肺移植围手术期治疗经验总结:附7例报告
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摘要
目的总结肺移植治疗终末期肺病的围手术期治疗经验。方法回顾性分析7例肺移植受体的围手术期临床资料,其中行双肺移植3例,单肺移植4例。观察肺移植受体的围手术期情况以及预后情况。结果 7例受体肺移植手术时间为(344±133)min。4例单肺移植的冷缺血时间为(236±74)min,3例双肺移植的两侧冷缺血时间为(480±120)min。重症监护室(ICU)停留时间为21(13～25)d,住院时间为101(64～117)d。术后前3 d中每日的出量均大于入量,差异均有统计学意义(均为P<0.05)。肺移植受体术后前3 d动脉血氧分压(PaO2)明显高于术前,差异均有统计学意义(均为P<0.05),而动脉二氧化碳分压(PaCO2)未见明显变化,差异均无统计学意义(均为P>0.05)。肺移植受体术后均出现肺部细菌感染,其中3例合并真菌感染;1例受体术后因胸腔活动性出血行剖胸探查止血术,1例受体术后出现原发性移植物失功(PGD),4例受体行二次气管插管。术后死亡2例,其中1例死于多重耐药鲍曼不动杆菌败血症;1例死于自行停用免疫抑制剂后的排斥反应;其余5例均顺利出院且恢复良好,最长生存期为3.1年。结论肺移植围手术期管理中,手术适应证的把握、术后精细化液体和血流动力学的监测与管理、肺保护性通气策略的实施、术后严重并发症的早期诊断及治疗,对肺移植受体安全渡过围手术期具有重要意义。
Objective To summarize the experience of perioperative treatment of lung transplantation for end-stage lung disease. Methods Perioperative clinical data of 7 recipients undergoing lung transplantation were retrospectively analyzed, including 3 cases with bilateral lung transplantation and 4 cases with unilateral lung transplantation. The perioperative status and clinical prognosis of lung transplantation recipients were observed. Results The operation time of 7 lung transplantation recipients was(344±133) min. Cold ischemia time was( 236±74) min in 4 cases of single-lung transplantation and(480±120) min in 3 cases of bilateral-lung transplantation. The length of Intensive care unit(ICU) stay was 21(13-25) d and the length of hospital stay was 101(64-117) d. In the first 3 d after surgery, the daily fluid output was significantly larger than the fluid input(all P<0.05). The arterial oxygen partial pressure(PaO_2) of lung transplantation recipients in the first 3 d after surgery was significantly elevated than preoperative level(all P<0.05), whereas the arterial carbon dioxide pressure(PaCO2) did not significantly change(all P>0.05). All recipients had pulmonary bacterial infection after lung transplantation, including 3 cases complicated with fungal infection. One recipient underwent exploratory thoracotomy for hemostasis due to active thoracic bleeding after operation, 1 recipient suffered from primary graft dysfunction(PGD) and 4 recipients received secondary endotracheal intubation. Two cases died after operation, 1 case died of septicemia caused by multidrug-resistant acinetobacter baumannii, the other case died of rejection reaction after self-terminating use of immunosuppressive agents. The remaining 5 cases were successfully discharged and recovered well. The longest survival period was 3.1 years. Conclusions In the perioperative management of lung transplantation, it has great significance to hold the surgical indications, monitor and manage postoperative refined fluid and hemodynamics, implement the strategy of protective pulmonary ventilation, and early diagnose and treat severe postoperative complications for the recipients of lung transplantation to safety through the perioperative period.
Objective To summarize the experience of perioperative treatment of lung transplantation for end-stage lung disease. Methods Perioperative clinical data of 7 recipients undergoing lung transplantation were retrospectively analyzed, including 3 cases with bilateral lung transplantation and 4 cases with unilateral lung transplantation. The perioperative status and clinical prognosis of lung transplantation recipients were observed. Results The operation time of 7 lung transplantation recipients was(344±133) min. Cold ischemia time was( 236±74) min in 4 cases of single-lung transplantation and(480±120) min in 3 cases of bilateral-lung transplantation. The length of Intensive care unit(ICU) stay was 21(13-25) d and the length of hospital stay was 101(64-117) d. In the first 3 d after surgery, the daily fluid output was significantly larger than the fluid input(all P<0.05). The arterial oxygen partial pressure(PaO_2) of lung transplantation recipients in the first 3 d after surgery was significantly elevated than preoperative level(all P<0.05), whereas the arterial carbon dioxide pressure(PaCO2) did not significantly change(all P>0.05). All recipients had pulmonary bacterial infection after lung transplantation, including 3 cases complicated with fungal infection. One recipient underwent exploratory thoracotomy for hemostasis due to active thoracic bleeding after operation, 1 recipient suffered from primary graft dysfunction(PGD) and 4 recipients received secondary endotracheal intubation. Two cases died after operation, 1 case died of septicemia caused by multidrug-resistant acinetobacter baumannii, the other case died of rejection reaction after self-terminating use of immunosuppressive agents. The remaining 5 cases were successfully discharged and recovered well. The longest survival period was 3.1 years. Conclusions In the perioperative management of lung transplantation, it has great significance to hold the surgical indications, monitor and manage postoperative refined fluid and hemodynamics, implement the strategy of protective pulmonary ventilation, and early diagnose and treat severe postoperative complications for the recipients of lung transplantation to safety through the perioperative period.
