肺移植术后原发性移植物功能丧失的预防和治疗

Prevention and treatment of primary graft dysfunction after lung transplantation （108 cases report）

目的探讨肺移植术后原发性移植物功能丧失（PGD）的预防和治疗。方法回顾性分析2002年9月至2（111年6月间108例肺移植的临床资料。术后监测所有受者的血液气体分析及胸部X线表现，连续监测有创动脉压、肺动脉压和（或）中心静脉压。术后3d保持受者液体负平衡，根据动脉血氧分压（PaO2）和（或）血氧饱和度控制吸入氧浓度（FiO2），根据血液气体分析结果及生命体征调节呼吸机通气参数，以预防PGD的发生。术后早期一旦出现PaO2／FiO2急剧下降（低于200），且胸部X线片显示移植肺中下肺野密度增高，在排除超急性排斥反应、静脉吻合口梗阻、心源性肺水肿及肺部感染后，根据国际心肺移植协会制定的标准将PGD分级为3级的患者明确诊断为PGD。对于PGD级别的不同，分别给予受者加强通气支持、液体负平衡、延长呼吸机治疗时间、使用肺血管扩张药如前列地尔及使用ECMO等治疗措施。结果术后共有10例受者发生PGD，发生率为9．3％（10／108）。10例患者中，6例常规使用呼吸机支持治疗，持续时间为（285．8±238．6）h，其中2例逆转，4例死于PGD后呼吸衰竭；4例使用了体外膜肺氧合（ECMO）辅助治疗，其中2例在发生PGD后24h内应用了ECMO，成功逆转后长期存活，另2例由于应用时间较晚（24h后），病情恶化，分别在应用ECMO后第8和第11天死于PGD导致的急性肾功能衰竭和多器官功能衰竭。结论肺移植后PGD的发生率高，应在围手术期加强管理，进行积极预防；一旦受者发生PGD，应尽快给予相应治疗，如达到使用ECMO的指征，应尽早使用。

Objective To evaluate the prevention and treatment of primary graft dysfunction （PGD） after lung transplantation （LTx）. Methods We retrospectively analyzed clinical data of 108 cases of lung transplantation from September 2002 to June 2011. All the recipients were given continuous monitoring of invasive arterial pressure, pulmonary artery pressure and （or） central venous pressure and artery blood gas analysis and chest X-ray examination postoperatively. The negative fluid balance of the recipients in the first 3 days was maintained. The inspired oxygen （FiO2） or ventilator parameters was adjusted according to the arterial oxygen tension （PaO2） and （or） oxygen saturation, to prevent the occurrence of PGD. Once PaO2/FiO2 sharp decline （less than 200）, and chest X-ray showed higher density of the lower transplanted lung fields in the early postoperative period, PGD could be diagnosed when acute rejection, venous anastomotic obstruction, cardiogenic pulmonary edema and pulmonary infections were excluded. According to the standards set by the International Association of Heart and Lung Transplantation, PGD is divided as 0, 1, 2 and 3. Different levels of PGD were treated by ventilatory support, negative fluid balance, extending the treatment time of the ventilator, the use of pulmonary vasodilators, such as prostaglandin E1 and the use of ECMO. Results PGD occurred in 11） cases, and the incidence rate was 9. 3%. 6 cases were given conventional ventilatory support for （285.8 ± 238.6） h （Two cases obtained reversal of PGD, and four cases died） ; the rest four cases were given ECMO （Two cases were supported by ECMO in 24 h after the occurrence of PGD and had a long-term survival after a successful reversal of PGD, and the rest two cases died from acute renal failure and multiple organ failure induced by PGD on the 8th and 11 th day of the application of ECMO due to the late application of ECMO （after 24 h）. Conclusion The high incidence of PGD causes high mortality perioperatively after lung transplantation. Preventing PGD can improve the survival rate of the lung transplant patients. Once PGD happens, appropriate treatment should be given as soon as possible.