肝移植术后急性肺损伤的治疗策略

The treatment strategy of early ALI after liver transplantation

目的探讨肝移植术后急性肺损伤(ALI)的治疗方法和策略。方法肝移植术后合并ALI患者18例,于术后早期给予预防感染、限液、减少炎症反应的措施,并积极纠正低氧血症。于出现低氧血症3 h内经提高吸氧浓度不能纠正低氧者,给予肺复张结合肺保护通气策略,即给予吸气压力25 cm H2O呼气未正压(及PEEP)17 cm H2O通气2 min,扩张已萎陷实变的肺泡,随后逐步降低PEEP至压力-容积曲线低位转折点(Pinf)以上2 cm H2O处,预防肺泡闭塞,保持肺泡复张。结果18例患者经综合治疗及肺复张后氧分压、氧饱和度及吸氧分数均有明显改善,除1例肺部严重感染患者肺复张后吸氧分数仅上升40％,余17例均对肺复张反应良好,吸氧分数上升>50％。复张后平均氧分压上升68 mm Hg,平均氧饱和度上升9．5％,平均吸氧分数上升104．7％,改善的氧合可维持2 -24 h。肺复张结合肺保护通气策略纠正低氧血症的有效率为94．4％,18例ALI患者均成功脱机拔管,康复出院。患者对肺复张的耐受性佳,无明显并发症。结论肝移植术后ALI需及时诊断和综合治疗,肺复张结合肺保护通气策略是治疗肝移植术后ALI或ARDS的安全有效措施。

Objective To investigate the treatment strategy of early acute lung injury（ALI） after liver transplantation. Methods 18 patients complicated with ALI after liver transplantation were given comprehensive therapies and two minutes of recruitment maneuver （RM） to open previously collapsed lung units and then lung protective ventilatory strategy within 3 hours of hypoxemia. The inspiratory pressure was 25 cm H2O and PEEP 17 cm H2O. Optimal PEEP were matained after RM to stabilize lung volume. Results The PaO2, SaO2 and PaO2/FiO2 of all 18 patients were improved greatly. RM was effective in 17 patients except one case of severe pulmonary infection, whose PaOJFiO2 was only improved by 40%. PaO2, SaO2 and PaO2/FiO2 were increased by 68 mm Hg, 9. 5%, and 104. 7% respectively. And the improved oxygenation can be maintained 2- 24 hours. The effective rate of RM was 94. 4%. All 18 patients were weaned and extubated successfully with the survival rate of 100%. RM was well tolerated without complications. Conclusion ALI post liver transplantation should be diagnosed and treated in early stage. RM combined with lung protective ventilatory strategy is a safe and effective treatment for early ALI after liver transplantation.