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19 例原位肝移植术中凝血弹性图变化及与ACT 相关性的临床研究
时间：2010-08-24 11:39:13 来源： 作者：
| 【Abstract】 Objective To determine the changes in TEG and correlation between TEG and ACT during orthotopic liver transplantation(OL T) in Chinese1Methods 19 patients with end2stage liver disease undergoing OL T were studied1 They are composed of two groups : acute hepatic failure group ( n = 8) and liver neoplasm group ( n = 11) 1 Anesthesia was induced with propofol 1152210mg/ kg , fentanyl 325μg/ kg and vecuronium 011mg/ kg and maintained with isoflurane or desflurane inhalation combined with continuous infusion of propofol at 224mg•kg - 1 •h - 1 1 The operation was divided into three phases : Ⅰpreanhepatic phase , Ⅱ anhepatic phase , and Ⅲ postreperfusion phase (after liver graft ) 1 Veno2venous bypass was performed during anhepatic phase1 Arterial blood samples were drawn from an existing arterial line for determination of celite2activated TEGand ACT at 8 intervals : before operation , preanhepatic phase (120min after operation was started Ⅰ+ 120) , 30min after liver was removed ( Ⅱ+ 30) , 5min before reperfusion ( Ⅲ25) and 5min ( Ⅲ+ 5) , 30min ( Ⅲ+ 30) , 60min ( Ⅲ+ 60) and 120min ( Ⅲ+ 120) after reperfusion1 In 6 patients among the 19 patients heparinase2celite TEG was measured 5min after reperfusion ( Ⅲ+ 5) in addition to celite TEG1 If there was significant differences in traces between the two TEG measurements , an iv bolus of 50270mg protamine was given and the heparinase2celite TEG was repeated1 The measured variables included the r ( reaction) time , representing the rate of initial fibrin formation , k ( coagulation) time , alpha angles (α) reflecting fibrin2platelet interaction , MA (maximal amplitude) indicating qualitative platelet function and percent fibrinolysis at 60min1Results In hepatic failure group changes in TEGoccurred at Ⅱ+ 30 , Ⅲ25 , and Ⅲ+ 5 while in liver neoplasm group changes in TEG were found at Ⅲ+ 5 , Ⅲ+ 30 , Ⅲ+ 60 as compared with preoperative value1 r and r + k times increased andαand MA decreased in the two groups1 There was positive correlation between r + k time and ACT in two groups1 At Ⅲ+ 5 there were significant differences in TEG( r , r + k ,α and MA) values between celite and heparin2celite TEG ( P < 0101) 1 After an iv bolus of 50275mg protamine the differences were not significant1 Conclusions During OL T coagulation disorder occurs mainly at anhepatic and early reperfusion phase1 A positive correlation exists between TEG( r + k) and ACT1 Heparinase2celite TEG discloses the presence of residual of heparin and the need for protamine1 【Key Words】 Liver transplantation ; Thrombelastography ; Blood coagulation tests 近年来,人们愈来愈关注原位肝移植术中凝血功能的调控,文献[1 ,2 ]报道凝血弹性图( TEG) 能及时、准确、动态地反映肝移植术中不同时期的凝血状况,指导血制品的输注及各种治疗药物(如鱼精蛋白、EACA 等) 的应用。