肝移植手術(shù)復(fù)雜，術(shù)中必須密切注意病人的血壓、脈搏、呼吸、體溫、心電圖、中心靜脈壓及尿量的變化，并準(zhǔn)確記錄，同時應(yīng)抽血查血糖、尿素氮、肌酐、鉀、鈉、氯、鈣、紅細(xì)胞計數(shù)、血紅蛋白、血細(xì)胞比容、凝血機(jī)制和血氣分析。
肝移植手術(shù)的整個手術(shù)過程可以分為3期：病肝切除期、無肝期和肝臟再灌注期。
病肝切除期是從病肝分離至門靜脈、肝動脈及下腔靜脈切斷為止；無肝期是指從門靜脈、肝動脈和下腔靜脈切斷至門靜脈和肝上下腔靜脈開放、肝臟血流部分恢復(fù)為止；再灌注期是門靜脈和肝上下腔靜脈開放、肝臟血流部分恢復(fù)至手術(shù)完成為止。這3期均會明顯影響受體的血流動力學(xué)和機(jī)體代謝狀態(tài)，應(yīng)根據(jù)各期不同的變化，做好充分準(zhǔn)備，及時防治。
�。�1)病肝切除期：由于受體往往合并有肝硬化，存在粘連和豐富的側(cè)支循環(huán)，在分離病肝時容易出血和滲血，這一期容易出現(xiàn)低血容量的休克，應(yīng)密切注意觀察失血量，動脈壓、中心靜脈壓和尿量，根據(jù)情況補(bǔ)充液體和全血，并要注意鈣離子的補(bǔ)充。我們的第1例病人由于術(shù)中失血過多出現(xiàn)動脈壓下降，經(jīng)補(bǔ)充血容量后動脈壓恢復(fù)正常。
�。�2)無肝期：由于病肝的切除，這一期可能出現(xiàn)高血糖、低血鉀、酸中毒、心律紊亂、凝血功能障礙及低體溫等。所以要注意病人的血壓、血糖、生化指標(biāo)、心電圖、血氣和體溫的觀測。出現(xiàn)低血壓昌可以給予多巴胺維持血壓；出現(xiàn)酸中毒時，可以用5%的碳酸氫鈉糾正；無肝期血糖往往偏高，但隨著新肝功能的建立，糖利用增加，血糖水平可以逐漸下降，這也是新肝具有代謝活性的一個標(biāo)志；無肝期體溫往往下降，可以降至33℃以下，可用電熱毯、熱水袋和輸液裝置加溫等方法來保持體溫。由于回流血量的減少，這一期中心靜脈壓（CVP)、肺動脈楔壓（PCWP)、平均動脈壓（MAP)均可以輕度下降，同時體循環(huán)阻力（SVR)升高而肺循環(huán)阻力（PVR)降低。
�。�3)再灌注期：這一期由于淤血胃腸道內(nèi)大量酸性代謝產(chǎn)物和腸道內(nèi)毒性物質(zhì)進(jìn)入體循環(huán)，可能出現(xiàn)高血鉀、酸中毒、凝血功能障礙和心律失常等，要嚴(yán)密觀測，高血鉀是再灌注早期的一個重要現(xiàn)象，平均可以升高1.5-2mmol/L，是手術(shù)過程中影響血流動力學(xué)穩(wěn)定和抑制心肌功能的潛在因素。如果血鉀過高，可以注射氯化鈣或葡萄糖酸鈣；可用5%的碳酸氫的鈉糾正酸中毒。隨著回流血量的恢復(fù)，這一期中心靜脈壓（CVP)，肺動脈楔壓（PCWP)、平均動脈壓（MAP)、體循環(huán)阻力（SVR)和肺循環(huán)阻力（PVR)均逐漸恢復(fù)正常。
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