardial zymogram was determined, meanwhile, perioperative heart rate, cardiac output, central venous pressure and mean arterial blood pressure were measured. RESULTS： According to intention-to-treat analysis, all the 20 patietns entered the analysis of results. ① Postoperative recovery： All patients received orthotopic liver transplantation successfully. The duration of operation was （335.74±74.04） minutes, and the time of anhepatic phase was （36.37±7.90） minutes. 3 Patients suffered from heart failure among whom 2 died after OLT, the others all recovered very well. ② Changes of hemodynamics： The cardiac output and central venous pressure were decreased at the anhepatic stage （P〈0.01） and increased at the reperfusion stage （P 〈 0.01 or P〈0.05）. The mean arterial blood pressure once decreased while blocking and opening the inferior vena cave, but it could keep stable after applying some vasoactive drugs. Heart rate increased while entering the anhepatic stage, when it came into the reperfusion stage, heart rate increased in the early period and rebounded to the preoperative level. ③ Changes of myocardial zymogram： Compared with the preoperative stage： Only myohaemoglobin was significantly increased （P 〈 0.01） at 30 minutes after anhepatic stage, and others had no significant differences （P 〉 0.05）; At 30 minutes after reperfusion and the end of the surgery, all of the values of myocardial zymogram were significant increased; And at the phase of 24 hour after operation, all the values increased significantly （P〈0.05 or 0.01） except that lactate dehydrogenase isoenzyme had no obvious changes （P 〉 0.05）. Compared with the stage of 30 minutes after reperfusion, aspartate aminotransferase, lactate dehydrogenasc, lactate dehydrogenase isoenzyme and alpha-hydroxybutyrate dehydrogenase at 24 hour after operation were significantly decreased （P〈0.05）, and creatine kinase was significantly increased （P〈0.05）, and isoenzyme of creatine kinase and myohaemoglobin had no significant differences （P〉0.05）. CONCLUSION： After reperfusion high hemodynamics occurred and myocardial zymogram increased generally, and myocardial zymogram recovered at 24 hours after OLT, which indicated that there is divergence phenomenon between hemodynamics and myocardial zymogram.
出处
《中国临床康复》
CSCD
北大核心
2005年第42期53-55,共3页
Chinese Journal of Clinical Rehabilitation
基金
国家自然科学基金资助项目(30271254)
广东省科技计划项目(2004B35001005)~~
