儿童肺移植受者术后ICU监护治疗期间心理护理一例

自1983年Cooper教授领导多伦多肺移植团队成功完成世界上首例临床肺移植以来,全球肺移植数量持续增长。肺移植术后受者的心理状态是评价临床疗效和疾病预后的一个重要方面。面对特殊的治疗环境以及在接受治疗、护理过程中所承受的种种痛苦体验,肺移植受者会产生紧张、焦虑和抑郁等情绪反应,可出现认知缺陷（包括定向障碍、记忆和判断力受损、不能集中注意力等）和人格变化,这些心理状态变化对受者术后康复有不可忽视的影响。国内儿童肺移植开展较晚,因此儿童肺移植受者术后精神和心理状态的相关报道尚不多,国外有研究报道儿童肺移植受者术后神经系统并发症发生率为45％。     

达芬奇机器人辅助单侧肺移植患者术后重症监护

总结1例达芬奇机器人辅助单侧肺移植术后患者重症监护经验。护理要点包括移植肺机械通气管理;严格限制患者液体入量,尤其注重控制隐形液体入量;进行规范的抗感染及免疫抑制治疗;早期行肠内营养支持和肺功能康复锻炼。患者入住重症监护室15 d后转至普通病房,继续住院治疗观察4 d后,顺利康复出院。     

达芬奇机器人辅助单侧肺移植患者术后重症监护

总结1例达芬奇机器人辅助单侧肺移植术后患者重症监护经验。护理要点包括移植肺机械通气管理；严格限制患者液体入量，尤其注重控制隐形液体入量；进行规范的抗感染及免疫抑制治疗；早期行肠内营养支持和肺功能康复锻炼。患者入住重症监护室15 d后转至普通病房，继续住院治疗观察4 d后，顺利康复出院。     

一例单肺移植围手术期的监护与处理

我院同兰州军区总医院合作于１９９６年１２月２５日为１例左侧结核性毁损肺并肺功能严重不全者行左胸膜全肺切除的同时施行了尸体供肺左肺移植，术后受者生存４３天。现将该例围手术期的监护与处理报告如下。一、临床资料患者为男性，５２岁。左侧结核性损毁肺伴咳血、脓...     

肺移植患者急性肾损伤的术后监护

目的总结肺移植并发急性肾损伤患者的术后护理经验。方法对8例成人肺移植术后发生急性肾损伤的患者,行肾脏替代疗法,同时给予抗感染、营养支持治疗;2例多器官功能衰竭患者行循环支持和呼吸机辅助呼吸。结果治疗后,2例肾病患者肾功能恢复至原有水平;6例SCr值恢复正常;住院时间10~32d痊愈出院。结论肺移植术后急性肾损伤患者早期行肾脏替代治疗,做好血流动力学及微循环的监测与护理,可有效改善患者预后。     

心脏术后监护期患儿的心理行为特点及护理

心内直视手术后,由于患儿机体重要脏器尚处于不稳定状态,身体上的不适及与亲人分离的痛苦,导致患儿术后产生一系列不良心理行为,直接影响康复.因此,对患儿不良心理行为的矫正,满足患儿心理需要是一项重要的护理工作,通过对31例心脏术后患儿心理行为特点的分析及护理,认为采取积极有效的行为护理有利于患儿安全渡过监护期.     

心内直视术后患儿的监护要点

先天性心脏病。手术后由于血液动力学的改变 ,易引起心律失常、低心排综合征等并发症 ,术后监护非常关键。我院于 1 998年 3月至 2 0 0 0年 1 2月治疗小儿先天性心脏病 63例 ,监护要点介绍如下。1　临床资料63例中 ,男 30例、女 33例。年龄 3～ 1 5岁 ,平均 6.9岁。体重 1 2～ 62 kg,平均 1 9.8kg。其中室间隔缺损 43例 ,房间隔缺损 4例 ,室间隔缺损合并房间隔缺损 8例 ,室间隔缺损合并动脉导管未闭 3例 ,右室双腔心 2例 ,部分型心内膜垫缺损 1例 ,法洛三联症 1例 ,法洛四联症 1例。均在全麻体外循环下行心内直视手术 ,术后入 ICU监护。 6…     

1例右侧单肺移植患者的围术期护理

按照护理程序对1例右侧单肺移植患者实施整体护理。结果该例肺移植患者与医护人员配合默契,术后恢复良好,肺功能明显改善,术后64d出院。提出术前周密的准备,术后对循环、呼吸系统和排异反应的严密监护以及严格的感染预防措施是保证手术成功的关键。     

