Annabel Blasi, M.D., John Feiner, M.D., John P. Roberts, M.D., Claus U. Niemann, M.D.
麻醉和围手术期护理，加州大学旧金山分校，旧金山，加利福尼亚。

背景：目前已经证实，2岁以下的小儿肝移植受体在手术后期会频繁出现肺水肿的临床症状，这种情况在成人和2岁以上的小儿肝移植受体身上都没有出现。肺水肿可能是由于流体静水压的升高或毛细血管渗漏造成的。此次回顾性研究的目的是检查小儿肝移植受体和成人肝移植受体在手术过程中所接受的治疗，以及发生肺水肿的概率。

方法：我们分别研究了15例小儿和成人活体肝移植受体的图表记录。所有的小儿受体都患有胆管闭锁，而大部分成人受体则患有乙肝或丙肝。所有的案例都应用了挥发性麻醉药和芬太尼来平衡麻醉。本研究机构之前已经发布了一项输液标准。我们根据患者的体重来调整血液制品、输液量，以及排尿量（UO）和预计失血量（EBL）。

结果：在此项研究中，成人患者的年龄为52.4± 12.0岁，小儿患者为9.2±3.5个月。60%的小儿患者通过胸部X射线检查证明出现了肺水肿，随后送入ICU，而成人患者则没有一例出现肺水肿的症状。手术和非手术期的治疗在不同的组并无区别。最后，小儿患者呈现出血红蛋白(Hb)水平较低、血小板数量较高的情况（P < 0.05）。小儿患者的EBL(P < 0.05)明显更高，需要输入更多的血液、晶体液和胶体液(P< 0.01)。在小儿组中，中心静脉压（CV，P <0.001)和UO(P < 0.001)在整个手术过程中明显更高。手术末期，两组的血红蛋白量（Hb）并无差别。

结论：小儿肝移植中具有浸润性的液体和血液置换是导致肺水肿发生率不均衡的原因。较高的血清腹水和中心静脉压表明，肺水肿是流体静水压输血相关性循环超负荷(TACO)，而不是输血相关急性肺损伤（TRALI）。

Intraoperative Fluid Managment of Adult and Pediatric Liver Transplant Recipients
Annabel Blasi, M.D., John Feiner, M.D., John P. Roberts, M.D., Claus U. Niemann, M.D.
Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California

Background: It has been our impression that pediatric liver transplant recipients (< 2 years) demonstrated frequently clinical signs of pulmonary edema at the end of surgery. This has not been observed in adults or older pediatric patients. Pulmonary edema can be either due to elevated hydrostatic pressure or capillary leakage. The goal of this retrospective study was to examine the intraoperative management of pediatric and adult liver transplant recipients as well as the incidence of pulmonary edema.

Methods: We retrospectively analyzed charts from 15 pediatric and 15 adult patients receiving a living donor liver graft. All pediatric patients suffered from biliary atresia while the majority of adult patients suffered from either Hepatitis C or B. Balanced anesthesia using volatile anesthetics and fentanyl were used for all cases. Transfusion criteria at our institution were published previously1. Blood product and fluid administration as well as urine output (UO) and estimated blood loss (EBL) were corrected for weight.

Results: The age was 52.4± 12.0 years and 9.2±3.5 months for adult and pediatric patients, respectively. Sixty percent of the pediatric patients demonstrated evidence of pulmonary edema on chest ray on admission to the ICU. None of the adult patients showed signs of pulmonary edema. Surgical and anhepatic times were not different between groups. At baseline, pediatric patients showed lower hemoglobin (Hb) levels and higher platelet counts (both P < 0.05). Pediatric patients experienced a significantly higher EBL (P < 0.05) and received significantly more blood products and crystalloid and colloid fluids (both P < 0.01). Central venous pressure (CV) was significantly higher during the procedure in the pediatric group (P <0.001) as well as UO (P < 0.001). Hb at the end of the procedure was not different between groups.

Conclusion: Aggressive fluid and blood product replacement in the pediatric population resulted in a disproportional incidence of pulmonary edema. The higher fluid totals and higher CVP values suggest that the pulmonary edema is hydrostatic transfusion associated circulatory overload (TACO) and not transfusion related acute lung injury (TRALI).

[责任编辑:刘 聪]