Mims T T, Fishbein T M, Feierman D E
Department of Anesthesiology, The Mount Sinai Medical Center, New York, New York 10029-6574, USA.
Transplant Proc. 2004 Mar;36(2):388-91. doi: 10.1016/j.transproceed.2003.12.005.
During the past few years, small bowel transplantation (SBT) has become a realistic alternative for patients with irreversible intestinal failure who have or will develop severe complications from total parenteral nutrition (TPN). Transplantation can be associated with large fluid shifts and massive blood loss necessitating rapid infusions of large quantities of crystalloid and/or blood products. Invasive monitoring and large-bore venous access are necessary in order to manage these patients intraoperatively. Because patients with irreversible intestinal failure are often managed with total parenteral nutrition via a central venous catheter, thrombotic intraluminal obstruction of major vessels may develop over time. Additionally, this may lead to superior vena cava (SVC) syndrome as well as challenging problems with vascular access. We present a 34-year-old woman with a past medical history for long-standing Crohn's disease with multiple small bowel resections and short gut syndrome who presented for an SBT. The patient had a long history of TPN use, complicated by SVC syndrome and inferior vena cava (IVC) obstruction. She was presently asymptomatic from her SVC obstruction. Central venous access was obtained by an interventional radiologist. A 7-French double-lumen Hickman minicatheter was placed in the left femoral vein with the tip of the catheter positioned just distal to the IVC narrowing. A left radial 20-gauge arterial line was placed for hemodynamic monitoring and frequent blood sampling. The patient's left and right dorsal-saphenous veins were cannulated with 16-guage catheters and adequate flow was observed. Lower extremity pressure was measured via the Hickman catheter in the left femoral vein. A multiplane transesophageal echo was used to assess ventricular volume. The options and intraoperative management of such patients are discussed.
在过去几年中，小肠移植（SBT）已成为患有不可逆肠衰竭且已出现或即将因全胃肠外营养（TPN）而发生严重并发症的患者的一种切实可行的替代方案。移植可能会伴有大量体液转移和大量失血，需要快速输注大量晶体液和/或血液制品。术中管理这些患者需要进行有创监测和大口径静脉通路。由于不可逆肠衰竭患者通常通过中心静脉导管进行全胃肠外营养，随着时间的推移，主要血管可能会发生血栓形成的管腔内阻塞。此外，这可能会导致上腔静脉（SVC）综合征以及血管通路方面的棘手问题。我们介绍一位34岁女性，她有长期克罗恩病病史，接受过多次小肠切除术并患有短肠综合征，前来接受小肠移植。该患者长期使用TPN，并发SVC综合征和下腔静脉（IVC）阻塞。她目前的SVC阻塞没有症状。介入放射科医生获得了中心静脉通路。将一根7法国双腔Hickman微型导管置于左股静脉，导管尖端位于IVC狭窄远端。放置了一根左桡动脉20号动脉导管用于血流动力学监测和频繁采血。患者的左右隐静脉用16号导管进行插管，观察到有足够的血流。通过左股静脉的Hickman导管测量下肢压力。使用多平面经食管超声心动图评估心室容积。讨论了此类患者的选择和术中管理。
