婴幼儿亲体肝移植术中应用保护性通气策略减少术后肺部相关并发症的临床研究

发布时间：2018-10-24 08:26

【摘要】：背景婴幼儿肝移植患者容易发生术后肺部并发症，肺保护性通气在ARDS及危重症患者中的应用价值已得到广泛认可，但对于其在接受亲体肝移植手术的婴幼儿中的作用仍不明确。 目的本研究旨在通过术中使用小潮气量联合呼气末正压通气（PEEP）及间歇性肺复张，明确保护性通气策略对亲属间活体肝移植（LRLT）婴幼儿术后早期肺部并发症乃至预后的影响。 方法根据一定的入选标准和排除标准选择接受LRLT的婴幼儿患者60名，将其随机分为三组，常规通气组（CV组）术中使用10-12ml/kg的潮气量进行机械通气，常规通气联合呼气末正压组（HV组）使用10-12ml/kg的潮气量联合5cmH2O水平的PEEP，保护性通气组（PV组）使用6-8ml/kg的潮气量联合5cmH2O水平的PEEP，并在新肝期始进行肺复张。主要观察指标为患者术后7天内肺部并发症的发生情况及术后30天内的死亡率。次要观察指标为术后7天内肺外并发症的发生情况、机械通气时间、ICU时间及住院时间，术中肺静态顺应性（Cst）、气道阻力（Raw）、氧合指数（OI）、呼吸指数（RI）、肺内分流比例（Fshunt）、肺血管渗透性指数（PVPI）及血管外肺水指数（ELWI）。 结果纳入分析的57名患儿基础情况基本一致，术后早期发生肺部并发症34例（59.6%），发生严重并发症（Ⅲ-Ⅳ级）共29例（50.9%），其中急性呼吸窘迫综合症（ARDS）26例（45.6%）肺炎25例（43.9%）。PV组术后早期肺部并发症发生率低于CV组（OR=0.19，，95%CI为0.05-0.77,P=0.02）和HV组（OR=0.22倍，95%CI为0.06-0.90,P=0.04），术后早期严重肺部并发症发生率低于CV组（OR=0.15，95%CI为0.04-0.62,P=0.009）。其中，PV组ARDS的发生率明显低于CV组（OR=0.22，95%CI为0.05-0.90，P=0.04）和HV组（OR=0.17，95%CI为0.01-0.73，P=0.02）。三组患者术后30天内死亡率无明显差异。PV组的术后机械通气时间明显短于CV组（P=0.02），术后早期肺外并发症的情况、术后ICU时间及住院时间组间比较无明显差异。术中观察指标Cst、Raw、OI、RI、Fshunt、PVPI及ELWI的比较显示PV组情况优于HV组及CV组。 结论婴幼儿亲体肝移植术中使用肺保护性通气可以降低常规机械通气对肺顺应性造成的不良影响、改善氧和功能、肺内分流情况及肺水肿，减少患者术后早期肺部并发症的发生率，特别是ARDS的发生率，有利于亲属间活体肝移植婴幼儿的近期预后。
[Abstract]:Background Pulmonary complications are easy to occur in infants with liver transplantation. The application value of lung protective ventilation in ARDS and critically ill patients has been widely recognized, but the role of lung protective ventilation in infants undergoing liver transplantation is still unclear. Objective to investigate the effect of protective ventilation strategy on early pulmonary complications and prognosis of infants after (LRLT) by using small tidal volume combined with positive end-expiratory pressure ventilation (PEEP) and intermittent pulmonary retraction during the operation. Methods according to the inclusion criteria and exclusion criteria, 60 infants and children who received LRLT were randomly divided into three groups: the routine ventilation group (CV group) was mechanically ventilated with the tidal volume of 10-12ml/kg during the operation. Routine ventilation combined with positive end-expiratory pressure (HV) combined with 10-12ml/kg tidal volume and 5cmH2O level of PEEP, protective ventilation group (PV group) used 6-8ml/kg tidal volume combined with 5cmH2O level PEEP, and lung reopening was performed at the beginning of the new liver phase. Main outcome measures: incidence of pulmonary complications and mortality within 30 days after operation. The secondary indexes were the occurrence of extrapulmonary complications, the time of mechanical ventilation, the time of ICU and the time of hospitalization. Intraoperative pulmonary static compliance (Cst), airway resistance (Raw), oxygenation index (OI), respiratory index (RI), intrapulmonary shunt ratio (Fshunt), pulmonary vascular permeability index (PVPI) and extravascular pulmonary water index (ELWI). Results the basic conditions of 57 children included in the analysis were basically the same. Early postoperative pulmonary complications occurred in 34 cases (59.6%) and severe complications (鈪

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