Tetsuro Sakai, M.D., Ph.D., Ibetsam A. Hilmi, M.D., Raymond M. Planinsic, M.D.
麻醉科，匹兹堡大学医学中心，匹兹堡大学，匹兹堡，宾夕法尼亚。

简介：原位肝移植（OLT）被视为最危险的非心脏外科手术之一。为了确定麻醉医师在手术过程中面对挑战的严重程度，作者在一个较大的成人肝移植中心回顾了OLT手术过程中，心脏骤停的发生率和造成的后果。

方法：对于在2004年1月1日至2006年12月31日期间进行原位肝移植、且手术过程中出现心脏骤停的患者，我们回顾性分析了他们的病例资料。为了研究的便利，我们将心脏骤停定义为需要通过胸外心脏按压或开胸心脏按摩才能复苏的事件。本研究中OLT的标准模式是伴静脉-静脉转流的背驼式技术；在手术监测过程中还用到了经食管超声心动图。我们对以下内容做了记录：早期复苏至少一小时后患者存活和患者出院存活。

结果：研究期间在651例连续的原位肝移植患者中，16例发生心脏骤停（2.5%）。大部分的心脏骤停发生在新肝期（14例，87.5%），其中6例在对移植肝进行再灌注5分钟之内发生（37.5%）；剩下的2例（12.5%）则发生在无肝期。心脏骤停后的立即存活率为43.8%（7例），住院存活率为37.5%（6例）。造成心脏骤停的主要原因是肺栓塞（43.8%，7例）和肺水肿（18.8%，3例）。爆发性肝衰竭的受体出现心脏骤停的概率是最高的（31例患者出现4例，占12.9%），而104例活体肝移植患者则没有一例出现心脏骤停。

结论：进行OLT的患者发生心脏骤停的概率明显比非心脏手术患者要高（2.5% vs 0.043%），而心脏骤停后的立即存活率（分别为43.8 % vs 46.6%）和住院存活率（分别为37.5% vs 34.5%）则无明显差别。研究表明，进行OLT的患者发生心脏骤停的整体概率比非心脏手术患者要高。大部分心脏骤停发生在新肝期，尤其是移植肝再灌注后的5分钟时间内。

参考文献：
1) Sprung et al. Predictors of Survival following Cardiac Arrest in Patients Undergoing Noncardiac Surgery: A Study of 518,294 Patients at a Tertiary Referral Center. Anesthesiology. 2003;99:259-69.

Incidence and Outcome of Cardiac Arrest during Adult Orthotopic Liver Transplantation
Tetsuro Sakai, M.D., Ph.D., Ibetsam A. Hilmi, M.D., Raymond M. Planinsic, M.D.
Department of Anesthesiology, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania

Introduction: Orthotopic liver transplantation (OLT) is considered to be one of the highest risk non-cardiac surgeries. To determine the magnitude of the challenge anesthesiologists must face during this operation, the authors reviewed the incidence of intra-operative cardiac arrest during OLT and its outcome in a large adult liver transplantation center.

Methods:Medical records of the patients who experienced intra-operative cardiac arrest during OLT for a 3-year period (January 1, 2004 - December 31, 2006) were reviewed. For the purpose of this study, we defined cardiac arrest as an event that required resuscitation with either closed-chest compressions or open cardiac massage. The standard mode of OLT during the study period was the piggyback technique with veno-venous bypass. Transesophageal echocardiography was included in the standard intra-operative monitors. The survival at least 1 hour after initial resuscitation (immediate survival) and survival to discharge from the hospital (hospital survival) were recorded.

Results: Cardiac arrest occurred in 16 of 651 consecutive isolated OLTs (2.5%) during the study period. The majority of the cardiac arrest occurred during the neo-hepatic phase in 14 cases (87.5%), of which 6 cases (37.5%) occurred within 5 minutes after reperfusion of the donor liver. The remaining 2 cases (12.5%) occurred during the an-hepatic phase. The immediate survival after cardiac arrest was 43.8% (7 cases), and the hospital survival was 37.5% (6 cases). The most likely causes of the cardiac arrest were pulmonary embolism in 43.8% (7 cases) and pulmonary edema in 18.8% (3 cases). The recipients with fulminant hepatic failure had highest rate of cardiac arrest (4 out of 31 cases in total: 12.9%). None of the 104 cases with living related liver transplantation had cardiac arrest.

Conclusions: The overall frequency of cardiac arrest for patients underwent OLTs was higher than that of other non-cardiac surgeries reported in a literature (2.5% vs 0.043%1) with comparable survival rate (Immediate survival after arrest was 43.8 % vs 46.6%1, and hospital survival was 37.5% vs 34.5%1). Most cardiac arrests occurred during the neo-hepatic phase, especially in 5 minutes after reperfusion of the implanted liver.

Reference:
Sprung et al. Predictors of Survival following Cardiac Arrest in Patients Undergoing Noncardiac Surgery: A Study of 518,294 Patients at a Tertiary Referral Center. Anesthesiology. 2003;99:259-69.

[责任编辑:刘 聪]