Park J, Lee M, Kim J, Choi H J, Kwon A, Chung H S, Hong S H, Park C S, Choi J H, Chae M S
Department of Anesthesiology and Pain Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Department of Surgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Transplant Proc. 2019 Mar;51(2):568-574. doi: 10.1016/j.transproceed.2018.12.019. Epub 2019 Jan 3.
Pericardial effusion is a common feature of end-stage liver disease. In this case report we describe the intraoperative management of recurrent pericardial effusion, without re-pericardiocentesis, to prevent circulatory collapse during a critical surgical time-point; that is, during manipulation of the major vessels and graft reperfusion.
A 47-year-old woman with hepatitis B was scheduled to undergo deceased donor liver transplantation (LT). A large pericardial effusion was preoperatively identified using transthoracic echocardiography (TTE). The patient also had paroxysmal atrial fibrillation. Two days before surgery, preemptive pericardiocentesis was performed and the 1150-mL effusion was drained. Intraoperatively, recurrence of the large pericardial effusion was identified using transesophageal echocardiography (TEE). During inferior vena cava manipulation, the surgeon consulted the anesthesiologist to evaluate the hemodynamic changes in the patient. After 3 attempts, the transplant team was able to determine the most appropriate anastomosis site, defined as that with the least impact on cardiac function. To prevent the development of severe postreperfusion syndrome, 10% MgSO (2 g) was gradually infused 20 minutes before portal vein declamping, and immediately before graft reperfusion a 100-μg bolus of epinephrine was administered.
During graft reperfusion, there was no evidence of heart chamber collapse or flow disturbance, as seen on the TEE findings. Postoperatively, the patient recovered completely and was discharged from the hospital. Six months after surgery, there was no sign of pericardial effusion on follow-up TTE.
Our intraoperative strategy may prevent cardiac collapse in patients with pericardial effusion detected during LT. Intraoperative TEE plays an important role in guiding hemodynamic management.
心包积液是终末期肝病的常见特征。在本病例报告中，我们描述了复发性心包积液的术中管理，无需再次进行心包穿刺术，以防止在关键手术时间点（即在主要血管操作和移植物再灌注期间）发生循环衰竭。
一名47岁的乙型肝炎女性计划接受尸体供肝移植（LT）。术前通过经胸超声心动图（TTE）发现大量心包积液。该患者还患有阵发性心房颤动。手术前两天进行了预防性心包穿刺术，引流了1150毫升积液。术中，通过经食管超声心动图（TEE）发现大量心包积液复发。在下腔静脉操作期间，外科医生咨询麻醉医生以评估患者的血流动力学变化。经过3次尝试，移植团队能够确定最合适的吻合部位，即对心脏功能影响最小的部位。为防止严重再灌注综合征的发生，在门静脉夹闭前20分钟逐渐输注10%硫酸镁（2克），在移植物再灌注前立即给予100微克肾上腺素推注。
在移植物再灌注期间，TEE检查结果未显示有心腔塌陷或血流紊乱的证据。术后，患者完全康复并出院。术后6个月，随访TTE未发现心包积液迹象。
我们的术中策略可能预防LT期间检测到的心包积液患者发生心脏衰竭。术中TEE在指导血流动力学管理方面发挥着重要作用。
