肾移植术后肺部感染致急性呼吸窘迫综合征的特征与治疗

摘要:

目的探讨肾移植术后肺部感染所致急性呼吸窘迫综合征(ARDS)患者的临床特征及预防控制措施。方法采用回顾性分析的方法，对2003年1月—2011年1月重症监护室40例肾移植术后并发肺部感染合并呼吸衰竭患者的临床资料进行分析。结果肾移植患者肺部感染多发生在术后3～6个月（32例，80.00%），发热是其主要症状，病情严重时出现胸闷、气急和呼吸困难，血氧饱和度下降，继而发展为ARDS。早期胸片仅有双肺纹理增粗、模糊或肺野有少许斑片状影，CT扫描逐渐发展为双侧下肺纹理增多、网格状、毛玻璃状等间质性改变。感染多以病毒和真菌等机会性感染为主。40例患者，存活16例，死亡24例，病死率60.00%。早期死亡原因主要为严重全身炎症反应综合征导致的多器官功能不全，晚期死亡原因主要为真菌及医院获得性耐药菌感染所致的呼吸衰竭。结论肾移植术后肺部感染所致ARDS病死率高。应及早诊断，合理调整及停用免疫抑制剂方案，经验性抗感染和使用肾上腺糖皮质激素治疗，在此基础上应用无创机械通气策略，加上减少误吸风险的合理营养支持方案和层流洁净病房的应用，将为患者的康复赢得时间。

Abstract:

ObjectiveTo evaluate the clinical characteristics and prevention and control measures of acute respiratory distress syndrome (ARDS) caused by pulmonary infection(PI) after renal transplantation.MethodsClinical data of 40 patients with PI and respiratory failure after renal transplantation in an intensive care unit through January,2003 to January, 2011 were analyzed retrospectively.ResultsPI mostly occurred in renal transplant patients after 3-6 months of operation (32 cases, 80.00%), the main clinical manifestation was fever, patients in serious condition could develop chest distress, dyspnea, decrease in blood oxygen saturation degree, and eventually ARDS. Early chest radiograph only displayed increased pulmonary markings, blurred or dotted patch. The lung interstitial changes by CT scanning showed increased bilateral subpulmonary markings, reticular or ground glass shadows. Viruses and opportunistic fungi were major infection agents. 16 patients were survived and 24 died, the death rate was 60.00%. Early death was mainly due to multiple organ dysfunction caused by severe systemic inflammatory response syndrome, and cause of death in advanced stage was respiratory failure caused by fungi or hospitalacquired resistant bacteria.ConclusionMortality of ARDS caused by PI in renal transplantation patients is high. Early diagnosis, rational adjust or stop immunosuppressant application, empirical antiinfective therapy and application of glucocorticoid, noninvasive ventilation, rational nutritional support for reducing risk of aspiration, and application of laminar flow ward will gain time for patients' rehabilitation.