Moreno Carlos, Sabaté Antoni, Figueras Joan, Camprubí Imma, Dalmau Antonia, Fabregat Joan, Koo Maylin, Ramos Emilio, Lladó Laura, Rafecas Antoni
Department of Anesthesiology, University Hospital of Bellvitge, Barcelona, Spain.
Liver Transpl. 2006 Nov;12(11):1607-14. doi: 10.1002/lt.20794.
We performed a prospective, randomized study of adult patients undergoing orthotopic liver transplantation, comparing hemodynamic and tissular oxygenation during reperfusion of the graft. In 30 patients, revascularization was started through the hepatic artery (i.e., initial arterial revascularization) and 10 minutes later the portal vein was unclamped; in 30 others, revascularization was started through the portal vein (i.e., initial portal revascularization) and 10 minutes later the hepatic artery was unclamped. The primary endpoints of the study were mean systemic arterial pressure and the gastric-end-tidal carbon dioxide partial pressure (PCO(2)) difference. The secondary endpoints were other hemodynamic and metabolic data. The pattern of the hemodynamic parameters and tissue oxygenation values during the dissection and anhepatic stages were similar in both groups At the first unclamping, initial portal revascularization produced higher values of mean pulmonary pressure (25 +/- 7 mm of Hg vs. 17 +/- 4 mm of Hg; P < 0.05) and wedge and central venous pressures. At the second unclamping, initial portal revascularization produced higher values of cardiac output and mean arterial pressure (87 +/- 15 mm of Hg vs. 79 +/- 15 mm of Hg; P < 0.05) and pulmonary blood pressure. Postreperfusion syndrome was present in 13 patients (42.5%) in the arterial group and in 11 patients (36%) in the portal group. During revascularization, the values of gastric and arterial pH decreased in both groups and recovered at the end of the procedure, but were more accentuated in the initial arterial revascularization group. In conclusion, we found that initial arterial revascularization of the graft increases pulmonary pressure less markedly, so it may be indicated for those patients with poor pulmonary and cardiac reserve. Nevertheless, for the remaining patients, initial portal revascularization offers more favorable hemodynamic and metabolic behavior, less inotropic drug use, and earlier normalization of lactate and pH values.
我们对接受原位肝移植的成年患者进行了一项前瞻性随机研究，比较移植肝再灌注期间的血流动力学和组织氧合情况。30例患者通过肝动脉开始血管再通（即初始动脉再通），10分钟后松开门静脉；另外30例患者通过门静脉开始血管再通（即初始门静脉再通），10分钟后松开肝动脉。该研究的主要终点是平均体动脉压和胃-呼气末二氧化碳分压（PCO₂）差值。次要终点是其他血流动力学和代谢数据。两组在解剖和无肝期的血流动力学参数和组织氧合值模式相似。在首次松开血管夹时，初始门静脉再通产生的平均肺动脉压（25±7 mmHg对17±4 mmHg；P<0.05）、楔压和中心静脉压更高。在第二次松开血管夹时，初始门静脉再通产生的心输出量、平均动脉压（87±15 mmHg对79±15 mmHg；P<0.05）和肺血压更高。动脉组13例患者（42.5%）和门静脉组11例患者（36%）出现再灌注综合征。在血管再通期间，两组的胃和动脉pH值均下降，并在手术结束时恢复，但在初始动脉再通组中更为明显。总之，我们发现移植肝的初始动脉再通对肺动脉压的升高不太明显，因此可能适用于肺和心脏储备较差的患者。然而，对于其余患者，初始门静脉再通具有更有利的血流动力学和代谢表现，更少使用正性肌力药物，乳酸和pH值更早恢复正常。
