婴幼儿患者亲体肝移植术的麻醉管理

发布时间：2018-08-13 14:16

【摘要】：目的总结婴幼儿亲体肝移植术的麻醉管理特点。方法 60例接受肝移植术的终末期肝病患儿,男32例,女28例,年龄6~30个月。麻醉诱导均采用静脉注射阿托品0.01mg/kg、甲基强的松龙1mg/kg、咪达唑仑0.05~0.1mg/kg、芬太尼2~5μg/kg、丙泊酚2~3mg/kg和罗库溴铵0.6~1.0mg/kg进行快速诱导;无外周静脉通路的患儿可先肌肉注射氯胺酮5~8mg/kg和阿托品0.02mg/kg后开放外周静脉通路。采用持续吸入2%~3%七氟醚、持续静脉输注瑞芬太尼0.1~0.2μg·kg-1·min-1和顺苯磺酸阿曲库铵1~2μg·kg-1·min-1维持麻醉。记录患儿肝血管阻断前即刻、阻断后即刻、无肝期30min、再灌注后即刻、新肝期1h和术毕的呼吸功能、血流动力学、凝血功能、体温、尿量、血糖(Glu)、血乳酸(Lac)和血电解质等。结果 60例患儿均未发生麻醉相关并发症并能顺利拔管。患儿预充氧后缺氧安全时限明显降低,易发生气道痉挛,经鼻插管更易出现插管失败和面罩通气困难。与阻断前即刻比较,阻断后即刻患儿HR明显增快、CVP明显降低(P0.01),但MAP差异无统计学意义;再灌注后即刻患儿MAP明显下降、HR明显减慢,伴有CVP的明显增高(P0.05或P0.01);新肝期患儿HR明显减慢(P0.01);无肝期30min至术毕患儿体温均明显降低(P0.01);无肝期至术毕激活凝血时间(SonACT)明显延长,纤维蛋白凝集速率(CR)水平和血小板功能(PF)水平逐渐减低(P0.05或P0.01),Na+水平逐渐升高(P0.01),K+水平明显降低(P0.01),再灌注后即刻至新肝期1h时Glu和Lac水平明显升高(P0.05或P0.01)。结论婴幼儿亲体肝移植术的麻醉管理有其特殊性,其中气道和呼吸系统的评估与管理最为关键,无肝期应积极采取措施预防再灌注后综合征的发生,新肝期应维持适宜的凝血功能以避免肝动脉血栓的发生,还应及时纠正电解质、酸碱和体温的失衡。
[Abstract]:Objective to summarize the anaesthesia management characteristics of infant related liver transplantation. Methods 60 children with end-stage liver disease received liver transplantation, 32 males and 28 females, aged 6 ~ 30 months. Anesthesia induction was induced by intravenous injection of atropine (0.01 mg / kg), methylprednisolone (1 mg / kg), midazolam (0.05 mg / kg), fentanyl (2 渭 g / kg), propofol (2~3mg/kg) and rocuronium (0.6~1.0mg/kg). Children without peripheral vein pathway could be injected with ketamine 5~8mg/kg and atropine 0.02mg/kg and then open peripheral vein pathway. Anesthesia was maintained with continuous inhalation of 3% sevoflurane, intravenous infusion of remifentanil 0.1 渭 g kg-1 min-1 and atracurium sulfonic acid 1 渭 g kg-1 min-1. The respiratory function, hemodynamics, coagulation function, body temperature, urine volume, blood glucose, (Glu), blood lactate (Lac) and blood electrolyte were recorded immediately before and immediately after hepatic vascular occlusion, 30 minutes after occlusion, 1 hour after reperfusion, 1 hour after reperfusion and 1 hour after operation. Results Anesthesia related complications were not found in all 60 cases. After preoxygenation, the time limit of anoxia and safety was obviously reduced, airway spasm was easy to occur, intubation failure and mask ventilation difficulty were more likely to occur through nasal intubation. Compared with those immediately before and after occlusion, HR increased and decreased significantly (P0.01), but there was no significant difference in MAP, MAP decreased significantly after reperfusion. There was a significant increase in CVP (P0.05 or P0.01), a significant decrease in HR (P0.01), a significant decrease in body temperature (P0.01) from anhepatic 30min to the end of operation, and a significant increase in the time of activated coagulation (SonACT) from the anhepatic phase to the end of the operation. The level of fibrin agglutination rate (CR) and platelet functional (PF) (P0.05 or P0.01) gradually decreased (P0.05 or P0.01). The level of Glu and Lac increased significantly (P0.05 or P0.01). Conclusion Anesthesia management of infant and mother liver transplantation has its particularity, among which the evaluation and management of airway and respiratory system is the most important. Measures should be taken to prevent the occurrence of reperfusion syndrome in anhepatic stage. The proper coagulation function should be maintained to avoid hepatic artery thrombosis and the imbalance of electrolyte, acid base and body temperature should be corrected in time.
【作者单位】：首都医科大学附属北京友谊医院麻醉科;首都医科大学附属北京友谊医院普外科;
【分类号】：R726.1

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