双肺移植治疗儿童囊性纤维化的多学科综合诊疗

目的  通过多学科综合诊疗（MDT）模式提高双肺移植治疗儿童囊性纤维化的外科疗效。方法  对1例国内罕见的终末期囊性纤维化10岁患儿进行肺移植术前MDT讨论,制定对应治疗方案。结果  患儿确诊囊性纤维化5年,肺移植指征明确,经过MDT讨论决定行Clam-shell切口下双肺移植术,术中维持生命体征稳定,术后给予呼吸机辅助通气、抗感染、免疫抑制、抑酸和预防应激性溃疡等治疗,并根据患儿特点给予个体化治疗方案,术后恢复良好。结论  通过肺移植术前MDT讨论,肺移植治疗儿童囊性纤维化的手术效果满意,减少了术后并发症的发生风险,值得临床推广。     

1例单肺移植围术期的监护与处理

我们对1例双侧特发性肺纤维化伴肺大龅病人施行了同种异体左肺移植手术，术后肺功能明显改善，病人治愈出院。现将围手术期的监护与处理总结报道如下。     

A contemporary analysis of induction immunosuppression in pediatric lung transplant recipients

There is an increasing trend in the use of induction immunosuppression in children undergoing lung transplantation (LTx). To evaluate the effect of this practice on survival, the United Network for Organ Sharing (UNOS) was queried from 1987 to 2012, restricting analysis to transplant patients 6–17 years old from 2001 to 2012, who received no induction (NONE) or induction (INDUCED) with the contemporary agents of basiliximab, alemtuzumab, thymoglobulin, antilymphocyte globulin (ALG), or antithymocyte globulin (ATG). Of 23 951 lung transplants, 330 met inclusion criteria with 177 (54%) being INDUCED. Of the INDUCED agents, 121 (68%) were basiliximab, 3 (2%) alemtuzumab, and 53 (30%) ALG/ATG/thymoglobulin. The mean patient age was 13.6 (SD = 3.2) and 14 (SD = 3.0) years for the INDUCED and NONE groups, respectively. The median survival in the INDUCED group was 77.4 months (95% CI: 46.1, 125.6) compared with 50.8 months (95% CI: 42.9, 61.3) for the NONE (log‐rank P‐value = 0.3601). The most common cause of death was due to allograft failure or pulmonary complications with only one patient dying from post‐transplant lymphoproliferative disorder. The estimated hazard ratio for INDUCED versus NONE was 0.859 (95% CI: 0.620, 1.191; P = 0.3618); there were no significant confounders or effect modifiers among the demographic and clinical variables. In conclusion, antibody‐based induction immunosuppression with contemporary agents had a trend toward a protective, but not statistically significant, effect in 6‐ to 17‐year‐old patients.     

COVID-19 in lung transplant recipients: A multicenter study

This study describes the clinical presentation, treatment, and outcomes of SARS-CoV-2 infection in lung transplant recipients (LTRs). This is a multicenter, retrospective study of all adult LTRs with confirmed SARS-CoV-2 infection from March 4 until April 28, 2020 in six Spanish reference hospitals for lung transplantation. Clinical and radiological data, treatment characteristics, and outcomes were reviewed. Forty-four cases were identified in that period. The median time from transplantation was 4.2 (interquartile range: 1.11–7.3) years. Chest radiography showed acute parenchymal abnormalities in 32 (73%) cases. Hydroxychloroquine was prescribed in 41 (93%), lopinavir/ritonavir (LPV/r) in 14 (32%), and tocilizumab in 19 (43%) patients. There was a strong interaction between tacrolimus and LPV/r in all cases. Thirty-seven (84%) patients required some degree of respiratory support and/or oxygen therapy, and 13 (30%) were admitted to intermediate or intensive critical care units. Seventeen (39%) patients had died and 20 (45%) had been discharged at the time of the last follow-up. Deceased patients had a worse respiratory status and chest X-ray on admission and presented with higher D-dimer, interleukin-6, and lactate dehydrogenase levels. In this multicenter LTR cohort, SARS-CoV-2 presented with high mortality. Additionally, the severity of disease on presentation predicted subsequent mortality.     

