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肾移植术后肺部感染的诊断与治疗课件

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移植 术后 肺部 感染 诊断 治疗 课件
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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 1 肾移植术后肺部感染的诊断与治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植术后由于免疫抑制剂的使用 导致了 免疫机制的损伤 再加上尿毒症患者术前长 期透析 贫血 营养不良等 导致机体免疫 力下降 患者容易并发肺部感染 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植后肺部感染特点 肾移植术后肺部严 重感染往往发生在患者免疫力过于低下状态 发病呈隐匿性 但有发展快 症状重 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 双重感染和混合感染多的特点 并且肾移植 术后普通性细菌和真菌感染所占比例下降 而 机会性感染的几率增加 病原体多样化 复 杂化 且有时病原体难以明确 部分患者虽经 治疗康复后 也未能明确病原体的诊断 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 其原因 忽视了对原虫 支原体 衣原体等 病原体的检查 事实上某些病例可能就是由这 些病原体引起 标本采集时间或方法不当 标本的采集部位不当 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 部分病人病情来势凶猛危重 在未检出病 原体前即死亡 死后虽经尸解 但也影响了 检出率 同时肺部感染和败血症是肾移植术 后患者死亡的主要原因 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 感染类型 细菌感染 结核感染 真菌感染 巨细胞病毒染 CMV 而以混合感染最常 见 其中有相当部分患者未能明确病原体 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 感染发生时间多见于术后1 18月 特点 至 感染发热时肾功能多正常 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床特点及进程 与2003年初流行我国的非 典型肺炎 SARS 相类似 早期以高热 38 42 为首发症状 少数为低热开始 不伴明 显咳嗽咳痰 或伴有轻到中度干咳或少量白 色泡沫痰 随病情发展 出现胸闷 呼吸急 促及轻度紫绀 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 实验室检查可有不同程度的低氧血症和低蛋 白血症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植术后肺部感染的临床X线征象 分析 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植术后肺部感染的X线表现多样且不典型 在形式上可为间质性改变 局灶性片状浸 润 间质性改变斑片状阴影等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 其早期常表现为间质性改变 进一步发展而出 现斑片状阴影 这与一般患者肺部的段叶性浸 润明显不同 因此对肾移植术后肺部感染患 者的早期X线平片首先关注的是间质性改变 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 由于患者病情发展变化快 X线平片上无表现 到两肺广泛病变仅需一天时间 且常与临床表 现不同步 X线征象出现晚于临床 因此需要 与临床密切结合 重视短期胸片复查 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 对于肾移植术后肺部感染的患者来说 胸片是 一种简便而又有价值的检查方法 它既是其早 期诊断肺部感染的依据 又是病情发展趋势的 观察 应予以重视 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植术后肺部感染的CT 表现主要 有 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 双肺多发病灶 单发者少见 以磨玻璃样影 为主 也有实变影 但实变病灶内有含气支气 管像 未见有肺不张 说明小支气管的通畅 病 灶分布中 上肺野为主 以肺门为中心 可呈 蝶翼形分布 这在其他普通肺部感染的影像中 少见 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 还发现部分患者 尤其轻症患者 表现为肺 纹理的增粗与似雾状的较淡的磨玻璃样影 弥 漫的较淡的磨玻璃样影加上 粗而不乱 的肺纹 理 形如东北的 雾淞 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病理基础基础 主要是肺间质的改变 如间质 的水肿 增厚等 这正是磨玻璃样影形成的主 要原因 实变病灶往往是在肺间质病变的基 础上出现肺实质的渗出 水肿和变性 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 磨玻璃样影或较淡雾状影的广泛分布 推测除 与感染因素有关的肺间质的病变外 是否还与 患者免疫抑制剂应用后肺间质易发生变态反 应性改变有关 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 与其他肺部感染的CT 影像鉴别 中上肺野多 发病灶 并以肺门为中心可呈蝶翼样分布 其 次是广泛分布或多发的磨玻璃样影 另外 较 淡雾状影基础上肺纹理增粗 形成所谓的 雾 淞征 可供参考 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 