Patients admitted in the intensive care unit after solid organ or bone marrow transplantation:Retrospective cohort study

BACKGROUND Solid organ transplantation(SOT)and hematopoietic stem cell transplantation(HSCT)revolutionized the survival and quality of life of patients with malignant diseases,various immunologic,and metabolic disorders or those associated with a significant impairment in a patient's quality of life.AIM To investigate admission causes and treatment outcomes of patients after SOT or HSCT treated in a medical intensive care unit(ICU).METHODS We conducted a single-center,retrospective epidemiological study in the medical ICU at the University Hospital Centre Zagreb,Croatia covering the period from January 1,2018 to December 31,2023.RESULTS The study included 91 patients with either SOT[28 patients(30.8%)]or HSCT[63 patients(69.2%)].The median age was 56(43.2-64.7)years,and 60.4%of the patients were male.Patients with SOT had more comorbidities than patients after HSCT[χ^(2)(5,n=141)=18.513,P<0.001].Sepsis and septic shock were the most frequent reasons for admission,followed by acute respiratory insufficiency in patients following HSCT.Survival rate significantly differed between SOT and HSCT[χ^(2)(1,n=91)=21.767,P<0.001].ICU survival was 57%in the SOT and 12.7%in the HSCT group.The need for mechanical ventilation[χ^(2)(1,n=91)=17.081,P<0.001]and vasopressor therapy[χ^(2)(1,n=91)=36.803,P<0.001]was associated with survival.The necessity for acute renal replacement therapy did not influence patients'survival[χ^(2)(1,n=91)=0.376,P=0.54].In the subgroup of patients with infection,90%had septic shock,and the majority had positive microbiological samples,mostly Gram-negative bacteria.The ICU survival of patients with sepsis/septic shock cumulatively was 15%.The survival of SOT patients with sepsis/shock was 45%.CONCLUSION Patients with SOT or HSCT are frequently admitted to the ICU due to sepsis and septic shock.Despite advancements in critical care,the mortality rate of patients with refractory septic shock and multiorgan failure in this patient population is extremely high.Early recognition and timely ICU admittance might improve the outcome of patients,especially after HSCT.

Delayed introduction of immunosuppressive regimens in critically ill patients after liver transplantation

BACKGROUND: The manipulation of immunosuppression therapy remains challenging in patients who develop infectious diseases or multiple organ dysfunction after liver transplantation. We evaluated the outcomes of delayed introduction of immunosuppression in the patients after liver transplantation under immune monitoring with ImmuKnow assay. METHODS: From March 2009 to February 2014, 225 consecutive liver recipients in our institute were included. The delayed administration of immunosuppressive regimens was attempted in 11 liver recipients with multiple severe comorbidities. RESULTS: The median duration of non-immunosuppression was 12 days (range 5-58). Due to the infectious complications, the serial ImmuKnow assay showed a significantly low ATP level of 64 +/- 35 ng/mL in the early period after transplantation. With the development of comorbidities, the ImmuKnow value significantly increased. However, the acute allograft rejection developed when a continuous distinct elevation of both ATP and glutamyltranspeptidase levels was detected. The average ATP level measured just before the development of acute rejection was 271 +/- 115 ng/mL. CONCLUSIONS: The delayed introduction of immunosuppressive regimens is safe and effective in management of critically ill patients after liver transplantation. The serial ImmuKnow assay could provide a reliable depiction of the dynamics of functional immunity throughout the clinical course of a given patient.

Intensive care unit-acquired weakness–preventive,and therapeutic aspects;future directions and special focus on lung transplantation

In this editorial,comments are made on an interesting article in the recent issue of the World Journal of Clinical Cases by Wang and Long.The authors describe the use of neural network model to identify risk factors for the development of intensive care unit(ICU)-acquired weakness.This condition has now become common with an increasing number of patients treated in ICUs and continues to be a source of morbidity and mortality.Despite identification of certain risk factors and corrective measures thereof,lacunae still exist in our understanding of this clinical entity.Numerous possible pathogenetic mechanisms at a molecular level have been described and these continue to be increasing.The amount of retrievable data for analysis from the ICU patients for study can be huge and enormous.Machine learning techniques to identify patterns in vast amounts of data are well known and may well provide pointers to bridge the knowledge gap in this condition.This editorial discusses the current knowledge of the condition including pathogenesis,diagnosis,risk factors,preventive measures,and therapy.Furthermore,it looks specifically at ICU acquired weakness in recipients of lung transplantation,because–unlike other solid organ transplants-muscular strength plays a vital role in the preservation and survival of the transplanted lung.Lungs differ from other solid organ transplants in that the proper function of the allograft is dependent on muscle function.Muscular weakness especially diaphragmatic weakness may lead to prolonged ventilation which has deleterious effects on the transplanted lung–ranging from ventilator associated pneumonia to bronchial anastomotic complications due to prolonged positive pressure on the anastomosis.

