Glanemann Matthias, Busch Thilo, Neuhaus Peter, Kaisers Udo
Department of General-, Visceral- and Transplantation Surgery, Charité, Campus Virchow-Klinikum, University Medical Center, Berlin, Germany.
Swiss Med Wkly. 2007 Apr 7;137(13-14):187-91. doi: 10.4414/smw.2007.11681.
Increased survival rates after orthotopic liver transplantation (OLT) in patients with end-stage liver disease have become possible due to an advanced understanding of the pathophysiology of liver disease, the establishment of multiorgan procurement and preservation techniques, and the development of safer and more potent immunosuppressive drugs. In addition, standardisation of surgical techniques and advances in anaesthetic management have contributed significantly to this development. The up-to-date concept of improving patient outcome following OLT includes a fast track approach in selected patient populations, which may shorten ICU and/or hospital stay and reduce costs. In particular, immediate postoperative extubation has been identified as an excellent tool to achieve both improved clinical results and a reduced drain on financial resources. Studies on fast tracking protocols have shown clearly that prolonged mechanical ventilation following surgery is no longer justified in the majority of patients. On current evidence at least 70-80% of transplant recipients can be extubated immediately following surgery. The incidence of reintubation is not increased hereafter when compared to patients extubated later. However, special attention should be focused on liver transplant recipients in poor clinical condition at the time of OLT, undergoing complicated surgery, or receiving liver grafts with severe preservation injury. These patients might not be eligible for fast tracking protocols and may be at increased risk of prolonged postoperative mechanical ventilation.
由于对肝病病理生理学有了更深入的了解、多器官获取和保存技术的建立以及更安全、更有效的免疫抑制药物的研发，晚期肝病患者原位肝移植（OLT）后的生存率得以提高。此外，手术技术的标准化和麻醉管理的进步也对这一发展做出了重大贡献。OLT后改善患者预后的最新理念包括对特定患者群体采用快速康复方法，这可能会缩短重症监护病房（ICU）和/或住院时间并降低成本。特别是，术后立即拔管已被视为实现改善临床效果和减少资源消耗的绝佳手段。关于快速康复方案的研究清楚地表明，对大多数患者而言，术后长时间机械通气已不再合理。根据目前的证据，至少70%-80%的移植受者术后可立即拔管。与延迟拔管的患者相比，此后再次插管的发生率并未增加。然而，应特别关注OLT时临床状况较差、接受复杂手术或接受有严重保存损伤的肝移植的受者。这些患者可能不符合快速康复方案的条件，术后长时间机械通气的风险可能会增加。