引文
[1]LEAL S,SACANELL J,RIERA J,et al.Early postoperative management of lung transplantation[J].Minerva Anestesiol,2014,80(11):1234-1245.
[2]叶书高,李慧星,刘峰,等.合并肺段挫伤供肺肺移植的临床疗效分析[J].器官移植,2018,9(1):58-62.DOI:10.3969/j.issn.1674-7445.2018.01.008.YE SG,LI HX,LIU F,et al.Clinical analysis of lung transplantation from donors combined with pulmonary contusion[J].Organ Transplant,2018,9(1):58-62.DOI:10.3969/j.issn.1674-7445.2018.01.008.
[3]SHAH RJ,DIAMOND JM.Primary graft dysfunction(PGD)following lung transplantation[J].Semin Respir Crit Care Med,2018,39(2):148-154.DOI:10.1055/s-0037-1615797.
[4]KING CS,VALENTINE V,CATTAMANCHI A,et al.Early postoperative management after lung transplantation:results of an international survey[J].Clin Transplant,2017,31(7).DOI:10.1111/ctr.12985.
[5]ALTUN GT,ARSLANTA?MK,CINEL?.Primary graft dysfunction after lung transplantation[J].Turk J Anaesthesiol Reanim,2015,43(6):418-423.DOI:10.5152/TJAR.2015.16443.
[6]BALSARA KR,KRUPNICK AS,BELL JM,et al.A singlecenter experience of 1500 lung transplant patients[J].JThorac Cardiovasc Surg,2018,156(2):894-905.DOI:10.1016/j.jtcvs.2018.03.112.
[7]POZZI M,BOTTIN C,ARMOIRY X,et al.Extracorporeal life support for primary graft dysfunction after heart transplantation[J].Interact Cardiovasc Thorac Surg,2018,27(5):778-784.DOI:10.1093/icvts/ivy157.
[8]NICOARA A,RUFFIN D,COOTER M,et al.Primary graft dysfunction after heart transplantation:incidence,trends,and associated risk factors[J].Am J Transplant,2018,18(6):1461-1470.DOI:10.1111/ajt.14588.
[9]COSTA J,SHAH L,ROBBINS H,et al.Use of lung allografts from donation after cardiac death donors:a singlecenter experience[J].Ann Thorac Surg,2018,105(1):271-278.DOI:10.1016/j.athoracsur.2017.07.023.
[10]BETIT P.Technical advances in the field of ECMO[J].Respir Care,2018,63(9):1162-1173.DOI:10.4187/respcare.06320.
[11]AGUILAR PR,BEMISS BC,WITT C,et al.Impact of delayed chest closure on surgical site infection after lung transplantation[J].Ann Thorac Surg,2017,104(4):1208-1214.DOI:10.1016/j.athoracsur.2017.05.023.
[12]SUBERVIOLA B,RELLAN L,RIERA J,et al.Role of biomarkers in early infectious complications after lung transplantation[J].PLoS One,2017,12(7):e0180202.DOI:10.1371/journal.pone.0180202.
[13]MATHAI SC,DANOFF SK.Management of interstitial lung disease associated with connective tissue disease[J].BMJ,2016,352:h6819.DOI:10.1136/bmj.h6819.
[14]徐鑫,彭桂林,韦兵,等.20例肺移植的早期临床经验总结[J].中华器官移植杂志,2017,38(8):455-458.DOI:10.3760/cma.j.issn.0254-1785.2017.08.002.XU X,PENG GL,WEI B,et al.Early experience of lung transplantation using graft lungs from donation after citizens death[J].Chin J Organ Transplant,2017,38(8):455-458.DOI:10.3760/cma.j.issn.0254-1785.2017.08.002.
