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The Risk Factors of Pulmonary Complications and the Characteristics and Drug Resistance Analysis of Bacterial Infection Following the Early Postoperative Period in Liver Transplantation

Author: TianYuWei
Tutor: ZhouJie
School: Southern Medical University,
Course: Hepatobiliary Surgery
Keywords: Liver transplant Pulmonary complications Risk factors Logistic regression Epidemiology Resistance Resistance mechanisms Prevention and cure Treatment
CLC: R657.3
Type: Master's thesis
Year: 2011
Downloads: 64
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Abstract


Since the U.S. Starzl Professor in 1963 in the world since the first line of the first case of human orthotopic liver transplant, liver transplantation has been nearly 50 years of development, has become the treatment of end-stage liver disease, acute liver failure in a the most effective choice, liver transplant recipient after survival, quality of life continue to be improved, but the liver transplant pulmonary complications and bacterial infection incidence is relatively high, the liver transplant pulmonary complications and bacterial infection remains is one of the leading cause of death by transplant patients, at home and abroad reported for liver transplantation in the incidence of postoperative pulmonary complications was 40% -60% up to 36% -80%, the incidence of bacterial infection, the case fatality rate was 30% -70%, higher than the acute rejection of renal failure and vascular, biliary complications. Complex factors of postoperative pulmonary complications of liver transplantation and may affect pulmonary complications factors including preoperative, intraoperative and postoperative variety of factors, severe pulmonary complications serious impact on postoperative recovery and survival time. After liver transplantation bacterial infection is an important and complex problem, one of the most important reason for postoperative recovery, graft dysfunction, loss of function. Reported that the vast majority of liver transplant recipients deaths associated with infection and complications caused by infections, especially multiple bacterial infections particularly difficult to deal with. In With the to the constantly to deepen of the people on the the the understanding of of the lungs complications and bacterial infections, against the the liver transplantation the complications dangerous factors of the of postoperative pulmonary analysis of and bacteria infection the characteristics and drug resistance analysis of get attach importance to, also to become the the the research of liver transplantation postoperative complications important issue. Author Nanfang Hospital, Southern Medical University in August 2004 - December 2009 163 cases studies, according to the experience of the center and the reference of relevant literature Comprehensive choose a variety of liver transplantation perioperative comprehensive analysis to find out analysis of liver transplantation and risk factors for pulmonary complications, postoperative bacterial infection epidemic characteristics and bacterial resistance, and thus provide a theoretical basis for the clinically more effective prevention and treatment. The first part of liver transplantation in early postoperative pulmonary complications risk factors [Objective] early pulmonary complications after liver transplantation is one of the main reasons of the early survival after liver transplantation patients, complications in patients with multiple risk factors such as multiple organ dysfunction, immune dysfunction, hypoalbuminemia existing lung disease, intraoperative massive blood transfusion and postoperative ICU routine care and treatment, and after a lot of fluid in patients. Liver transplantation was mainly targeted at patients with end-stage liver disease, such as primary liver cancer, hepatitis, cirrhosis, liver failure, congenital hepatic metabolic diseases, liver transplant recipient preoperative general and multi poor nutritional status, liver transplantation surgery a long time, trauma, postoperative immunosuppressive treatment and a longer period of time after the intravenous fluid therapy with specificity. Perioperative management view of the liver transplant and liver transplantation surgery particularity, it is necessary before liver transplantation, surgery, of postoperative pulmonary complications related factors to find out the main risk factors for perioperative period provide a theoretical basis for the prevention of pulmonary complications. I Nanfang Hospital, Southern Medical University in August 2004 - December 2009 to meet the requirements of the implementation of the 154 cases of orthotopic liver transplant clinical data were retrospectively analyzed to find the dangers associated with early postoperative pulmonary complications factors, and this proposed preventive measures. [] 1, General Information The group of 154 cases, including 134 cases and 20 females. Average age (48.5 ± 8.7) years, the average length of stay (54.9 ± 5.6) d, the average intensive care room (intensive care unit, ICU), observation time (3.8 ± 1.7) d. 43 cases, 92 cases of primary liver cancer, 17 cases of severe hepatitis primary disease, including hepatitis, cirrhosis, Budd-Chiari syndrome, liver degeneration. Pulmonary complications after liver transplantation occurred into complications and control groups. 