山莨菪堿在非轉(zhuǎn)流經(jīng)典原位肝移植中的應(yīng)用研究

1、山莨菪堿在非轉(zhuǎn)流經(jīng)典原位肝移植中的應(yīng)用研究 西安交通大學(xué)醫(yī)學(xué)院第一附屬醫(yī)院麻醉科 陜西西安 710061朱宇麟，景桂霞，李小剛，劉齊寧，高燕風(fēng)，朱敦摘要 目的 觀察山莨菪堿對(duì)非轉(zhuǎn)流經(jīng)典原位肝移植術(shù)血流動(dòng)力學(xué)、氧代謝和腎功能的影響。方法 選擇行非轉(zhuǎn)流經(jīng)典原位肝移植患者30例，ASA分級(jí)，隨機(jī)分為山莨菪堿組和對(duì)照組，每組15例。山莨菪堿組術(shù)中使用1g/L山莨菪堿10mg/h，對(duì)照組使用相同容量的生理鹽水。分別于術(shù)前、無肝期前、無肝期30min、新肝期60min和術(shù)畢測定血流動(dòng)力學(xué)、組織氧代謝和腎功能指標(biāo)。結(jié)果 與無肝期前相比，兩組無肝期30min 中心靜脈壓（CVP）明顯降低，新肝期60min C

2、VP明顯升高（P 0.05）；兩組間各時(shí)點(diǎn)的心率（HR）、平均動(dòng)脈壓（MAP）和CVP均無顯著性差異（P 0.05）；兩組手術(shù)時(shí)間、無肝期時(shí)間、出血量、總?cè)肓烤鶡o顯著性差異（P 0.05）；與對(duì)照組相比，山莨菪堿組尿量顯著增多（P 0.05），而速尿的用量顯著減少（P 0.05）；兩組肌酐（Cr）和2-微球蛋白（2-MG）術(shù)中各時(shí)點(diǎn)與術(shù)前相比及兩組之間相比差異均無顯著性（P 0.05）。與術(shù)前比較，兩組無肝期30min乳酸鹽（LAC）水平明顯增高，持續(xù)至術(shù)畢（P0.01）；與對(duì)照組相比，山莨菪堿組在無肝期30min后各時(shí)點(diǎn)LAC明顯降低（P0.05）。討論 肝移植過程中存在著代謝障礙，無氧代謝

3、增加，表現(xiàn)為血乳酸增高。本研究中兩組無肝期后LAC都明顯上升。山莨菪堿具有阻斷膽堿能受體，解除血管痙攣，改善局部血流的作用。本研究中應(yīng)用山莨菪堿明顯緩解了無肝期后LAC的升高幅度，并且增加了術(shù)中尿量，減少了速尿的用量。山莨菪堿的這種作用可能是多方面的綜合作用結(jié)果。一是解除內(nèi)臟微循環(huán)前后平滑肌的痙攣狀態(tài)，改善內(nèi)臟血流灌注；二是減少NO的釋放，提高機(jī)體對(duì)兒茶酚胺的敏感性，改善低血壓狀況；三是減輕肝臟缺血再灌注損傷，與山莨菪堿能穩(wěn)定細(xì)胞膜、抑制鈣超載、減少自由基和炎性因子生成等多種因素有關(guān)。本研究雖然未能證實(shí)山莨菪堿能改善肝移植術(shù)中的腎功能狀況，但山莨菪堿組尿量明顯較對(duì)照組增多。肝移植患者不存在少尿

4、的患者具有更好的預(yù)后。結(jié)論 肝移植術(shù)中使用山莨菪堿能改善組織微循環(huán)，增加術(shù)中尿量，對(duì)改善腎功能有一定意義。關(guān)鍵詞： 肝移植 ； 微循環(huán)； 腎功能； 山莨菪堿The Study of Application of Anisodamine in Orthotopic Liver Transplantation without Venovenous BypassZhu Yulin, Jing Guixia, Li Xiaogang, Liu Qining, Gao Yanfeng,Zhu Dun(Department of Aesthesiology ,First Affiliated Hospit

5、al ,Medical School of Xian Jiaotong University , Xian 710061)ABSTRACT：Objective To observe the effect of anisodamine to hemodynamics ,oxygen metabolism and renal function in orthotopic liver tansplantation(OLT) without venovenous bypass. Method Thirty ASA patients undergoing orthotopic liver transpl

6、antation without venovenous bypass were randomly divided into two groups of 15 patients each: Anisodamine group and Control group. 1g/L anisodamine were infused at 10mg/h in Anisodamine group. The same volume of saline were infused in Control group. The parameter of hemodynamics, oxygen metabolism a

7、nd renal function were recorded at preoperational period, preanhepatic phase, 30min at anhepatic phase,60min at neohepatic phase and at the end of operation. Results In both groups, compared with preoperation, central venous pressure (CVP) decreased at 30min of anhepatic phase significantly and incr

8、eased at 60min of neohepatic phase significantly（P 0.05）. There were no significant difference in heart rate (HR)、mean arterial pressure (MAP) and CVP between the two groups at each time point（P 0.05）.There were also no significant difference in duration of operation and anhepatic phase, volume of h

9、emorrhage and transfusion between the two groups. Compared with Control group, there was more urine output and less furosemide in Anisodamine group（P 0.05）;In two groups, there were no significant difference in creatinine (Cr) and 2 microglobulin (2-MG) not only comparing with preoperation but also

10、between each time point（ P0.05）.The lactate(LAC) level increased significantly at 30min of anhepatic phase and lasted to the end of operation compared with preoperation, but the LAC level at the time point after 30min of anhepatic phase was significantly lower in Anisodamine group than in Control gr

11、oup（P0.05）.Discussion Metabolic dysfunction that lead anaerobic metabolism existed during the OLT which represented as LAC elevating. LAC level in both groups of our study increased after anhepatic phase. Anisodamine has the effect of blocking cholinergic receptor, relieving vasospasm and improving

12、regional circulation. In our study, the use of anisodamine decreased the elevating extent of LAC after anhepatic phase significantly, and also increased urine output and reduced furosemide dosage. Such effect of anisodamine may be a integrated result of various actions. Anisodamine can firstly relie

13、ve spasm of anterior and posterior smooth muscle of visceral microcirculation which improve blood perfusion of viscera; and secondly it reduces the releasing of NO that elevating bodys sensitivity to catecholamine and correcting hypotensive status ; and thirdly it alleviates hepatic ischemia reperfu

14、sion injury which relates to factors such as stabilizing cell membrane ,inhibiting calcium overload and reducing the production of free radical and inflammatory factor et al. Although our study failed to confirm that anisodamine could ameliorate renal function during OLT, but it increased urine output significantly comparing with control group. OLT patients without oliguria would have a better prognosis. Conclusion Using anisodamine in li