Intensive care management of liver transplanted patients

Advances in pre-transplant treatment of cirrhosis-related organ dysfunction,intraoperative patient management,and improvements in the treatment of rejection and infections have made human liver transplantation an effective and valuable option for patients with end stage liver disease.However,many important factors,related both to an increasing "marginality" of the implanted graft and unexpected perioperative complications still make immediate post-operative care challenging and the early outcome unpredictable.In recent years sicker patients with multiple comorbidities and organ dysfunction have been undergoing Liver transplantation;appropriate critical care management is required to support prompt graft recovery and prevent systemic complications.Early post-operative management is highly demanding as significant changes may occur in both the allograft and the "distant" organs.A functioning transplanted liver is almost always associated with organ system recovery,resulting in a new life for the patient.However,in the unfortunate event of graft dysfunction,the unavoidable development of multi-organ failure will require an enhanced level of critical care support and a prolonged ICU stay.Strict monitoring and sustainment of cardiorespiratory function,frequent assessment of graft performance,timely recognition of unexpected complications and the institution of prophylactic measures to prevent extrahepatic organ system dysfunction are mandatoryin the immediate post-operative period.A reduced rate of complications and satisfactory outcomes have been obtained from multidisciplinary,collaborative efforts,skillful vigilance,and a thorough knowledge of pathophysiologic characteristics of the transplanted liver.

Impact of COVID-19 pandemic on liver,liver diseases,and liver transplantation programs in intensive care units

Emerging worldwide data have been suggesting that coronavirus disease 2019(COVID-19)pandemic consequences are not limited to the respiratory and cardiovascular systems but encompass adverse gastrointestinal manifestations including acute liver injury as well.Severe cases of liver injury associated with higher fatality rates were observed in critically ill patients with COVID-19.Intensive care units(ICU)have been the center of disposition of severe cases of COVID-19.This review discusses the pathogenesis of acute liver injury in ICU patients with COVID-19,and analyzes its prevalence,consequences,possible drug-induced liver injury,and the impact of the pandemic on liver diseases and transplantation programs.

Liver transplantation is beneficial regardless of cirrhosis stage or acute-on-chronic liver failure grade:A single-center experience

BACKGROUND Liver transplantation for the most critically ill remains controversial;however,it is currently the only curative treatment option.AIM To assess immediate posttransplant outcomes and compare the short(1 year)and long-term(6 years)posttransplant survival among cirrhotic patients stratified by disease severity.METHODS We included cirrhotic patients undergoing liver transplantation between 2015 and 2019 and categorized them into compensated cirrhosis(CC),decompensated cirrhosis(DC),and acute-on-chronic liver failure(ACLF).ACLF was further divided into severity grades.Our primary outcomes of interest were total days of intensive care unit(ICU)and hospital stay,development of complications and posttransplant survival at 1 and 6 years.RESULTS 235 patients underwent liver transplantation(CC=11,DC=129 and ACLF=95).Patients with ACLF had a significantly longer hospital stay[8.0(6.0-13.0)vs CC,6.0(3.0-7.0),and DC 7.0(4.5-10.0);P=0.01]and developed more infection-related complications[47(49.5%),vs CC,1(9.1%)and DC,38(29.5%);P<0.01].Posttransplant survival at 1-and 6-years was similar among groups(P=0.60 and P=0.90,respectively).ACLF patients stratified according to ACLF grade[ACLF-1 n=40(42.1%),ACLF-2 n=33(34.7%)and ACLF-3 n=22(23.2%)],had similar ICU and hospital stay length(P=0.68,P=0.54),as well as comparable frequencies of overall and infectious posttransplant complications(P=0.58,P=0.80).There was no survival difference between ACLF grades at 1 year and 6 years(P=0.40 and P=0.15).CONCLUSION Patients may benefit from liver transplantation regardless of the cirrhosis stage.ACLF patients have a longer hospital stay and frequency of infectious complications;however,excellent,and comparable 1 and 6-year survival rates support their enlisting and transplantation including those with ACLF-3.

