肝移植术后急性呼吸窘迫征的病因、预防和处理治疗  

ETIOLOGY OF ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) FOLLOWING LIVER TRANSPLANTATION

作　　者：李岗山[1] 叶启发[1] 夏穗生[1] 陈知水[1] 曾凡军[1] 林正斌[1] 宫念樵[1] 张伟杰[1] 文志向[1] 沙波[1] 蒋继贫[1] 

机构地区：[1]华中科技大学同济医学院同济医院,同济器官移植研究所武汉430030

出　　处：《中国现代医学杂志》2003年第7期30-32,35,共4页China Journal of Modern Medicine

摘　　要：目的 :通过观察肝移植术后ARDS的临床特征 ,研究其原因、并讨论其预防和治疗的方法。方法 :回顾作者单位 10 4例患各种不同的终末期肝病而行肝移植病例。结果 :17(16 .3% ,17/ 10 4 )例患者肝移植后诊断为ARDS。其中 10例包括 1例术中死亡患者发生于术后 2 4h ,7例拔除气管插管后在甲基强的松龙递减的过程中于术后 3～ 4d发生 ,以上 17例患者中的 14例因为切除病肝过程中严重出血 ,手术时间延长 ,输入了大量的晶体和诸如血浆、血小板等血液成分以及全血。 1例由于严重的全身感染 ,术中发生了DIC ,有 4例于术后第3天在环孢素静注过程中突发ARDS。以上 4例中的 1例包括了所有的原因 ,2例发生了呕吐物的误吸。 17例中的 5例 (30 % ,5 / 17)经过机械通气 (PEEP) ,尽可能吸痰、利尿、激素冲击和根据细菌培养应用抗生素以及发生少尿性肾衰时进行血透等一系列综合治疗而存活。结论 :ARDS是肝移植术后发生率和死亡率很高的一种多因素并发症。最可能的病因是大量的输血和输液造成的液体过量。其他的诸如感染、静脉应用环孢素、激素减量过快、和误吸可能加重了其发生和发展。另外的如输血相关的肺损伤 (TRALI)和移植肝的再灌注损伤可能也起一定作用。虽然其治疗主要是支持性的 ,明白其各种病因对于其预防和处理治?Objective:To describe the clinical profile of a group of patients who developed ARDS post liver transplantation and to evaluate the incidence ,etiology, and outcome ,in order to take clinical action in time.Methods:Retrospective review of the clinical records of 104 patients with various end-stage liver diseases who had liver transplantations in the authors' hospital.Results:17(16.3%, 17/104) patients were diagnosed with ARDS post liver transplantation. 10 of them developed ARDS within 24 hours including 1 who died during the operation, and 7 developed ARDS 3 or 4 days posterior to the day when they were extubated and when the MP (methylprednisolone) was being tapered.14 of the 17 ARDS cases (14/17) were found to have overloaded crystalloid infusions, massive transfusions of blood or blood products such as plasma, platelets etc. and a prolonged surgical time secondary to serious bleeding during the diseased liver resection without evidence of active infection. 1 was found to have serious systemic infection, and operatively disseminated intravascular coagulation (DIC), and 4 of the last recipients developed ARDS suddenly thereafter IV administration of cyclosporine on the 3rd day post-operation. The last patient of the 4 had all of the aforementioned factors. The remaining 2 patients suffered from gastric aspiration. 5(30%, 5/17) of them survived ARDS with the combined treatment consisting of positive end-expiratory pressure (PEEP) mechanical ventilation, suctioning as much edema fluid or sputum as possible, administration of a diuretics, bolus of corticosteroids and culture-based antibiotics, etc. Hemeodialysis was indicated in patients with oliguric renal failure. Conclusions: ARDS is a serious multifactoral complication post liver transplantation with high mortality and fatality.The most likely cause is fluid overload from crystalloid liquid infusion or massive transfusion.The other predisposing or contributing factors include sepsis, IV use of cyclosporine, fast tapering of corticosteroids, and gastric aspirat

关 键 词：ARDS 肝移植 病因 

分 类 号：R657.3[医药卫生—外科学]