成人肝移植术后早期肝外脏器功能管理策略

doi:10.16139/j.1007-9610.2023.05.04

摘要/Abstract

摘要：

随着外科技术的发展，肝移植手术的适应证向病情复杂、严重的病人扩展，这些病人除肝功能处于终末期外，通常还合并其他重要肝外器官的功能损伤。肝移植术后早期肝外脏器功能管理策略有助于肝移植病人早期快速康复。本文就心、肺、肾、脑等重要肝外脏器在成人肝移植术后早期的管理策略作详细论述。术后继续进行血流动力学监测有助于维持供肝灌注，对前负荷、心肌收缩力及后负荷三个方面的评估管理非常重要。目前指南明确推荐术后早期拔管，对于术后肺部并发症的常规筛查有助于脱机。术后急性肾损伤的诊断遵循改善全球肾脏病预后组织(Kidney Disease: Improving Global Outcomes, KDIGO)的定义，肝移植术后早期延迟使用钙调磷酸酶抑制剂方案有利于肾功能保护。启动肾脏替代治疗的时机目前没有统一意见。肝硬化和肝性脑病病史会引起神经系统恢复受损，对肝性脑病正确诊断非常重要但很困难。

关键词: 肝移植, 肝外器官, 重症监护

Abstract:

With the improvements in surgical technique, the indications for liver transplantation(LT) are being expanded to more complex and severe patients, who not only have liver function in the terminal stage, but also extrahepatic organs involve of varying degrees dysfunction. It was demonstrated that the strategy of extrahepatic organs management in early period after LT was associated with improving recovery. This paper summarized the strategy of extrahepatic organs management in early period after adult LT. Continuing to monitor system hemodynamics is helpful for stable graft perfusion. It is necessary to manage derangements of preload, myocardial contractility, and afterload. Early postoperative extubation is recommended by current guidelines. Routine screening pulmonary complications may help weaning from the ventilator. The diagnosis of acute kidney injury(AKI) after LT has been reported to using Kidney Disease: Improving Global Outcomes(KDIGO) criteria, a delayed calcineurin inhibitor initiation strategy may be beneficial for renal protection. Currently, there is no consensus on timing of renal replacement therapy initiation in patients with AKI. Patients with cirrhosis and a history of hepatic encephalopathy(HE) displays impaired neurological recovery, the diagnosis of HE is crucial and challenging.

Key words: Liver transplantation, Extrahepatic organ, Intensive care

中图分类号:

R657.3

邓羽霄, 赵贤元, 皋源. 成人肝移植术后早期肝外脏器功能管理策略[J]. 外科理论与实践, 2023, 28(05): 415-419.

DENG Yuxiao, ZHAO Xianyuan, GAO Yuan. The strategy of extrahepatic organs management in early period after adult liver transplantation[J]. Journal of Surgery Concepts & Practice, 2023, 28(05): 415-419.

图/表 2

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WHC分期	ISHEN分期	症状描述	建议操作标准	备注
轻微型	隐匿性	在检测意识活动的速度、执行能力或神经心理学变化的测试中，发现心理测量或神经心理学的变化，但缺乏心理变化的临床证据	心理测量或神经心理学测试结果异常，但无临床表现	无通用的诊断标准，采用当地标准或专家要求
Ⅰ期	隐匿性	轻微的注意不集中欣快感或焦虑感注意持续时间变短加减法计算能力受损	尽管无时间和空间的定向障碍，但临床测试中，在病人自已或监护者看来，病人存在认识和行为的衰退	临床发现经常无法复现
Ⅱ期	显性	昏睡或淡漠时间定向障碍明显的性格改变行为异常	时间定位障碍（以下项目中至少3项错误：星期、日期、月份、季节、年份）	临床发现多变，可一定程度上复现
Ⅲ期		嗜睡乃至半昏迷状态对刺激有反应迷糊严重空间定向障碍行为怪异	时间定位障碍和空间定位障碍（以下项目中至少3项错误：国家、省、市、具体地点）	临床发现一定程度上可复现
Ⅳ期		昏迷	疼痛刺激无反应	昏迷状态通常可复现