重症医学科特殊宿主——器官移植患者的医院感染预防

随着移植技术的普及,越来越多的终末期器官功能衰竭患者接受移植手术,此类患者大多需在重症医学科接受进一步监护治疗。由于器官移植患者存在免疫抑制,其发生医院感染的风险显著升高。因此,对于此类患者,需更严格地落实呼吸机相关性肺炎、导管相关血流感染、导管相关尿路感染、手术部位感染预防的集束化管理措施;同时,需要采用更严格的医院感染制度和人员管理策略。本文结合指南推荐意见及临床经验,围绕器官移植患者的医院感染预防展开论述,以期为重症医学科临床诊疗提供参考和借鉴。

自体肺移植术后继发支气管胸膜瘘患者的护理

总结1例自体肺移植术后继发支气管胸膜瘘患者的护理体会。针对患者自体肺移植术后极易出现支气管胸膜瘘严重并发症,缺乏循证护理方案等问题,术前开展支气管胸膜瘘高风险筛查并组建多学科小组;术后继发支气管胸膜瘘实施早期预警;制订目标性气道管理计划、精准控制血糖波动范围,建立以目标为导向的综合化营养管理等一系列围手术期护理;实施个性化心理支持与疏导。经过29 d积极治疗和护理,患者顺利出院。

体外膜肺氧合混合转流模式在肺移植患者中的应用

总结6例肺移植患者行体外膜肺氧合混合转流模式的护理经验。针对该组肺移植患者体外膜肺氧合混合模式转流过程复杂、管理难度大、安全隐患多的问题,采取如下护理措施:建立体外膜肺氧合流转专项工作机制,医护高效配合;精准化流量调节确保有效心肺支持;清晰标识管路管理确保患者安全;多模式监测神经系统症状;密切监测并发症发生。经过精细化护理,6例患者在ECMO转流期间均未出现相关并发症,顺利撤机。

新型冠状病毒感染后肺纤维化患者肺移植术后并发病毒性脑病的护理

总结1例新型冠状病毒感染后肺纤维化患者双肺移植术后并发病毒性脑病的护理体会。针对患者病情复杂、脑病症状突出和出血风险高等问题,采取肺移植术后病毒性脑病的早期预警,被动-主动渐进康复训练,以血小板计数为导向的抗凝管理,免疫抑制药物动态管理,听觉言语反馈认知训练等措施。经过58 d的救治和护理,患者病情稳定出院,出院后随访2个月,状况良好。

1例儿童心脏移植术后快速康复的护理实践

总结1例儿童心脏移植术后快速康复的护理实践经验。护理要点包括早期识别与处理大供心综合征、右心衰竭并发症;优化呼吸支持策略,帮助患儿快速脱机;开展静息能量消耗测定,实施序贯式营养支持;强化Ⅰ期心脏康复训练,促进患儿心功能恢复;实施个体化的出院指导,加强出院后随访。经过49 d的康复治疗与护理,患儿心功能恢复至Ⅱ级,无严重并发症,顺利出院,随访3个月恢复良好。术后快速康复管理策略能有效缩短心脏移植患儿住院时间,恢复正常生活。

肺移植术后原发性移植物失功患者行体外膜肺氧合支持下俯卧位通气的护理

总结8例肺移植术后重度原发性移植物失功患者行体外膜肺氧合支持下俯卧位通气治疗的护理经验。针对该组患者液体控制、气道维护、俯卧位通气、肺康复等问题,采取精准化液体管理、加强肺水肿期间气道管理、基于患者安全的综合措施、早期肺康复训练等护理措施。7例患者顺利转入移植病房,1例因多脏器功能衰竭死亡。

肝移植术后腹压监测的临床研究

目的 研究腹压（intraabdominal pressure，IAP）增高对肝移植术后患者尿量、平均动脉压（MAP）和中心静脉压（CVP）的影响。方法 对105例肝移植患者进行腹压监测；根据腹压情况将患者分为两组：腹压正常组53例（IAP〈20cm H2O，1cmH2O=0．098kPa）和腹压异常组52例（≥20cmH2O），其中又将腹压异常组分为20～〈30cmH2O（42例）、30～〈40cmH2O（4例）、≥40cmH2O（6例）3个亚组。患者入ICU后即测量基础腹腔压力，平均每8～12h测量1次，当腹压≥20cmH2O时每4h监测1次。结果 正常腹压组患者的MAP、CVP、尿量与腹压改变无相关性（P〉0．05）；异常腹压组患者的尿量与腹压呈显著负相关（P〈0．05），同时MAP、CVP上升；当腹压升至30～40cmH2O且尿量减少时，MAP、CVP也下降（P〈0．01）。结论 正常腹压不影响肝移植患者尿量和循环稳定性；腹压增高导致少尿，而且腹压增高患者的CVP、MAP呈现双相变化。