2, surgical and immunosuppressive regimen classic 98 cases, the piggyback 56 cases. Immunosuppressants program: after conventional triple anti-rejection therapy: 1.5-2.5 mg twice daily tacrolimus, mycophenolate mofetil dispersible tablets 180-360 mg 2 times a day, methylprednisolone sodium succinate 160-20-80-40-20mg daily diminishing; 5d later changed to tacrolimus 1.0-2.5 mg twice daily, mycophenolate mofetil dispersible tablets 180-360 mg 2 times a day prednisone tablets 10-20 mg daily, the plasma concentration of FK506 maintained at 8 to 12 ng / mL. Acute rejection were treated with high-dose methylprednisolone dragon shock treatment and increase the anti-rejection drug tacrolimus, mycophenolate mofetil dosage, infection control is not ideal to reduce or disable the anti-rejection drug. 3, the selection of the relevant factors as follows based on the experience of the center and References select 22 factors were statistically analyzed. ① preoperative factors: gender, age, smoking history, hepatopulmonary syndrome, lung disease (such as lung inflammation and infection, chronic obstructive pulmonary disease, bronchial asthma, etc.), hypoproteinemia, liver function Child- Pugh rating C-level, diabetes, preoperative the Hb / (g · L-1), preoperative Hct /%. ② intraoperative factors: donor warm ischemia time, cold ischemia time, operative time, anhepatic phase, the amount of bleeding, the total amount of intraoperative blood transfusions, intraoperative transfusion of red blood cells, the amount of intraoperative fluid volume. ③ postoperative factors: longer stays in the intensive care unit (ICU), invasive mechanical ventilation, postoperative before at least 2d 3d rehydration fluid balance ≤ -500 mL postoperative least 1d 3d rehydration fluid balance ≤-500mL / cases before and other factors. 4, the statistically processing will be the of the cases of in line with the the above-mentioned diagnostic criteria classified as the positive group of the pulmonary complications, the the remaining cases have normalized the negative group of the pulmonary complications. First of all liver transplant recipients perioperative major independent variables were analyzed by univariate hazard analysis (including count data was used to compare the X2 test, measurement data were compared using independent sample t-test), the differences between the pulmonary complications and control groups , initially to find out the risk factors associated with pulmonary complications. View of certain factors may interact, there will be significant risk factors included in the logistic regression analysis to identify the main risk factors. SPSS13.0 statistical software, according to test the level of a = 0.05, P lt; 0.05 difference was statistically significant. [Results] 1, relevant factors univariate analysis will affect the 22 liver transplant pulmonary complications related factors were analyzed to which preoperative liver function Child-Pugh rating for the C-Class, intraoperative red blood cell transfusion gt; 10u the total infusion gt; 10L, hypoproteinemia, transfusion of blood products gt; 4L, had longer stays in the ICU ≥ 5d invasive ventilation, ventilation time ≥ 48h least 1d 3d rehydration liquid balance before postoperative ≤ -500 mL surgery after the the 3d before rehydration least 2d liquid balance ≥ -500 mL, these nine factors associated with pulmonary complications. Multifactorial risk factors above nine significant factors as independent variables, logistic regression analysis of postoperative pulmonary complications as the dependent variable, to elect the factors affecting the early postoperative pulmonary complications, including low albumin, transfusion of blood products gt; 4L, had longer stays in the ICU ≥ 5d postoperative 3d rehydration before at least 2d ≤-500ml of fluid balance, into the logistic regression equation. 