肺移植围术期的并发症处理(附18例报告)

Perioperative care in lung transplantation: report of 18 cases

目的观察肺移植围术期患者重症监护室(ICU)监测与治疗手段对并发症的影响。方法于2002年9月—2005年4月,江苏省无锡市第五人民医院有18例肺移植患者,其中肺气肿9例,肺纤维化5例,矽肺、支气管扩张、肺血管平滑肌瘤病及室间隔缺损(室缺)合并艾森曼格综合征患者各1例。手术方式:左肺移植9例,右肺移植5例,室缺修补加右肺移植1例,双肺移植3例。术后带管进入ICU行机械通气、免疫抑制治疗,并预防感染和再灌注损伤等并发症的出现。术前常规心脏超声监测肺动脉收缩压并通过动脉血气分析监测动脉血二氧化碳分压(PaCO2),计算氧合指数(动脉血氧分压/吸入氧浓度,PaO2/FiO2)。结果术后机械通气平均脱机时间(7.39±4.89)d,平均ICU停留时间为(9.72±8.32)d。术后1周通过SwanGanz导管测得患者的肺动脉收缩压较术前有明显下降(48.94±14.45)mmHg比(39.59±7.45)mmHg,1mmHg=0.133kPa,P<0.05;PaO2/FiO2明显改善(263.89±82.09)mmHg比(345.56±92.18)mmHg,P<0.05;PaCO2明显下降(63.29±22.56)mmHg比(38.37±9.19)mmHg,P均<0.05。术后短期内有3例患者死亡,其中1例于术后15d死于急性排斥,1例于术后28d死于真菌感染,1例术后36d死于肺梗死。15例恢复良好出院,最长生存达32个月。结论肺移植是治疗终末期肺病患者的最佳选择,而肺移植术后围术期并发症的处理是肺移植手术成功和长期生存的关键。

Objective To evaluate monitoring and cares in the intensive care unit （ICU） after lung transplantation. Methods From September 2002 to April 2005, there were 18 cases of lung transplant recipients, who had suffered from emphysema （9 cases）, pulmonary fibrosis （5 cases）, pneumosilicosis （1 cases）, bronchiectasis （1 case）, pulmonary vascular leiomyoma （1 case）, ventricular septal defect and Eisenmenger＇s syndrome （1 case）, respectively. Operative procedures included 9 cases with left-lung transplantation, 5 right-lung transplantation, 1 case right single lung transplantation and ventricular septal defect repair, and 3 cases bilateral lung transplantations. All the patients received mechanical ventilation, immunosuppressive agents, antibacterial prophylaxis, and prevention of reperfusion injury in the ICU after operation. Preoperatively, echocardiography （ECHO）, artery blood gas, and oxygenation index （partial pressure of oxygen in artery/fraction of inspired oxygen, PaO2/FiO2） were observed. Results The average weaning time from the ventilator was （7.39±4.89） days. The average ICU stay time was （9.72±8.32） days. The systolic pulmonary artery pressure （Ppa, syst） was monitored with Swan -Ganz catheterization 1 week postransplant, and it was found to have decreased significantly from （48.94 ± 14.45） mmHg （1 mm Hg=0.133 kPa） to （39.59±7.45） mm Hg （P〈0.05）. At the same time, oxygenation index was improved from （263. 894±82.09） mm Hg to （345. 564±92.18） mm Hg （P〈0.05）, partial pressure of carbon dioxide in artery （PaCO2） was decreased from （63. 294±22.56） mm Hg to （38. 374±9.19） mm Hg （P〈0.05）. In-hospital mortality （HM） was 16.7% （3/18 cases）, and an early death was due to severe infection on the 30 th postoperative day in 1 patient and acute rejection on the 15 th postoperative day in another patient, and the other patient died due to pulmonary vein embolism on the 36 th day. Fifteen patients recovered quickly and discharged from the hospital. One patient was followed up for 32 months. Conclusion Lung transplantation remains the only hope for many patients with end-stage pulmonary disease. It is important that the lung transplant team possesses a working knowledge of the treatment of common complications, the time of these complications mostly likely to occur and how best to treat them when they do arise, to ensure long-term survival and success.