肝移植术后膈肌麻痹的监测与处理

Paralysis of the right hemidiaphragm after liver transplantation： diagnosis and management

目的总结肝移植术后膈肌麻痹致严重肺部并发症的监测与处理经验。方法回顾性分析中山大学附属孙逸仙纪念医院2001年2月至2007年3月60例成人肝移植患者资料，探讨术后右侧膈肌麻痹所致严重呼吸道并发症的病理生理变化、临床过程及处理对策。结果在60例肝移植患者中，有40例术后发生呼吸系统并发症，其中5例为膈肌麻痹所致。5例术后均因严重的膈肌麻痹导致反常呼吸，呼吸机支持时间延长，4例患者实施了气管切开。呼吸机支持期间同时合并发生细菌性肺炎和真菌性肺炎5例、肺不张4例、急性呼吸窘迫综合征4例、肝肺综合征4例、肺间质水肿3例。除1例于术后第31天死于急性呼吸窘迫综合征和多器官衰竭外，其余4例均治愈出院。结论严密监测呼吸功能及正确使用呼吸机等综合治疗是肝移植术后的重要环节。如果怀疑膈神经功能不全，应延长呼吸机支持时间并早期果断实施气管切开。

Objective To review our experience in the diagnosis and management of paralysis of the right hemidiaphragm after liver transplantation. Methods 60 adult patients received liver transplantation from February 2001 to March 2007 in Sun Yat-sen Memorial Hospital were retrospectively analyzed. The pathophysiologic changes, clinical progress, and management of serious respiratory complications caused by post-transplant paralysis of the right hemidiaphragm were studied. Results Among 60 patients, 40 developed postoperative respiratory complications, and 5 were due to paralysis of the right hemidiaphragm. The 5 patients presented with paradoxical respiration and the ventilator supporting times were 14, 16, 34, 45, and 60 days, respectively. Tracheostomy was performed in 4. These patients developed pneumonia in 5, atelectasis in 4, acute respiratory distress syndrome （ARDS） in 4, hepatopulmonary syndrome in 4, and pulmonay interstitial edema in 3. Among the 5 patients, 4 patients survived and 1 patient died of ARDS and multiple organs failure 31 days after the transplantation. Conclusions After liver transplantation, strict monitoring of the respiratory function and timely use of a respirator for patients with the paralysis of the hemidiaphragm is very important. For patients with suspicious hemidiaphragm paralysis, tracheostomy should be decisively performed.