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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。
Objective To investigate the clinical characteristics and prevention and control measures of acute respiratory distress syndrome (ARDS) caused by pulmonary infection after renal transplantation. Methods A retrospective analysis was conducted to analyze the clinical data of 40 patients with lung infection complicated with respiratory failure after renal transplantation in the ICU from January 2003 to January 2011. Results The lung infection occurred mostly in 3 to 6 months (32 cases, 80.00%) after renal transplantation, and fever was the main symptom. When the condition was serious, chest tightness, shortness of breath and difficulty breathing and oxygen saturation decreased and then developed ARDS. Early chest X-ray only thickening of the lungs, blurring or lung field have a little patchy shadow, CT scan gradually developed bilateral bilateral lower lung texture, mesh-like, frosted glassy interstitial changes. Infections are mostly opportunistic infections such as viruses and fungi. 40 patients, 16 patients survived, 24 died, the fatality rate was 60.00%. The main causes of early death were multiple organ dysfunction caused by severe systemic inflammatory response syndrome. The main causes of late death were respiratory failure caused by fungi and hospital-acquired drug-resistant bacteria. Conclusions ARDS mortality due to pulmonary infection after kidney transplantation is high. Early diagnosis, reasonable adjustment and discontinuation of immunosuppressive regimens, empirical anti-infectives and the use of glucocorticoid therapy should be based on noninvasive mechanical ventilation strategies coupled with reasonable nutritional support programs and laminar flow to reduce the risk of aspiration The application of a clean ward will win time for the patient’s recovery.