肝移植术后急性肺损伤特点

Characteristics of acute lung injury after liver transplantation

目的：观察分析肝移植术后急性肺损伤发生原因及处理措施。方法：选择2000-02/2005-05在解放军总医院第二附属医院接受原位肝移植患者130例,均签署手术知情同意书。术毕给予呼吸机控制呼吸,自主呼吸恢复后给予呼吸机辅助呼吸,平均6.8h脱呼吸机,之后双鼻导管吸氧3-10L。定时测定血气分析、肝功能、肾功能、血常规、凝血4项、血乳酸、血氨、电解质及血糖,每日做痰、胆汁、腹腔引流液培养。防治细菌感染,预防真菌及病毒感染。进行抗排斥反应、保肝、营养代谢支持、利尿与扩血管等综合治疗。结果：①肝移植受者130例术后48h内死亡3例,术后3-10d内死亡9例均并发肺部感染,存活病例发生肺部感染28例。存活118例发生急性肺损伤87例（占73.7%）,经治疗后各脏器均恢复正常。②患者发生急性肺损伤时间多为术后两三天,其中29例发生急性呼吸窘迫综合征,大部分经加大吸氧浓度或面罩吸氧,增加氧气雾化吸入次数等综合救治措施均恢复。③术中出血量为2000-8000mL者共76例,发生急性肺损伤69例;术中出血量〉8000mL者18例,术后均出现急性肺损伤。急性肺损伤与术后出量（尿量、T管、腹腔引流）关系比较大。④原发病为肝炎肝硬化肝功能失代偿患者急性肺损伤的发病率最高,显著高于原发病为慢性肝炎肝硬化肝癌患者（85%,39%,P〈0.05）。结论：肝移植术后急性肺损伤发生与原发疾病、手术损伤、术中血流动力学不稳定、术后出量有一定关系。临床除氧疗外,应做好全身综合治疗。

AIM： To analyze causative factors and treatment of acute lung injury after the liver transplantation. METHODS： A total of 130 cases of orthotopic liver transplantation were selected from Second Affiliated Hospital, General Hospital of Chinese PLA from February 2000 to May 2005. They all signed the informed consent. After operation, the control-mode ventilation was used, and assisted-mode ventilation was used after the resume of spontaneously breathing. Oxygen inhalation （3-10 L） by nasal catheter was performed after weaning （averagely 6.8 hours）. Blood gas analysis, liver and kidney function, blood routine examination, blood coagulation function, blood lactic acid, blood ammonia, electrolyte, blood sugar were detected regularly, and sputum, bile and abdominal cavity drain were cultured daily. Composite treatment after operation included the prevention and treatment of infection of bacterium, fungus and virus, the immunosuppression management, liver protecting, nutritional support, diuresis and vasodilation were also included. RESULTS：①Among the 130 cases, 3 patients were dead within 48 hours after operation. Totally 37 cases supervened pneumonia, 9 of them ware dead after 3-10 days after operation. Among the survived 118 cases, there were 87 cases of acute lung injury （73.7%）. After treatment every organ recovered to normal.②Most acute lung injury occurred 2-3 days after operation, and 29 of them supervened acute respiratory distress syndrome （ARDS）. Most of them recovered by increasing oxygen concentration or facemask absorbing oxygen, increasing oxygen atomization inhalation and so on.③Totally 69 of 76 patients （blood loss 2 000-8 000 mL） and 18 of 18 patients （blood loss 〉 8 000 mL） respectively supervened acute lung injury. Acute lung injury was highly correlated with the blood loss （urine volume, T tube, abdominal drainage） after operation. ④Incidence rate of acute lung injury was the highest in patients with primary diseases of hepatitis, hepatic cirrhosis and decompensation of hepatic function, which was significantly higher than those of patients with primary diseases of chronic hepatitis, hepatic cirrhosis and liver cancer （85%, 39%, P 〈 0.05）. CONCLUSION： The occurrence of acute lung injury is related to the primary disease, operative trauma, instability of the hemodynamics, and the quantity of blood loss after liver transplantation. Systemic treatment is necessary for the patients with acute lung injury besides the oxygen therapy.