肝移植手术中的肺内分流和矛盾性空气栓塞:病例报告

Bradly Brown, Peter E Frasco, Alexander D. Stoker
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摘要

患者: 男性,60 岁男性,60 岁 最终诊断:并发肺血栓栓塞症状:低血压 临床程序: - 专科:麻醉科背景:异常临床过程:当进入中心静脉循环的空气通过心内分流或肺内分流进入全身循环时,就会发生矛盾性空气栓塞(PAE)。即使没有肝肺综合征,接受肝移植的患者也会因肺动脉血管扩张而出现肺内分流。在此,我们介绍一例被认为是由 PAE 引起的血流动力学衰竭病例,该病例在术中通过经食道超声心动图(TEE)确诊。病例报告:一名 60 岁的男性被诊断为非酒精性脂肪性肝炎肝硬化,在使用常温机器灌注的情况下接受了死亡供体正位肝移植手术。肝脏异体移植再灌注后,TEE 检测到肺内分流,导致左心房、左心室和升主动脉内有空气。患者出现严重的双心室功能障碍,心电图监测显示ST段改变,肝脏再灌注5分钟后出现急性低血压和明显的肝充血。医生使用了大剂量的肌力和血管加压支持以及吸入一氧化氮。经过 30 分钟的药物治疗后,患者恢复了健康。肝移植手术顺利完成,患者于术后第 7 天出院回家。结论肝移植再灌注时的心内空气可能来自供体同种异体,并在肺内分流的情况下导致 PAE。PAE可由冠状动脉内空气导致,在肝移植术中出现血流动力学不稳定时应考虑PAE,尤其是在左心房、左心室和升主动脉内出现空气时。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Intrapulmonary Shunting and Paradoxical Air Embolism in Liver Transplantation: A Case Report
Patient: Male, 60-year-old Final Diagnosis: Paradoxical pulmonary thromboembolism Symptoms: Hypotension Clinical Procedure: — Specialty: Anesthesiology Objective: Unusual clinical course Background: A paradoxical air embolism (PAE) occurs when air entering the central venous circulation reaches the systemic circulation, occurring through an intracardiac shunt or intrapulmonary shunting. Patients presenting for liver transplantation often have intrapulmonary shunting due to pulmonary arterial vasodilation, even in the absence of hepatopulmonary syndrome. Here, we present a case of hemodynamic collapse believed to be caused by a PAE, which was diagnosed intraoperatively with transesophageal echocardiography (TEE). Case Report: A 60-year-old man who was diagnosed with non-alcoholic steatohepatitis cirrhosis presented for deceased donor orthotopic liver transplantation with utilization of normothermic machine perfusion. Following reperfusion of the liver allograft, TEE detected intrapulmonary shunting resulting in air within the left atrium, left ventricle, and ascending aorta. The patient developed severe biventricular dysfunction with ST-segment changes on electrocardiography monitoring and became acutely hypotensive with significant hepatic congestion 5 min after liver reperfusion. High doses of inotropic and vasopressor support were used as well as inhaled nitric oxide. The patient recovered after 30 min of medical management. The liver transplantation operation was successfully completed and the patient was discharged home on postoperative day 7. Conclusions: Intracardiac air at the time of reperfusion during liver transplantation can originate from the donor allograft and result in PAE in the setting of intrapulmonary shunting. PAE can result in intracoronary air and should be considered in cases of hemodynamic instability in liver transplantation, especially if air is seen within the left atrium, left ventricle, and ascending aorta.
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