[15]KIM J,KIM YW,LEE SM,et al.Successful lung transplantation in a patient with dermatomyositis and acute form of interstitial pneumonitis[J].Clin Exp Rheumatol,2009,27(1):168-169.
[16]YASUDA S,KONO M,SHIMAMURA S,et al.Prognosis and progress in immunotherapies for organ involvements in systemic autoimmune diseases[J].Nihon Rinsho Meneki Gakkai Kaishi,2016,39(1):8-17.DOI:10.2177/jsci.39.8.
[2]叶书高,李慧星,刘峰,等.合并肺段挫伤供肺肺移植的临床疗效分析[J].器官移植,2018,9(1):58-62.DOI:10.3969/j.issn.1674-7445.2018.01.008.YE SG,LI HX,LIU F,et al.Clinical analysis of lung transplantation from donors combined with pulmonary contusion[J].Organ Transplant,2018,9(1):58-62.DOI:10.3969/j.issn.1674-7445.2018.01.008.
[3]SHAH RJ,DIAMOND JM.Primary graft dysfunction(PGD)following lung transplantation[J].Semin Respir Crit Care Med,2018,39(2):148-154.DOI:10.1055/s-0037-1615797.
[4]KING CS,VALENTINE V,CATTAMANCHI A,et al.Early postoperative management after lung transplantation:results of an international survey[J].Clin Transplant,2017,31(7).DOI:10.1111/ctr.12985.
[5]ALTUN GT,ARSLANTA?MK,CINEL?.Primary graft dysfunction after lung transplantation[J].Turk J Anaesthesiol Reanim,2015,43(6):418-423.DOI:10.5152/TJAR.2015.16443.
[6]BALSARA KR,KRUPNICK AS,BELL JM,et al.A singlecenter experience of 1500 lung transplant patients[J].JThorac Cardiovasc Surg,2018,156(2):894-905.DOI:10.1016/j.jtcvs.2018.03.112.
[7]POZZI M,BOTTIN C,ARMOIRY X,et al.Extracorporeal life support for primary graft dysfunction after heart transplantation[J].Interact Cardiovasc Thorac Surg,2018,27(5):778-784.DOI:10.1093/icvts/ivy157.
[8]NICOARA A,RUFFIN D,COOTER M,et al.Primary graft dysfunction after heart transplantation:incidence,trends,and associated risk factors[J].Am J Transplant,2018,18(6):1461-1470.DOI:10.1111/ajt.14588.
[9]COSTA J,SHAH L,ROBBINS H,et al.Use of lung allografts from donation after cardiac death donors:a singlecenter experience[J].Ann Thorac Surg,2018,105(1):271-278.DOI:10.1016/j.athoracsur.2017.07.023.
[10]BETIT P.Technical advances in the field of ECMO[J].Respir Care,2018,63(9):1162-1173.DOI:10.4187/respcare.06320.
[11]AGUILAR PR,BEMISS BC,WITT C,et al.Impact of delayed chest closure on surgical site infection after lung transplantation[J].Ann Thorac Surg,2017,104(4):1208-1214.DOI:10.1016/j.athoracsur.2017.05.023.
[12]SUBERVIOLA B,RELLAN L,RIERA J,et al.Role of biomarkers in early infectious complications after lung transplantation[J].PLoS One,2017,12(7):e0180202.DOI:10.1371/journal.pone.0180202.
[13]MATHAI SC,DANOFF SK.Management of interstitial lung disease associated with connective tissue disease[J].BMJ,2016,352:h6819.DOI:10.1136/bmj.h6819.
[14]徐鑫,彭桂林,韦兵,等.20例肺移植的早期临床经验总结[J].中华器官移植杂志,2017,38(8):455-458.DOI:10.3760/cma.j.issn.0254-1785.2017.08.002.XU X,PENG GL,WEI B,et al.Early experience of lung transplantation using graft lungs from donation after citizens death[J].Chin J Organ Transplant,2017,38(8):455-458.DOI:10.3760/cma.j.issn.0254-1785.2017.08.002.
[15]KIM J,KIM YW,LEE SM,et al.Successful lung transplantation in a patient with dermatomyositis and acute form of interstitial pneumonitis[J].Clin Exp Rheumatol,2009,27(1):168-169.
[16]YASUDA S,KONO M,SHIMAMURA S,et al.Prognosis and progress in immunotherapies for organ involvements in systemic autoimmune diseases[J].Nihon Rinsho Meneki Gakkai Kaishi,2016,39(1):8-17.DOI:10.2177/jsci.39.8.