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出处：WebMD医学新闻
May 3, 2007（洛杉矶讯）－过去的回溯性研究已经证实，接受移植病患其中央静脉压力（CVP）高或是PaO2/FiO2（动脉氧气分压/吸气氧气浓度）低，在手术后，相较于没有这些症状的病患，仍然需要呼吸器辅助、或是早期死亡风险较高。根据一项发表于国际心脏与肺脏移植学会第27届年会与科学座谈的研究，现在，研究者已经发现在手术后加护时使用一种标准治疗流程，可以缩短病患仍然需要呼吸器的时间、且降低发生重大移植器官功能不全的机率。
为了要降低这类并发症，David Pilcher医师，澳洲墨尔本Alfred医院一位资深加护病房（ICU）医师与其同事发展一种治疗指引，在移植后前72个小时进行；在简单一张双面表格，被设计可以挂在病床边，且实用到足以让护理人员与年轻医师使用，该流程包括一面的血液动力学照护指引、与另一面的呼吸照护。
血液动力学照护指引是根据病患的中央静脉压力是否低于7 mmHg，这是过去被认为与并发症有关的阀值；该流程建议根据病患目前的血压、心脏作工指标使用血管收缩药物、静脉输注液体、与利尿剂。
同样的，呼吸照护指引是根据PaO2/FiO2比值，这提供了如何以及何时协助病患脱离呼吸器；该流程也提供一份清单，内容包括许多有关于移植的因素，也包含何时应该寻求资深医师协助的相关资讯。
Pilcher医师的团队前瞻性地针对56位于2005年10月至2007年1月之间接受移植的病患进行研究，并找了53位于2004年3月与2005年9月之间于同样医院接受肺脏移植病患作为控制组，这两组病患是相似的，虽然控制组病患发生阻塞性肺部疾病的机率较高，且接受指引治疗的病患CVP升高的人数较多；Pilcher医师表示，这两个变项被预期偏好控制组。
Pilcher医师发现接受指引治疗的病患相较于控制组，少部份会发生第2或3级原始移植物功能异常（于48小时时的P值为0.03），之间的差异在72小时时，虽然有偏向接受指引治疗组较佳的趋势（P＝0.11），但研究者也发现，接受指引治疗组病患，接受呼吸器辅助呼吸的时间较短（于24小时与之后的P<0.02）；在试验期间，接受指引治疗组累积体液显著较低（P<0.02）、且使用的正肾上腺素剂量也较低（P=0.01）。
早期与晚期病患族群在死亡率（两组皆为1.9%）、ICU住院率（9.4%比上10.7%）、或是待在ICU的时间（3.1比上3.6天）皆无差异。
Pilcher医师表示，我的结论是，一项处理流程或是治疗指引已经引领出改善早期预后的趋势，且实际执行是可行的，而顺从性是可接受的。
Pilcher医师向Medscape表示，这项研究提供了一群我们不熟悉且反应与你们一般ICU病患不太一样病患处理的架构，举例来说，透过这个指引，可以避免不适当地使用输液，这可能使肺部功能更糟，另一方面可以使病患早点拔管脱离呼吸器；护理人员与年轻医师可以使用这个清单来看他们做的是否正确？而不是总是依赖较资深的医师。
这项座谈会的主持人，德国Ziekenhuizen Leuven大学Dirk Van Raemdonck医师向Medscape表示，通常是ICU的医师在决定是否尝试新的疗法，其他医院也有类似的指引，但是我认为（Pilcher医师的团队）是第一个证实，如果你照着一个严谨的指引做，可以改善肺脏移植后病患的预后。
Pilcher医师表示，在他们的团队分享他们的指引之前，他们希望这项结果可以在更大型的多中心研究中得到证实。
该研究由该医院一项小型计划经费资助，作者表示无相关资金上的往来。
原文：
Treatment Guideline Improves Post Lung Transplant ICU Care
By
Medscape Medical News
May 3, 2007 (San Francisco) –– Previous retrospective studies have suggested that lung transplant patients who have a high central venous pressure (CVP) or a low PaO2/FiO2 (arterial oxygen partial pressure/inspired oxygen concentration) shortly after surgery are likely to remain on ventilation longer and have a higher risk for early death than those lacking such symptoms. Now, researchers have found that the use of a standardized treatment algorithm during postoperative intensive care shortens the time patients remain on ventilator support and reduces the likelihood of developing primary graft dysfunction, according to work presented at the 27th annual meeting and scientific sessions of the International Society for Heart and Lung Transplantation.