本研究试图初步探讨19 例肝移植术中TEG的变化以及与激活的全血凝块形成时间(ACT) 的相关性。 资料与方法 一般资料 19 例分别来自中山医科大学附属一院(16 例) 、第一军医大学南方医院(1 例) 以及第三军医大学西南医院(2 例) 。分为两组:急性肝衰组(8 例,男5 、女3) ,肝肿瘤组(11 例,男8 、女3) 。麻醉方法 麻醉前按需用药,采用静吸复合全麻。诱导用异丙酚115～2mg•kg - 1 、维库溴铵011mg•kg - 1 、芬太尼3～5μg•kg - 1 ,麻醉维持采用异氟醚或地氟醚吸入,异丙酚2～4mg•kg - 1•h - 1微泵静注。转流方法 无肝期均采用体外静脉2静脉转流, 预充液为全血、林格氏液和碳酸氢钠, 另肝素 015mg/ kg 加入预充液中,无肝期转流量为550～ 1 800 ml•h - 1 。研究方法 整个手术过程分为无肝前期( Ⅰ) 、无肝期( Ⅱ) 及新肝期( Ⅲ) ,于术前、Ⅰ+ 120min (手术开始后120min) 、Ⅱ+ 30min ( 无肝后30min) ,以及Ⅲ25min (新肝前5min) 、Ⅲ+ 5min 、Ⅲ+ 30min、Ⅲ+ 60min、Ⅲ+ 120min (新肝后5 、30 、60 、120min) 分别采集动脉血检测硅燥土激活的全血TEG,同时测定ACT。硅藻土加入全血后能使血样在TEG分析仪(Haemoscope 公司) 内的检测时间减少一半且能减少变异性。另外,19 例中选择6 例于Ⅲ+ 5min 采血样分成两份,其中一份加有肝素酶,两份标本同时检测,观察肝素酶修正后的全血TEG与无肝素酶修正的全血TEG以及ACT 的变化,若两组TEG图形不重叠且差异明显,则予以鱼精蛋白50～75mg静注,然后重复上述检测。统计分析 所有数据以均数±标准差( x ±s)表示,采用SPSS/ SS 统计软件进行分析,同一指标不同时间的变化与术前值比较采用方差分析,ACT与r + k 相关性比较采用Pearson 相关分析,肝素酶修正的全血组与非肝素酶修正的全血组的TEG值比较采用两独立样本的t 检验, P < 0105 为有统计学意义。 结 果 急性肝衰组患者术前TEG值明显偏离正常(见表1) ,无肝前期经过输注冰冻血浆、血小板及冷沉 .jpg)
淀后各指标接近正常;进入无肝期及新肝期早期后,与术前值相比, r 与r + k 明显延长( P < 0105 ,0101) ;MA 变小( P < 0101) ,alpha 角度(α) 的变化(变小, P < 0101) 在无肝期30min。ACT 在无肝前期、无肝期及新肝早期均延长( P < 0101 ,0105) 。术后各指标均接近术前值。相关分析发现r + k 与ACT 的变化呈正相关(r 为01743 , P < 0101) 。 参考文献 1 Metcalf K 1Thrombelastograph monitoring : a clinical perspecti2ve1Nurse Anesth ,1990 ,1 :332371 2 McNicol PL , Liu G, Harley ID , et al1 Patterns of coagulopathy during liver transplantation :experience with the first 75 cases using thrombelastography1Anaesth Intens Care ,1994 ,22 :65926651 3 Kang Y, Martin DJ , Marquez J , et al1 Intraoperative changes in blood coagulation and thromboelastographic monitoring in liver transplantation1Anesth Analg , 1985 , 64 :88828961 4 Lewis J H , Bontempo FA , Awad SA ,et al1 Liver transplantation :intraoperative changes in coagulation factors in 100 first transplants1Hepatology ,1989 ,9 :71027141 5 陈秉学,黄文起,黑子清,等1 原位肝移植围麻醉期血液动力学与 凝血功能调控的探讨1 中华麻醉学杂志,1998 ,18 :20922121 6 Hickman R ,Bracher M , Pienaar BH ,et al1 Heparin as the cause of coagulopathy which may complicate grafting of the liver1Surg Gynecol Obset ,1991 ,172 :19722061 7 Bellani KG, Estrin JA , Ascher NL ,et al1 Reperfusion coagulopathy during human liver transplantation1Transplant Proc , 1987 ,19 :712721 8 Harding SA , Mallett SV , Peachey TD , et al1Use of heparinase modified thrombelastography in liver transplantation1Br J Anaesth ,1997 ,78 :17521791 9 Evan G1Pivalizza , David C , et al1Thromboelastography with heparinase in orthotopic liver transplantation1J Cardiothorac Vascu Anesth , 1998 ,12 :30523081 10 Mallet SV ,Cox DJA1Thrombelastography1Br J Anaesth ,1992 ,69 :30723131 |
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