Li Min, Zhang Li-ping, Yang Lu
Department of Anesthesiology, Peking University Third Hospital, Beijing 100083, China.
Chin Med J (Engl). 2007 Nov 20;120(22):1963-8.
There have been many studies investigating the impact of the model for end-stage liver disease (MELD) score on predicting post-transplant outcome. But it is unclear whether MELD is correlated to intraoperative fluid therapy and coagulation status. We investigated the relationship between the severity of liver diseases as measured by MELD score and intraoperative fluid requirements and the changes of coagulation characteristics.
Ninety patients were included in this retrospective study. The patients were stratified into three groups according to the MELD scores: < 15 (low), 15 - 25 (medium) and > 25 (high). Intraoperatively, volume was restored with allogeneic and/or salvaged red blood cells (RBC), fresh-frozen plasma (FFP), platelet and other types of fluids according to hemodynamic data, hematocrit, and clotting data. Intraoperative coagulation data, blood requirements and other fluids administered were compared among the 3 groups.
Before surgery, in addition to the three variables used to calculate MELD scores in other baseline laboratory values, including ratio of activated partial thromboplastin time (R-APTT), D-Dimer, hematocrit, platelet and blood urea nitrogen (BUN) were significantly different among the 3 groups. The blood loss increased with increasing MELD. The volume of RBC (allogeneinc, salvaged and total), FFP, platelet and the total volume of transfusion were also significantly different among the three groups (P < 0.01). The requirements for prothrombin complex and fibrinogen showed a similar pattern. During operation, the changing trends of each coagulation variable were different. Compared with baseline, during each intraoperative stage, INR and R-APPT increased in the low MELD group. While in the medium MELD and high MELD groups, INR did not changed significantly during the operation, and R-APPT significantly increased only after reperfusion.
This study provided some useful information for perioperative management of patients undergoing liver transplantation. Careful preoperative planning and resource preparation are crucial for patients with high MELD scores. Close communication between surgeon, anesthesiologist and the transfusion staff of blood bank before and during surgery should be stressed.
已有许多研究探讨终末期肝病模型（MELD）评分对预测移植后结局的影响。但尚不清楚MELD是否与术中液体治疗及凝血状态相关。我们研究了用MELD评分衡量的肝脏疾病严重程度与术中液体需求量及凝血特性变化之间的关系。
本回顾性研究纳入了90例患者。根据MELD评分将患者分为三组：<15（低）、15 - 25（中）和>25（高）。术中，根据血流动力学数据、血细胞比容和凝血数据，用异体和/或回收的红细胞（RBC）、新鲜冰冻血浆（FFP）、血小板及其他类型的液体来补充血容量。比较三组术中的凝血数据、血液需求量及其他给予的液体量。
术前，除用于计算MELD评分的三个变量外，其他基线实验室值，包括活化部分凝血活酶时间比值（R - APTT）、D - 二聚体、血细胞比容、血小板及血尿素氮（BUN）在三组间有显著差异。失血量随MELD升高而增加。三组间红细胞（异体、回收及总量）、FFP、血小板的用量及输血总量也有显著差异（P < 0.01）。凝血酶原复合物和纤维蛋白原的需求量也呈现类似模式。术中，各凝血变量的变化趋势不同。与基线相比，在每个术中阶段，低MELD组的国际标准化比值（INR）和R - APPT升高。而在中MELD组和高MELD组，术中INR无显著变化，R - APPT仅在再灌注后显著升高。
本研究为肝移植患者的围手术期管理提供了一些有用信息。对于高MELD评分的患者，仔细的术前规划和资源准备至关重要。应强调手术医生、麻醉医生与血库输血人员在手术前及手术期间的密切沟通。