To try to limit such complications, David Pilcher, MD, a senior intensive care unit (ICU) physician at Alfred Hospital in Melbourne, Australia, and colleagues developed a treatment guideline to direct care in the first 72 hours after transplant. On a simple 2-sided sheet of paper, designed to be hung at the bedside and practical enough to be useful to nurses and junior physicians, the algorithm includes direction on hemodynamic care on 1 side and respiratory care on the other.
Hemodynamic management was based on whether a patient had a CVP above or below 7 mmHg, which is the cutoff previously associated with complications. The algorithm advises on the use of vasoconstrictors, intravenous fluids, and diuretics, based on the patient’s current blood pressure and cardiac index.
Similarly, the respiratory guideline is based on the PaO2/FiO2 ratio, and provides directions about how and when to wean a patient from ventilation. It provides a checklist for a number of factors regarding the transplant and includes information on when senior help should be called.
Dr. Pilcher’s team tested the algorithm prospectively in 56 lung transplant patients who underwent surgery between October 2005 and January 2007. A historical cohort of 53 patients who had undergone lung transplantation at the hospital between March 2004 and September 2005 served as a control group. The 2 groups were similar, although obstructive lung disease occurred in more patients in the control group and there were more patients with elevated CVP in the guideline-treated group. Both variables would be expected to favor the control group, Dr. Pilcher said.
Dr. Pilcher found that a smaller proportion of patients in the guideline-treated group developed grade 2 or 3 primary graft dysfunction than in the control group (P = .03 at 48 hours). The difference was not significant at 72 hours, although there was a trend toward benefit in the guideline group (P = .11). The researchers also saw a nonsignificant trend for shorter times on ventilation in the guideline-treated group (P ≤ .02 at 24 hours and beyond). Cumulative fluid balance was significantly lower at all time points as well (P ≤ .02), and noradrenaline dose was reduced at all time points (P = .01).
There was no difference in mortality (1.9% in each), ICU readmission rate (9.4% vs 10.7%), or duration of ICU stay (3.1 vs 3.6 days) between the early and late cohorts, respectively.
“My conclusions are that a management algorithm or guideline has led to a trend in improved early outcomes, and its implementation is feasible, and compliance is acceptable,” Pilcher said.
“It provides a framework for the management of an unfamiliar group of patients who respond slightly differently compared to your normal ICU patients,” Dr. Pilcher told Medscape. “Use of the guidelines, for example, can help avoid the inappropriate use of fluids, which can make the lungs worse, and also gets the patient to a point where they can be extubated more quickly. Nurses and junior physicians can use the checklist to see that they are doing something right, ... rather than relying on someone more senior to do that all the time.”
“It is usually the ICU doctor who decides to try this or that,” Dirk Van Raemdonck, MD, PhD, of Universitaire Ziekenhuizen Leuven, Germany, who chaired the session, told Medscape. “I think other hospitals have guidelines as well, but I think [Dr. Pilcher’s group is] the first to show that if you follow a strict guideline, patient outcomes improve” in the post lung transplant setting.
Dr. Pilcher said that before his team shares the guidelines widely, they want to see the outcomes replicated in a bigger multicenter study.
The study was funded by a small projects grant from the hospital. The authors report no relevant financial relationships.
ISHLT 27th Annual Meeting and Scientific Sessions: Abstract 17. Presented April 25, 2007.