3, the relationship between pulmonary complications in patients with risk factors in 98 cases of 85 cases were cured, 13 patients died, the fatality rate was 13.26%, of which 10 cases of pulmonary complications directly related fatality rate of 10.20%, 10 cases patients, preoperative liver failure with hypoproteinemia eight cases of blood products more than 11 cases of postoperative rehydration negative fluid balance, intraoperative input invasive mechanical ventilation time greater than 48h in the ICU for observation over five days in 9 patients. [Conclusion] 1, preoperative liver function Child-Pugh rating for the C-Class, intraoperative RBC gt; 10u, transfusion of blood products gt; 4L, the total infusion gt; 10L, hypoproteinemia, ICU observation time ≥ 5d, there are invasive ventilation ventilation time ≥ 48h, the 3d rehydration at least 1d liquid balance before the the postoperative is ≤ -500 mL of, 3d rehydration at least 2d liquid balance prior to in the postoperative ≤ -500 mL, etc. The 9 is the the liver transplantation postoperative pulmonary complications related factors. Hypoproteinemia, transfusion of blood products gt; 4L, had longer stays in the ICU ≥ 5d at least 2d 3d rehydration fluid balance before postoperative ≤-500ml is a major risk factor for liver transplant pulmonary complications. 2, for the above-mentioned risk factors to take effective prevention and treatment measures, to strengthen the monitoring of patients with pulmonary complications in the early postoperative strive to early detection and timely treatment; help to reduce the mortality of postoperative pulmonary complications to improve the success rate of surgery. The second part of the liver transplant early postoperative epidemiology of bacterial infection and drug resistance [Objective] after liver transplantation early bacterial infections still affect an important complication of liver transplant success rate and postoperative survival, with bacterial spectrum changes and drug abuse, reported at home and abroad after liver transplantation gradual increase in the incidence of bacterial infection, bacterial infection, bacterial spectrum have been some changes, resistance rates became more complex. Of bacteria in the the the 163 cases the liver transplantation in patients with in the the we in force in in the August 2004 to December 2009 of the cases of infection, through the the bacterial culture Identification and Drug Sensitivity test analysis bacteria infection characteristics of, so as to more effective to prevention and the treatment of bacterial infection. [Method] The source of specimen from August 2004 to December 2009 in our hospital 163 cases of liver transplant patients for the study, after regular (2-3 times / week) to collect specimens for bacterial smears specimen types include : respiratory specimens, abdominal pleural effusion, bile, urine, blood, deep vein puncture tubes clinical specimens. There are the corresponding the local and systemic of infection symptoms, or the the corresponding parts of is twice in a row or the specimens on more than two occasions for the the same strains decidable for the bacterial infection (rule out the the pollution and normal flora), the positive persons of the results of the smear examination repeated several times acquisition the the corresponding specimens were sent to bacterial culture and sensitivity test. 2, bacterial culture and identification and susceptibility testing of bacteria isolated and cultured according to the National Clinical Laboratory Procedures separated specimen inoculation loop routine immunization in diameter the gcm of the MH (Muller-Hinton) agar plates (Jiangmen Kaelin trade Limited production), placed in a 35 ° C incubator (United States SHELAB production) and incubated for 18-24 hours, and picked up a number of typical colonies required, adjusted according to the the turbidimetry instrument (BD Biosciences) bacterial culture with sterile saline identification of selection the American BD PHOENIX-100 bacteria fully automatic analyzer, criteria and the results explained with reference to the Committee of the American Society for Clinical Laboratory Standards (CLSI) standards designating the year 2007 was designated standard. 3, the reference to \① patients with fever, cough, diarrhea, abdominal pain, nausea, vomiting, frequent urination, urgency, dysuria and other local or systemic clinical manifestations of infection and other complications can not explain. ② specimens collected from sterile sites (blood, clean urine, bile, pleural fluid drainage fluid, intravenous catheters, etc.) more than once isolated pathogens. ③ bacteria parts of specimens collected from the same culture for pathogens and, if necessary, line imaging, surgery or pathologic examination revealed more than two times in a row or two of training with one kinds of pathogens or different parts with one kinds of pathogens isolated. ④ bacterial colonization or bacterial skin infections are not included in the statistical category. 