器官移植受者新型冠状病毒肺炎的临床特点和疫情期间的管理策略(第1版)

2019年12月,我国湖北省武汉市多家医院陆续发现多例不明原因肺炎病例,病原体为一种新型冠状病毒(新冠病毒),可导致新型冠状病毒肺炎(新冠肺炎),严重者可危及生命。随后新冠肺炎疫情迅速在我国多省市蔓延。总结分析实体器官移植(SOT)受者新冠肺炎的临床特点,优化对其的预防、早期诊断和治疗策略尤为重要。为此,我们组织国内移植专家针对SOT受者肺部感染的特点并结合目前新冠肺炎的特点,参考国内外相关指南和规范撰写本文,供我国移植科医师借鉴。本管理策略会随着人类对于新冠病毒感染认识的不断深入,随时进行修订。

重危患者同种异体肾移植麻醉处理

[目的]探讨重危患者同种异体肾移植麻醉处理。[方法]回顾性分析了1995年1月～2005年12月重危患者12例的临床资料。[结果]在12例重危患者中经抢救及麻醉处理得当,10例安全度过围手术期,1例术后5d死亡,1例因严重的排斥反应放弃手术。[结论]正确及时的麻醉处理是重危患者同种异体肾移植手术成功的关键。

肝移植术后急性呼吸窘迫综合征患者俯卧位通气的护理

总结1例劈离式肝移植重症患者术后并发呼吸窘迫综合征行个体化俯卧位通气的护理体会。护理要点:针对该案例术后肝断面易出血,俯卧位腹部受压风险大,在充分评估、有效固定患者腹部伤口的情况下实施个体化俯卧位通气方案;持续动态监测腹内压;以腹内压为导向进行体位管理及肠内营养策略调整;加强俯卧位期间腹腔引流管的观察与护理。患者术后5d内共实施4次俯卧位通气治疗,治疗后患者肺功能明显好转,无肝脏出血、移位等不良事件发生。术后第5天顺利拔除气管插管,术后第39天康复出院。

儿童脑型肾上腺脑白质营养不良行造血干细胞移植的护理

总结2例儿童脑型肾上腺脑白质营养不良行造血干细胞移植的护理体会。针对患儿进行性运动及吞咽功能退化,移植后容易出现营养不良,予建立多学科诊疗团队,及早开展营养风险筛查及评估;严密观察病情变化,及早发现肠移植物抗宿主病、迟发型出血性膀胱炎等并发症;给予患儿及家长心理支持,缓解焦虑情绪;制订个性化康复锻炼及多学科联合随访计划,促进疾病早日康复。经过精心治疗及护理,2例患儿移植后骨髓功能正常,病情稳定出院。

重度肺动脉高压合并严重心力衰竭患者行肺移植的术后护理

总结1例重度肺动脉高压合并严重心力衰竭患者行肺移植的术后护理体会。护理要点:肺移植术后左心室功能障碍早期预警;术后静脉-动脉体外膜肺氧合监测和撤机管理;分阶段呼吸管理和个体化运动康复方案实施,促进心肺康复;同时做好多模式超前镇痛管理。经过多学科联合诊治及精心护理,患者于术后第29天康复出院。随访半年,患者状况良好。

胆管癌患者行离体肝切除联合自体肝移植的围手术期护理

总结1例胆管癌患者行离体肝切除联合自体肝移植围手术期的护理体会。护理要点:术后1周目标导向精准静脉抗凝护理;利用劳尔比色卡动态观察引流液,主动预防和识别前哨出血;控制腹内压、做好术后24 h内液体管理,保证肝脏有效灌注,降低肝脏缺血和再灌注损伤;围手术期充分观察和预防小肝综合征发生;关注术后胃肠道功能恢复,实施分阶段营养方案。经过精心护理,患者术后第45天康复出院。

肾移植术后人微小病毒B19感染患者的护理

总结37例肾移植术后人微小病毒B19(human parvovirus B19,HPV-B19)感染患者的护理经验。针对肾移植术后HPV-B19感染患者在抗病毒治疗期间易发生排斥反应、感染及药物不良反应的问题,采取对于排斥反应和感染早期症状的观察、指导患者规范服用免疫抑制药物、落实预防感染的各项措施和健康指导;在静脉注射免疫球蛋白期间监测药物不良反应,并建立病区HPV-B19管理制度,预防抗病毒治疗相关并发症的发生。37例患者经过综合治疗和护理均好转出院,4例患者出院后因HPV-B19感染复发再次入院,经住院治疗后康复出院。