Outcomes of telehealth care for lung transplant recipients

Telehealth uses videoconferencing to provide long‐distance clinical care. Experience with telehealth in the setting of organ transplantation is limited. The purpose of this cohort study was to compare the impact of telehealth vs in‐person follow‐up of lung transplant recipients. Telehealth eligible patients were three or more years post‐transplant and resided in Ontario outside the Greater Toronto Area. Patients with initial telehealth visits between July 1, 2009, and Dec 31, 2014, were retrospectively reviewed to assess outcomes of chronic lung allograft dysfunction progression and mortality until December 31, 2016, compared with eligible patients seen in‐person. Of eligible patients (n = 204), 119 (58.3%) were seen via telehealth. Most patients (97%) rated telehealth as equivalent or superior to clinic visits. Telehealth visits resulted in significant out‐of‐pocket cost savings and travel distance savings for patients. There was no significant difference in mortality from the time of first visit (HR 0.81, 95% CI 0.49‐1.32, P = 0.4) or from the time of transplant between groups (HR 0.72, 95% CI 0.43‐1.17, P = 0.2). Telehealth can safely and effectively be used in select transplant recipients to increase access to care and reduce time and financial burdens for patients residing greater distances from primary transplant centers.     

In‐hospital and subsequent mortality among lung transplant recipients with a prolonged initial hospitalization

The care of lung transplant recipients with prolonged index hospitalizations can be ethically complex, with conflicts arising over whether the expected outcomes justify ongoing intensive interventions. There are limited data to guide these conversations. The objective of this study was to evaluate survival to discharge for lung transplant recipients based on length of stay (LOS). This was a retrospective cohort study of adult lung transplant recipients in the Scientific Registry of Transplant Recipients. For each day of the index hospitalization the mortality rate among patients who survived to that length of stay or longer was calculated. Post‐discharge survival was compared in those with and without a prolonged hospitalization (defined as the 97th percentile [>90 days]). Among the 19 250 included recipients, the index hospitalization mortality was 5.4%. Posttransplant stroke and need for dialysis were the strongest predictors of index hospitalization mortality. No individual or combination of available risk factors, however, was associated with inpatient mortality consistently above 50%. Recipients with >90 day index hospitalization had a 28.8% subsequent inpatient mortality. Their 1, 3 and 5 year survival following discharge was 53%, 26%, and 16%. These data provide additional context to goals of care conversations for transplant recipients with prolonged index hospitalizations.     

胸外专科重症监护室过渡性护理对减少食管癌术后肺部感染的作用

目的回顾性分析食管癌术后胸外科专科重症监护室（ICU）过渡性护理对减少术后肺部感染的作用。 方法根据食管癌术后患者是否进入胸外专科ICU接受过渡性护理,分为试验组和对照组。试验组术后转入胸外专科ICU观察治疗2~3 d再转回普通病房,在ICU期间除常规的食管癌术后护理外,重点加强气道管理。让患者转出ICU时能有效自主咳嗽、咳痰,呼吸道无痰储留,能自主或在陪护协助下下地活动。对照组则按食管癌术后护理常规护理。 结果试验组和对照组在年龄、性别、BMI、吸烟指数、高血压史、糖尿病史、哮喘病史、第1秒用力呼气量占用力肺活量百分比（FEV1/FVC）的实测值与预计值比值、最大自主通气量占预测值百分比（MVV%）、食管肿瘤部位、手术术式、美国麻醉医师协会（ASA）分级、手术时间、术中出血量、术后呼吸机辅助呼吸、术后肿瘤TNM分期等可能影响肺部感染发生率的因素差异均无统计学意义（均P>0.05）。试验组术后经鼻/口吸痰管吸痰率高于对照组（66.67% vs 16.67%,P<0.001）。术后肺部感染发生率低于对照组（7.02% vs 27.08%,P<0.001）。术后住院时间少于对照组（13.75±2.21 d vs 16.40±2.79 d,P<0.001）。 结论食管癌术后患者予胸外专科ICU过渡性护理,强化气道管理,可以有效降低肺部感染的发生率,有利于患者康复,减少术后住院时间。     

重症监护室交班护理中断事件的专项管理

目的减少ICU交班过程中护理中断事件的发生,提高交班效率。方法分析常规交班120次中发生护理中断事件724次的原因;针对原因采取专项管理,分别统计专项管理前后各120次交班中护理中断事件发生情况及护士工作满意度。结果专项管理措施实施后护理中断事件发生频次、持续时间及交班时间显著少于专项管理措施实施前,护士工作满意度显著提高(均P0.01)。结论护理中断事件专项管理可有效减少ICU交班过程护理中断事件的发生,提高交班效率,从而提高护士工作满意度。