4, grouping grouping: meet the diagnostic criteria cases, classified as a bacterial infection group, the rest of the cases classified as the control group. Statistically SPSS13.0 statistical software to calculate the frequency and percentage. [Results] 1,86 cases of bacteria suspected of being infected patients diagnosed with clinical data based on the diagnostic standard total of 86 cases have been diagnosed as bacterial infection, the infection rate was 52.7%, including 72 males and 14 females. Average age of 54.3 (32-74) years, the average length of stay 71.4 (33-193) d. Primary disease, including hepatitis and cirrhosis in 41 patients (3 patients with acute liver failure), 38 cases of primary liver cancer (pathological type: hepatocellular liver cancer patients, 37 cases, cholangiocarcinoma 1 cases) , 7 cases of severe hepatitis. 86 patients after conventional triple anti-rejection treatment [of tacrolimus (FK506), mycophenolate mofetil, methylprednisolone sodium succinate; 5d later changed to FK506, mycophenolate mofetil, strong cancellous sheet), FK506 the blood of drug concentrations have been maintaining in the 8 ~~ the Contents of. 2 types of infectious pathogens and portions 163 and 163 patients received 86 patients with concurrent bacterial infection in liver transplant patients, 166 strains were isolated. G-78 strains of the bacteria infection (46.2%), G 64 strains (39%), fungi and 24 (14.5%), infected bacteria: Bowman Acinetobacter, Staphylococcus haemolyticus, Klebsiella pneumoniae primary bacteria, Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis, feces field cocci, Enterococcus faecalis, Stenotrophomonas oligonucleotide raising single Aeromonas casein yellow hen enterococci, site of infection to the respiratory tract, followed by blood night, urine, bile, puncture fluid and equipment. 3, bacterial infection the time distribution infection occurred an average of 13.6 (1-52) d, 98.8% of which occurred in January after bacterial infection time distribution analysis found that after one week after two weeks three weeks, four weeks and five weeks, respectively, were 73, 63, 20, 8, 2. 1 and 2 weeks after the highest detection rate, with time, the detection rate of a downward trend. Susceptibility test results G-bacteria on the second and third generation cephalosporins and quinoline Well ketones higher resistance to carbapenems and p-lactam inhibitor additive package sensitive, G bacteria sensitive amino glycopeptide (vancomycin, teicoplanin) and oxazolidinones (linezolid). 5, treatment and outcome of 86 cases of bacterial infections in patients receiving antimicrobial therapy, suspected of being infected patients, bacterial culture and drug sensitivity results return before take empirical medication, according to the different parts of penicillins, cephalosporins, susceptibility results return after adjustment regimen, sufficient quantities and press antibiotic therapy. There are 69 cases of be cured, 17 cases death in the the 86 cases, the case fatality rate for the 19.7%; the of which with the the Being Infected with Pathogenic Bacterium the directly related to the those who 10 cases of, the case fatality rate for the 11.6%, there are five cases for the Bowman's Acinetobacter infection in the the 10 cases in the the in patients with is death three cases of enterococcal infections, 2 patients with Bowman Acinetobacter and Stenotrophomonas malt oligotrophic monocytogenes, Staphylococcus aureus. The direct cause of the deaths is graft-versus-host reaction (GVHD), 4 cases of biliary and vascular complications of death, one cases of pulmonary hemorrhage after death [Conclusion] after liver transplantation infection bacteria order: Bowman Acinetobacter hemolytic Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis, feces field cocci, Enterococcus faecalis, Stenotrophomonas oligotrophic Aeromonas buttermilk yellow hen intestinal cocci. G-bacteria than G bacteria, the G bacteria tended to increase in the proportion of domestic and foreign reports. 2, the site of infection of the respiratory tract (68.2%), 98.8% in January after distribution analysis found that postoperative bacterial infection, after one week, two weeks mainly as postoperative time prolong OF, the the incidence of infection by the bacteria declining trend. 3, susceptibility test results of this study showed that the carbapenems enzyme inhibition antibiotics and aminoglycosides, oxazolidinone class of G-bacteria and G bacteria highly sensitive. With antimicrobial drugs are widely used in liver transplantation prophylactic and empirical treatment, continuous emergence of new disease-causing bacteria and drug-resistant strains of multi-resistant bacteria gradually increased. 4, anti-bacterial treatment should be combined with the type of pathogen reasonable choice of drugs, drug-resistant characteristics. Patients should be confirmed to have been infected with sensitive drugs, according to the results of susceptibility sufficient quantities, the courses of antimicrobial therapy. 5 different bacterial resistance mechanisms selected changes in bacterial resistance to different antibiotics.

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