张晓勤+潘灵爱+黄晓波

[摘要] 目的 总结肺移植术后重症医学科管理经验。 方法 四川省人民医院2015年共完成2 例肺移植手术，病例1为矽肺患者，病例2为肺间质纤维化患者，术前合并严重呼吸衰竭，大剂量应用糖皮质激素，以ECMO辅助；2例患者均行同种异体原位双肺移植术，术后给予控制肺水、免疫抑制、感染防控、早期康复等治疗。探讨重症医学科对肺移植患者的管理经验。 结果 病例1恢复良好，术后第3天可随意下床活动，术后21 d顺利出院，至今生活良好。病例2因先后并发支气管吻合口瘘、重症肺炎、肝功能衰竭，给予积极抗感染、保肝降黄、营养支持及康复治疗，但治疗效果不佳，于术后73 d死亡。 结论 良好的重症医学科管理是肺移植术后患者康复的重要保障。术前使用大剂量激素的患者，术后吻合口瘘的发生风险更高。ECMO是危重患者安全度过围术期的有力保障，一旦患者呼吸、循环稳定，宜尽早撤除。

[关键词] 肺移植；重症医学科；管理；糖皮质激素；体外膜肺氧合

[中图分类号] R617 [文献标识码] B [文章编号] 1673-9701（2016）35-0158-03

Experience of management to patients with lung transplantation in intensive care unit

ZHANG Xiaoqin PAN Ling'ai HUANG Xiaobo

Department of Intensive Care Unit， Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital， Chengdu 610072， China

[Abstract] Objective To summarize the experience of management to patients with lung transplantation in intensive care unit. Methods Two cases of lung transplantation were carried out in Sichuan Provincial People's Hospital in 2015. Case 1 was a silicosis patient. Case 2 had pulmonary fibrosis with severe respiratory failure. We applied large doses of glucocorticoid and ECMO for this patient before surgery. The surgical approache was sequential bilateral single-lung transplantation. Measures for lung water control， immunosuppression， and anti-infection， rehabilitation were carried out after transplantation. The experience of management to patients with lung transplantation in intensive care unit was explored. Results Case 1 recovered well. The patient could be free to get out of bed at the 3rd day after surgery and discharged at the 21st day. Case 2 died at the 73rd day after surgery because of bronchial anastomotic fistula， severe pneumonia and liver failure， although the patient was recieved positive anti-infection， liver protection， nutritional support and rehabilitation， but the treatment was ineffective. Conclusion Good management in intensive care unit is the important guarantee of the recovery with lung transplantation. The patient who use of large doses of glucocorticoid before surgery with higher risk of bronchial anastomotic fistula after surgery. ECMO is an important supportion for critical patient in perioperation. Once the breathing and circulation of the patient stably， we should remove ECMO as soon as possible.

[Key words] Lung transplantation； Intensive care unit； Management； Glucocorticoid； ECMO

肺移植是终末期肺部疾病的有效治疗手段，自Cooper等1983年成功实施首例临床肺移植手术，肺移植手术逐渐在世界范围内开展起来。然而肺移植手术的开展规模，远较其他实体器官如肝、肾移植的规模小，其原因除了肺是直接对外开放的器官，且其本身与免疫功能密切相关，肺移植最容易发生感染[1]，圍术期管理的复杂性也是其中的重要因素。重症医学科围手术期恰当的监测和治疗，可以减少肺移植并发症的发生，使肺移植患者及早康复。……