Department of Anesthesiology, University of Pittsburgh Medical Center/University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
Br J Anaesth. 2012 Mar;108(3):469-77. doi: 10.1093/bja/aer392. Epub 2011 Dec 15.
Intraoperative pulmonary thromboembolism (PTE) is an often overlooked cause of mortality during adult liver transplantation (LT) with diagnostic challenge. The goals of this study were to investigate the incidence, clinical presentation, and outcome of PTE and to identify risk factors or diagnostic predictors for PTE.
Four hundred and ninety-five consecutive, isolated, deceased donor LTs performed in an institution for a 3 yr period (2004-6) were analysed. The standard technique was a piggyback method with veno-venous bypass without prophylactic anti-fibrinolytics. The clinical diagnosis of PTE was made with (i) acute cor pulmonale, and (ii) identification of blood clots in the pulmonary artery or observation of acute right heart pressure overload with or without intracardiac clots with transoesophageal echocardiography.
The incidence of PTE was 4.0% (20 cases); cardiac arrest preceded the diagnosis of PTE [75% (15)] and PTE occurred during the neo-hepatic phase [85% (17)], especially within 30 min after graft reperfusion [70% (14)]. Operative and 60 day mortalities of patients with PTE were higher (P<0.001) than those without PTE (30% vs 0.8% and 45% vs 6.5%). Comparison of perioperative data between the PTE group (n=20) and the non-PTE group (n=475) revealed cardiac arrest and flat-line thromboelastography in three channels (natural, amicar, and protamine) at 5 min after graft reperfusion as the most significant risk factors or diagnostic predictors for PTE with an odds ratio of 154.32 [95% confidence interval (CI): 44.82-531.4] and 49.44 (CI: 15.6-156.57), respectively.
These findings confirmed clinical significance of PTE during adult LT and suggested the possibility of predicting this devastating complication.
术中肺血栓栓塞症（PTE）是成人肝移植（LT）期间经常被忽视的死亡原因，具有诊断挑战。本研究的目的是探讨 PTE 的发生率、临床表现和结局，并确定 PTE 的风险因素或诊断预测因素。
分析了在一个机构进行的 3 年期间（2004-6 年）的 495 例连续、孤立的、已故供体 LT。标准技术是使用背驮式方法进行静脉-静脉旁路转流，不使用预防性抗纤维蛋白溶解药物。PTE 的临床诊断是通过（i）急性肺心病和（ii）在肺动脉中发现血栓或通过经食管超声心动图观察到急性右心压力过载伴或不伴有心内血栓来做出的。
PTE 的发生率为 4.0%（20 例）；心脏骤停先于 PTE 的诊断[75%（15 例）]，PTE 发生在新肝期[85%（17 例）]，特别是在移植物再灌注后 30 分钟内[70%（14 例）]。PTE 患者的手术和 60 天死亡率高于无 PTE 患者（30% vs 0.8%和 45% vs 6.5%）（P<0.001）。在 PTE 组（n=20）和非 PTE 组（n=475）之间比较围手术期数据，发现心脏骤停和再灌注后 5 分钟时三个通道（自然、氨甲环酸和鱼精蛋白）的平板血栓弹性描记术是 PTE 的最显著风险因素或诊断预测因素，其优势比为 154.32[95%置信区间（CI）：44.82-531.4]和 49.44（CI：15.6-156.57）。
这些发现证实了成人 LT 期间 PTE 的临床意义，并提示有可能预测这种毁灭性并发症。