特殊肺感染的鉴别如SARS 主要鉴别点在 SARS 的病灶分布以下肺野及胸膜下部位较 多 与SARS 的相似点为磨玻璃样影或肺野 普遍密度增高 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病原体监测 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 对所有病例常规进行血 痰 咽拭子及中 段尿细菌和真菌的培养 如无阳性发现 要 反复进行 如无痰标本 则行纤维支气管镜 检查取得样本 检查血CMV 抗原和抗体 检 测痰和尿中抗酸杆菌 并检查结核抗体 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 常见病原体监测结果 细菌感染 肺炎克雷白 杆菌 肺炎链球菌 大肠杆菌 金黄色葡萄球 菌 阴沟杆菌 表皮葡萄球菌 真菌感染 白 色念球菌 平滑念珠菌 曲霉菌 CMV感染 结核感染 相当部分患者以上的检查中均 未发现有意义的阳性结果 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 治疗方法 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 入院初期 在做各种病原体检查的同时 均 采用综合治疗方法 嘱咐患者卧床休息 吸氧 改善低氧血症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 加强支持疗法 纠正低蛋白血症 联合给予抗细菌和 或抗病毒和 或抗真菌治 疗甚至抗结核治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 调节免疫抑制剂的用法 多数中心采用患 者停用MMF 减少CsA 的用量 使CsA 谷值 浓度维持在100 150ng ml左右 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 在反复检查未能明确病原体的情况下 根 据患者临床情况可逐步停用抗真菌 病毒 或细菌的药物 并给予复方甲基异恶唑 SMZco 或克林霉素对卡氏肺囊虫进行试验治 疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 停用其他免疫抑制剂的同时 即常规开始 静脉应用甲基泼尼松龙 MP 160mg d 3 5 天后减量至80mg d维持 根据临床表现再减 量至40mg d 临床症状彻底消失后改为口服 泼尼松维持 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 根据临床情况和T细胞亚群分析 逐步加用 CsA FK506和 或MMF 但用量均比感染前 减少 MP应用时间9 29天 同时应用有效 的制酸剂 并补充钙剂 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植术后肺部感染的临床特点和进程与 SARS相类似 使用适当剂量的MP能有效减 轻炎症反应 使炎症中的充血 血浆渗出 白细胞浸润和吞噬等现象显著减轻 减少肺 泡渗出和肺毛细血管通透性 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 炎症后期 能抑制纤维母细胞的增生和肉芽 组织的形成 减轻肺间质纤维化 并能防止 停用其他免疫抑制剂导致的移植肾排斥反应 减少死亡率和移植肾的丧失 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植植术后肺部感染的康复 需要积极 的综合治疗 但患者自身免疫能力的提高也 是非常关键的一点 免疫力过低 尽管使用 多种药物也很难有效 因此 在治疗过程中 必要时一定要果断使用丙种球蛋白 胸腺肽 等可以提高机体免疫力的药物 提高机体本 身的抗病能力 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植患者肺部感染多呈隐匿性发病 病情 发展迅速 同时又缺乏特征性临床表现 而 胸片表现往往较滞后 且肺部感染也不一定 伴有菌血症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 及时 尽早治疗 不能一味依赖胸片和病原 体的检查 丧失早期治疗的良好时机 肺部 感染发生率和死亡率的增加与未及时进行有 效抗菌治疗有关 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 对发展迅速 出现呼吸困难甚至ARDS患者 及时面罩给氧 甚至使用呼吸机辅助呼吸 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 在我们重视肾移植后肺部感染治疗的同时 还 要加强对其预防的观念 免疫抑制剂用量要 合适 不要一味照搬照抄某些文献过大剂量 从而使患者的免疫状态过低下 在考虑预 防排斥反应的同时要重视感染并发症的危险 性 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾移植患者的上呼吸道感染 尤其是伴发 热的上呼吸道感染 要给予高度重视 及时 正规治疗 要进行适量的体育锻炼 增加体 质 提高自身的抗病能力 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 表1 40 例病人病原菌种类 病原菌 例次 铜绿假单胞菌 11 金黄色葡萄球菌 9 不动杆菌 5 大肠杆菌 5 莫拉杆菌 3 沙雷氏菌 2 军团肠杆菌 2 结核杆菌 11 巨细胞病毒 14 白色念珠菌 13 热带念珠菌 4 不典型分枝杆菌 3 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 表2 感染类型 感染类型 例次 细菌 13 真菌 3 巨细胞病毒 2 结核杆菌 2 细菌 巨细胞病毒 混合 1 细菌 结核杆菌 混合 5 巨细胞病毒 结核杆菌 混合 1 细菌 真菌 巨细胞病毒 混合 11 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 43
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