【摘要】：背景嬰幼兒肝移植患者容易發(fā)生術(shù)后肺部并發(fā)癥，肺保護(hù)性通氣在ARDS及危重癥患者中的應(yīng)用價(jià)值已得到廣泛認(rèn)可，但對(duì)于其在接受親體肝移植手術(shù)的嬰幼兒中的作用仍不明確。 目的本研究旨在通過術(shù)中使用小潮氣量聯(lián)合呼氣末正壓通氣（PEEP）及間歇性肺復(fù)張，明確保護(hù)性通氣策略對(duì)親屬間活體肝移植（LRLT）嬰幼兒術(shù)后早期肺部并發(fā)癥乃至預(yù)后的影響。 方法根據(jù)一定的入選標(biāo)準(zhǔn)和排除標(biāo)準(zhǔn)選擇接受LRLT的嬰幼兒患者60名，將其隨機(jī)分為三組，常規(guī)通氣組（CV組）術(shù)中使用10-12ml/kg的潮氣量進(jìn)行機(jī)械通氣，常規(guī)通氣聯(lián)合呼氣末正壓組（HV組）使用10-12ml/kg的潮氣量聯(lián)合5cmH2O水平的PEEP，保護(hù)性通氣組（PV組）使用6-8ml/kg的潮氣量聯(lián)合5cmH2O水平的PEEP，并在新肝期始進(jìn)行肺復(fù)張。主要觀察指標(biāo)為患者術(shù)后7天內(nèi)肺部并發(fā)癥的發(fā)生情況及術(shù)后30天內(nèi)的死亡率。次要觀察指標(biāo)為術(shù)后7天內(nèi)肺外并發(fā)癥的發(fā)生情況、機(jī)械通氣時(shí)間、ICU時(shí)間及住院時(shí)間，術(shù)中肺靜態(tài)順應(yīng)性（Cst）、氣道阻力（Raw）、氧合指數(shù)（OI）、呼吸指數(shù)（RI）、肺內(nèi)分流比例（Fshunt）、肺血管滲透性指數(shù)（PVPI）及血管外肺水指數(shù)（ELWI）。 結(jié)果納入分析的57名患兒基礎(chǔ)情況基本一致，術(shù)后早期發(fā)生肺部并發(fā)癥34例（59.6%），發(fā)生嚴(yán)重并發(fā)癥（Ⅲ-Ⅳ級(jí)）共29例（50.9%），其中急性呼吸窘迫綜合癥（ARDS）26例（45.6%）肺炎25例（43.9%）。PV組術(shù)后早期肺部并發(fā)癥發(fā)生率低于CV組（OR=0.19，，95%CI為0.05-0.77,P=0.02）和HV組（OR=0.22倍，95%CI為0.06-0.90,P=0.04），術(shù)后早期嚴(yán)重肺部并發(fā)癥發(fā)生率低于CV組（OR=0.15，95%CI為0.04-0.62,P=0.009）。其中，PV組ARDS的發(fā)生率明顯低于CV組（OR=0.22，95%CI為0.05-0.90，P=0.04）和HV組（OR=0.17，95%CI為0.01-0.73，P=0.02）。三組患者術(shù)后30天內(nèi)死亡率無明顯差異。PV組的術(shù)后機(jī)械通氣時(shí)間明顯短于CV組（P=0.02），術(shù)后早期肺外并發(fā)癥的情況、術(shù)后ICU時(shí)間及住院時(shí)間組間比較無明顯差異。術(shù)中觀察指標(biāo)Cst、Raw、OI、RI、Fshunt、PVPI及ELWI的比較顯示PV組情況優(yōu)于HV組及CV組。 結(jié)論嬰幼兒親體肝移植術(shù)中使用肺保護(hù)性通氣可以降低常規(guī)機(jī)械通氣對(duì)肺順應(yīng)性造成的不良影響、改善氧和功能、肺內(nèi)分流情況及肺水腫，減少患者術(shù)后早期肺部并發(fā)癥的發(fā)生率，特別是ARDS的發(fā)生率，有利于親屬間活體肝移植嬰幼兒的近期預(yù)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

本文編號(hào)：2290859