肝移植手術(shù)復(fù)雜，術(shù)中必須密切注意病人的血壓、脈搏、呼吸、體溫、心電圖、中心靜脈壓及尿量的變化，并準(zhǔn)確記錄，同時(shí)應(yīng)抽血查血糖、尿素氮、肌酐、鉀、鈉、氯、鈣、紅細(xì)胞計(jì)數(shù)、血紅蛋白、血細(xì)胞比容、凝血機(jī)制和血?dú)夥治觥?/P>
肝移植手術(shù)的整個(gè)手術(shù)過程可以分為3期：病肝切除期、無肝期和肝臟再灌注期。
病肝切除期是從病肝分離至門靜脈、肝動(dòng)脈及下腔靜脈切斷為止；無肝期是指從門靜脈、肝動(dòng)脈和下腔靜脈切斷至門靜脈和肝上下腔靜脈開放、肝臟血流部分恢復(fù)為止；再灌注期是門靜脈和肝上下腔靜脈開放、肝臟血流部分恢復(fù)至手術(shù)完成為止。這3期均會(huì)明顯影響受體的血流動(dòng)力學(xué)和機(jī)體代謝狀態(tài)，應(yīng)根據(jù)各期不同的變化，做好充分準(zhǔn)備，及時(shí)防治。
�。�1)病肝切除期：由于受體往往合并有肝硬化，存在粘連和豐富的側(cè)支循環(huán)，在分離病肝時(shí)容易出血和滲血，這一期容易出現(xiàn)低血容量的休克，應(yīng)密切注意觀察失血量，動(dòng)脈壓、中心靜脈壓和尿量，根據(jù)情況補(bǔ)充液體和全血，并要注意鈣離子的補(bǔ)充。我們的第1例病人由于術(shù)中失血過多出現(xiàn)動(dòng)脈壓下降，經(jīng)補(bǔ)充血容量后動(dòng)脈壓恢復(fù)正常。
�。�2)無肝期：由于病肝的切除，這一期可能出現(xiàn)高血糖、低血鉀、酸中毒、心律紊亂、凝血功能障礙及低體溫等。所以要注意病人的血壓、血糖、生化指標(biāo)、心電圖、血?dú)夂腕w溫的觀測。出現(xiàn)低血壓昌可以給予多巴胺維持血壓；出現(xiàn)酸中毒時(shí)，可以用5%的碳酸氫鈉糾正；無肝期血糖往往偏高，但隨著新肝功能的建立，糖利用增加，血糖水平可以逐漸下降，這也是新肝具有代謝活性的一個(gè)標(biāo)志；無肝期體溫往往下降，可以降至33℃以下，可用電熱毯、熱水袋和輸液裝置加溫等方法來保持體溫。由于回流血量的減少，這一期中心靜脈壓（CVP)、肺動(dòng)脈楔壓（PCWP)、平均動(dòng)脈壓（MAP)均可以輕度下降，同時(shí)體循環(huán)阻力（SVR)升高而肺循環(huán)阻力（PVR)降低。
�。�3)再灌注期：這一期由于淤血胃腸道內(nèi)大量酸性代謝產(chǎn)物和腸道內(nèi)毒性物質(zhì)進(jìn)入體循環(huán)，可能出現(xiàn)高血鉀、酸中毒、凝血功能障礙和心律失常等，要嚴(yán)密觀測，高血鉀是再灌注早期的一個(gè)重要現(xiàn)象，平均可以升高1.5-2mmol/L，是手術(shù)過程中影響血流動(dòng)力學(xué)穩(wěn)定和抑制心肌功能的潛在因素。如果血鉀過高，可以注射氯化鈣或葡萄糖酸鈣；可用5%的碳酸氫的鈉糾正酸中毒。隨著回流血量的恢復(fù)，這一期中心靜脈壓（CVP)，肺動(dòng)脈楔壓（PCWP)、平均動(dòng)脈壓（MAP)、體循環(huán)阻力（SVR)和肺循環(huán)阻力（PVR)均逐漸恢復(fù)正常。
參考文獻(xiàn)
1.Fleitas MG,Casanova D,Martino Eet al.Could the piggyback operation in liver transplantation be routinely used?Arch Surg,1994,129:842
2.Griffith BP,Shaw BW,Hardesty RL.et al Veno-venous bypass without systemic anticoagulation for transplantation of the human liver.Surg Gynecol Obstet,1985,160:271
3.Tzabis A,Todo S,Starzl TE.Orthotopic liver transplantation with preservation of the inferior vena cava.Ann Surg.1989,210:649
4.O’Cherqui D,Lauzet JY,Botman N et al .Orthotopic liver transplantation with preservation of the caval and portal flows.Transplantation.1994,58:793
5.Belghiti J,Noun R,Sanvanci .Temporary portocaval anastomosis with preservation of caval flow during orthotopic liver transplantation .Am J Surg,1995,169:277
6.Belghiti J,Panis Y,Sauvanet A new technique of side to side caval anastomosis during orthotopic hepatic transplantation without inferior vena caval occlusion.Surg Gynecol Obstet,1992,175:271
7.Lerut J,de Goyet J,Donataccio M et al.Piggyback transplantation with side-to-side cavocavostomy is an ideal technique for right split split liver allograft implantation.J Am Coll Surg,1994,179:573
8.Durand F,Aschechoug J,Sauvanet A et al .Preservation of renal perfusion and postoperative renal function by side-to-side cavo-caval anastomosis in liver transplant recipients.Transpl Int,1995,8:407
9.Shaw BW,Iwatsuki S,Bron K et al .Portal vein graft in hepatic transplantation.Surg Gynecol Obstet,1985,161:67
10.Millis JM,Melinek J.Csete M et al .Randomized controlled trials to evaluate flush and reperfusion techniques in liver transplantation .Transplantation,1997,63:397
11.Klintmalm GB,Olson LM,Paulen AW et al .Hepatic arterial thrombosis after liver transplantation:intraoperative electromagnetic blood flow evaluation.Transplant Proc,1988,10:616
12.Yanaga K,Makowka L,Shimada M et al .Hepatic arrery thrombosis following pediatric liver transplantation:assessment of blood flow measure-ment in allografts .Hepatology,1989,3:184
13.Ccsavilla A,Gordon RD,Starzl TE et al .Techniques of liver transplantation.In:Blumgart LH ed.Surgery of the liver and biliary tract.London:Churchill Livingstone Inc,1994:1180-1185
14.Goss JA,Seu P,Shackleton CR et al.Lower extremity paralysis after use of the supraceliac aorta for hepatic arterial reconstruction of the liver transplanter liver.Transplantation,1997,63:163
15.Sankary HN,Mc Chesney L,Frye E et al.A simple modification in operative technique can reduce the incidence of nonanastomotic biliary structure after orthotopic liver transplantation.Hepatology,1995,21:63
16 Chaib E,friend PJ,Jamieson NV et al .Biliary tract reconstruction:comparison of different techniques after 187 pediatric liver transplantation.Transplant Int,1994,7:39
17.Randall HB.Wachs ME,Somberg KA et al .The use of the Ttrbe after orthotopic liver transplantation .Transplantation.1996,61:258
18.Neuhaus P,Blumhardt G,Bechstein WO et al .Technique and results of biliary reconstruction using side-to-side holedochocholedochostomy in 300orthotopic liver transplants.Ann Surg.1994:426
19.Vougas V,Rela M,Gane E et al .A prospective randomized trial of bile duct reconstruction at liver transplantation:T tube or no tube?Transplant Int ,1996,9:392
