捆绑式诊治方案在肾移植术后巨细胞病毒性肺炎并发急性呼吸窘迫综合征中的作用

Clinical effect of the binding diagnosis and therapy for renal transplantation recipients with cyto- megaloviral pneumonia followed by acute respiratory distress syndrome

目的探讨捆绑式诊治方案在肾移植术后巨细胞病毒（CMV）性肺炎并发急性呼吸窘迫综合征（ARDS）中的作用。方法将ICU收治的43例CMV肺炎并发ARDS的患者分为非捆绑式诊治方案组（A组）和捆绑式诊治方案组（B组）。捆绑式诊治方案包括：①肾移植受者因肺部感染出现ARDS后，早期经气管插管行机械通气治疗；②早期经气管插管行诊断性支气管肺泡灌洗；③被确诊为CMV肺炎后，在抗CMV治疗的同时给予规范化的糖皮质激素治疗。比较两组患者入ICU当天和气管插管当天的最低PaO2／FiO2、APACHEⅡ评分以及入ICU后的CMV肺炎确诊时间、确诊为CMV肺炎后的ICU累积糖皮质激素使用剂量和ICU死亡率。结果A组和B组ICU死亡率分别为68．4％（13／19）、37．5％（9／24），B组ICU死亡率显著低于A组（P〈0．05）；两组患者入ICU当天的最低PaO2／FiO2及APACHEII评分比较差异无统计学意义（均P〉0．05）；B组气管插管当天的最低PaO2／FiO2显著高于A组（P〈0．05），APACHEⅡ评分显著低于A组（P〈0．01）；B组入ICU后的CMV肺炎确诊时间显著早于A组（P〈0．01），累积糖皮质激素使用剂量显著高于A组（P〈0．01）。结论采用捆绑式诊治方案有利于肾移植术后CMV肺炎并发ARDS患者的早期诊治，并显著降低了其在ICU的死亡率。

Objective To investigate the curative effect of the binding diagnosis and therapy for renal transplantation recipients with cytomegaloviral （ CMV） pneumonia followed by acute respiratory distress syndrome （ARDS）. Method 43 cases with CMV pneumonia followed by ARDS in ICU were divided into group A and group B, the patients in group B were treated with the binding diagnosis and therapy but not in group A. This binding method included the following measures： ①eady mechanical ventilation were made by tracheal intubation, when the patients had ARDS caused by pulmonary infection in the renal transplantation recipients, ②diagnostic bronchoalveolar lavage by tracheal intubation was carried out as soon as possible, ③once the patients were definitely diagnosed as CMV pneumonia, standardized doses of glucoeorticoid was given. The minimum PaO2/FiO2 , APACHE Ⅱ score, the time from the ICU - admitted day to the CMV pneumonia - diagnosed day, cumulative doses of glucocorticoid after CMV pneumonia was difinitely diagnosed during ICU and ICU mortality were compared between group A and group B. Results ICU mortality in group A and group B was respectively 13/19 （ 68.4% ） and 9/24 （37.5%） , ICU mortality was significantly lower in group B than in group A （P 〈 0.05）. The minimum PaO2/FiO2 and APACHE Ⅱ score were not significantly different on the ICU - admitted day between two groups （P 〉0. 05）. On the day of tracheal intubation, the minimum PaOE/FiO2 was significantly higher （ P 〈 0.05 ） and APACHE Ⅱ score was significantly lower （ P 〈 0. 01 ） in group B than in group A. The time of CMV pneumonia definitely diagnosed during ICU was significantly earlier in the group B than in the group A （ P 〈 0. 01 ）. Cumulative doses of glucocorticoid was significantly higher in the group B than in the group A. Conclusions Application of the binding diagnosis and therapy reduced significantly the ICU mortality of renal transplantation recipients with CMV pneumonia caused by ARDS.