Kim W H, Joo H S, Ko J S, Gwak M S, Lee S K, Kim G S
Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
Transplant Proc. 2013 Jun;45(5):1920-3. doi: 10.1016/j.transproceed.2012.10.064.
The requirements of nondepolarizing neuromuscular blocking agent during liver transplantation show conflicting results. We sought to evaluate the requirements according to the operative phase and find extrahepatic factors that influence neuromuscular blocking agent requirements.
We enrolled 35 patients undergoing living donor liver transplantation. Continuous infusion of vecuronium was adjusted every 15 minutes for consistent neuromuscular blockade aimed at T1/Tc of 0.10 monitored with a neuromuscular transmission module. We compared the mean infusion dose in each phase, and investigated whether it is correlated with preoperative Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, graft-recipient weight ratio (GRWR), or time to recovery of first twitch response to train-of-four (TOF) stimulation.
There was a significant difference between vecuronium doses during each phase (P < .001): 0.48 ± 0.16 μg/kg/min, preanhepatic; 0.38 ± 0.14 μg/kg/min, anhepatic and 0.26 ± 0.07 μg/kg/min, neohepatic phase. There was a significant positive correlation between vecuronium infusion dose in the preanhepatic phase and CTP scores (P = .006, correlation coefficient = 0.465). There was also a significant negative correlation between the time to recovery of first twitch response of TOF stimulation and vecuronium infusion dose in the preanhepatic phase (P = .001, correlation coefficient = -0.546). The infusion dose during the preanhepatic phase was not associated with the MELD score, and that of neohapatic phase not with GRWR.
The vecuronium infusion dose requirement during the anhepatic decreased compared with that in the preanhepatic phase. It further decreased during the neohepatic phase compared with the previous phases. Vecuronium infusion dose reduction is suggested especially during the neohepatic phase for early extubation. The dose during the preanhepatic phase is suggested to be determined considering the CTP score and the time to recovery of the TOF response.
肝移植期间非去极化神经肌肉阻滞剂的需求量呈现出相互矛盾的结果。我们试图根据手术阶段评估其需求量，并找出影响神经肌肉阻滞剂需求量的肝外因素。
我们纳入了35例行活体肝移植的患者。每15分钟调整维库溴铵的持续输注量，以维持稳定的神经肌肉阻滞，目标是通过神经肌肉传递模块监测使T1/Tc为0.10。我们比较了各阶段的平均输注剂量，并研究其是否与术前终末期肝病模型（MELD）评分、Child-Turcotte-Pugh（CTP）评分、移植物与受者体重比（GRWR）或四个成串刺激（TOF）刺激后第一个肌颤搐反应恢复时间相关。
各阶段维库溴铵剂量存在显著差异（P <.001）：无肝前期为0.48±0.16μg/kg/min；无肝期为0.38±0.14μg/kg/min；新肝期为0.26±0.07μg/kg/min。无肝前期维库溴铵输注剂量与CTP评分之间存在显著正相关（P =.006，相关系数 = 0.465）。无肝前期TOF刺激第一个肌颤搐反应恢复时间与维库溴铵输注剂量之间也存在显著负相关（P =.001，相关系数 = -0.546）。无肝前期的输注剂量与MELD评分无关，新肝期的输注剂量与GRWR无关。
无肝期维库溴铵的输注剂量需求较无肝前期降低。与之前各阶段相比，新肝期进一步降低。建议在新肝期尤其要降低维库溴铵输注剂量以实现早期拔管。建议根据CTP评分和TOF反应恢复时间来确定无肝前期的剂量。
