Nirav J. Shah, M.D., Sachin Kheterpal, M.D., M.B.A., Subramanian Sathishkumar, M.B.B.S., F.F.A.R.C.S.I.
麻醉学，密歇根大学，安娜堡，密歇根
简介：肝移植患者发生再灌注综合征的特征是体循环阻力（SVR）不稳定和心输出量（CO）不稳定。在移植肝再灌注的5分钟内，再灌注综合征能使平均动脉压（MAP）比基线值低30%（1），且持续时间至少为1分钟；但是在再灌注完成之后，这种状态能持续数小时乃至数天的时间。再灌注综合征的发病率高达30%，但是很少有人研究发病率如此之高的原因；它是原位肝移植术后并发症的主要原因之一，并能导致多器官功能衰竭（2）。我们在三级保健机构中，对原位肝移植患者术后发生再灌注综合征进行了初步研究。
方法：经过科研审查委员会（IRB）的批准后，我们回顾性分析了2003年7月至2006年7月期间进行原位肝移植的患者的病例资料，其中不包括小儿肝移植、器官联合移植、再次移植，以及未标明再灌注时间的移植。所有的数据都来自麻醉信息系统（AIS），在下述情况下得到血压读数：AIS基线值（手术切口之前）、再灌注前5分钟、再灌注后5分钟、再灌注后10分钟。我们计算了每个案例中血压的百分比差异，然后据此来判断以上患者再灌注综合征的发病率。为了判断从基线值到再灌注后5分钟、10分钟的MAP是否有显著的差别，我们使用了配对样本t检验。与此同时，对于使用独立样本t检验的患者（不管有没有再灌注综合征），我们还分析了终末期肝病模型（MELD）分数的差异。
结果：[见下表]
| |
MAP基线
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再灌注后5分钟
|
再灌注后10分钟
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MAP均值
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83
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64 (p=0.019)
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64 (p=0.016)
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MAP中数
|
82
|
62
|
62
|
基线平均减少值
|
n/a
|
.22
|
.21
|
再灌注综合征发病率
|
n/a
|
.37
|
.38
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再灌注综合征患者和无再灌注综合征患者MELD分数的不同
|
|
p=.034
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p=.105
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讨论：
肝移植术后低血压的发病率与Aggrawal等人的研究结果均表明，再灌注综合征是一个严重的问题。目前已有专家指出，氧自由基是肝移植再灌注后发生顽固性低血压的原因之一。一项研究指出了甘露醇的作用，它具有清除自由基以减轻再灌注损伤的功能（2）。我们计划对此项研究进行追踪调查，以探讨甘露醇在肝移植中的应用，以及它对再灌注综合征的影响。移植肝再灌注5分钟之后（不是10分钟之后），MELD分数便出现差异，研究人员应该对这一发现展开进一步的调查。
参考文献：
1. Aggrawal S, Kang Y, Freeman JA, Fortunato FL, Pinsky MR. Post-reperfusion syndrome: cardiovascular collapse following hepatic reperfusion during liver transplantation. Transplant Proc 1987; 199(suppl): 54-55.
2. Weinbroum AA, Shapira I, Ben-Abraham R, Szold A. Mannitol dose-dependently attenuates lung reperfusion injury following liver ischemia reperfusion: a dose-response study in an isolated perfused double-organ model. Lung 2002; 180: 327-338.
Prevalance of Reperfusion Syndrome Following Orthotopic Liver Transplantation
Nirav J. Shah, M.D., Sachin Kheterpal, M.D., M.B.A., Subramanian Sathishkumar, M.B.B.S., F.F.A.R.C.S.I.
Anesthesiology, University of Michigan, Ann Arbor, Michigan
Introduction: Reperfusion syndrome in liver transplant patients is characterized by labile systemic vascular resistance (SVR) and cardiac output (CO). It has been defined as decreased mean arterial pressure (MAP) of at least 30% from baseline, sustained for at least one minute within five minutes of reperfusion; however, it can last as long as hours to days. The incidence of reperfusion syndrome is quoted as high as 30%（1），but there are a limited number of studies that describe its prevalence. Reperfusion syndrome is a major cause of morbidity in orthotopic liver transplants and can result in multi-organ failure2. Our pilot study looked at the prevalence of reperfusion syndrome in orthotopic liver transplant patients at our tertiary care institution.
Methods：After IRB approval, we reviewed the records of 165 patients who underwent liver transplants between 7/2003 and 7/2006. Excluded were pediatric, combined organ, re-do transplants, as well as transplants where reperfusion time was not noted. All data was collected from our anesthesia information system (AIS). Blood pressure readings were abstracted from our AIS at baseline (before surgical incision), 5 mins before reperfusion, 5 mins after reperfusion, and 10 mins after reperfusion. For each case, we calculated the percentage difference in blood pressure from baseline to 5 minutes and 10 minutes after reperfusion. Then we determined the prevalence of reperfusion syndrome in our patient population. Paired sample t-tests were used to determine if there was a significant difference in MAP from baseline to 5 and 10 minutes after reperfusion. We also analyzed differences in Model for End-Stage Liver Disease (MELD) scores for patients with or without reperfusion syndrome using independent samples t-test.
Results：[table1]
| |
Baseline MAP
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5 Minutes After Reperfusion
|
10 Minutes After Reperfusion
|
|
Mean MAP
|
83
|
64 (p=0.019)
|
64 (p=0.016)
|
|
Median MAP
|
82
|
62
|
62
|
|
Mean Decrease From Baseline
|
n/a
|
.22
|
.21
|
|
Prevalence of Reperfusion Syndrome
|
n/a
|
.37
|
.38
|
|
Difference in MELD score between patients with reperfusion syndrome versus patients without reperfusion syndrome
|
|
p=.034
|
p=.105
|
Discussion：The prevalence of hypotension following liver transplants is similar to Aggrawal et al, and demonstrates that it continues to be a significant issue. Oxygen free radicals have been proposed as a cause of refractory hypotension following reperfusion. There is a promising study of limited power describing the use of mannitol, which has been found to have free radical scavenging properties, to mitigate reperfusion injury（2）. We plan to initiate a follow-up of this study to look at the use of mannitol in liver transplants in our institution and determine its effect on reperfusion syndrome. MELD score differences are seen at 5 minutes after reperfusion, but not 10 minutes. This finding should be further investigated.
References：
1. Aggrawal S, Kang Y, Freeman JA, Fortunato FL, Pinsky MR. Post-reperfusion syndrome: cardiovascular collapse following hepatic reperfusion during liver transplantation. Transplant Proc 1987; 199(suppl): 54-55.
2. Weinbroum AA, Shapira I, Ben-Abraham R, Szold A. Mannitol dose-dependently attenuates lung reperfusion injury following liver ischemia reperfusion: a dose-response study in an isolated perfused double-organ model. Lung 2002; 180: 327-338.
[责任编辑:刘 聪]
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