Urban Michael K, Jules-Elysee Kethy M, Beckman James B, Sivjee Khillil, King Thomas, Kelsey Webster, Boachie-Adjei Oheneba
Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
Spine J. 2005 May-Jun;5(3):269-76. doi: 10.1016/j.spinee.2004.10.049.
Previous reports have shown that 15% of patients who undergo sequential anterior, then posterior, surgical corrections for spinal deformities demonstrate evidence of acute lung injury. By analyzing the bronchoalveolar lavage (BAL) fluid from these patients for evidence of acute inflammation, we might gain some insight into the etiology of this acute lung injury.
To elucidate the etiology of acute lung injury after corrective surgery for adult spinal deformities.
STUDY DESIGN/SETTING: Fifteen adult patients with scoliosis scheduled for elective sequential anterior then posterior corrective (A/P) spinal deformity surgery.
Consecutive adult patients with scoliosis scheduled for elective corrective surgery with the author (OBA).
Patients were assessed for postoperative respiratory complications by oxygen requirements, continued mechanical ventilation, and radiological evidence of diffuse bilateral interstitial or alveolar infiltrates. An acute pulmonary inflammatory response included the presence of inflammatory cells and elevated cytokines in BAL fluid.
BAL were performed after induction of anesthesia but before surgery, at the completion of surgery, and on the morning after surgery with the patient still intubated. BAL fluid was analyzed for inflammatory cells and cytokine interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) levels. Patients were assessed postoperatively for increased pulmonary vascular resistance, radiological evidence of diffuse bilateral alveolar infiltrates, and the requirement for ventilatory support beyond the first postoperative day (POD1).
The cell counts of BAL fluid demonstrated significant increases in neutrophils, lymphocytes, and lipid laden macrophages (LLMAC) with surgery. The concentration of the cytokines IL-6 and TNF-alpha also increased with surgery. The elevations in BAL inflammatory cells and cytokine levels correlated positively with increased pulmonary vascular resistance and the requirement for mechanical ventilation.
After A/P spine fusions, patients have evidence of an acute inflammatory pulmonary injury. Several etiologies exist for this finding, including blood and fluid infusions, direct trauma to the lung, a systemic inflammatory response, and the embolization of fat and bone-marrow debris. The presence of LLMAC in the lungs of these patients and the finding that the patient with the requirement for the longest ventilatory support also had the highest BAL LLMAC count, suggest that the embolization of fat and bone debris released from the spine during surgery may be at least partially responsible for the lung injury. Further studies on the mechanism of lung injury during this procedure are warranted.
先前的报告显示，接受脊柱畸形前后序贯手术矫正的患者中有15%出现急性肺损伤迹象。通过分析这些患者的支气管肺泡灌洗（BAL）液以寻找急性炎症的证据，我们或许能对这种急性肺损伤的病因有所了解。
阐明成人脊柱畸形矫正手术后急性肺损伤的病因。
研究设计/地点：15例计划择期进行前后序贯矫正（A/P）脊柱畸形手术的成年脊柱侧弯患者。
连续的成年脊柱侧弯患者，由作者（OBA）安排进行择期矫正手术。
通过氧需求、持续机械通气以及双侧弥漫性间质或肺泡浸润的影像学证据来评估患者术后的呼吸并发症。急性肺部炎症反应包括BAL液中炎症细胞的存在以及细胞因子升高。
在麻醉诱导后但手术前、手术结束时以及术后患者仍插管的早晨进行BAL。分析BAL液中的炎症细胞以及细胞因子白细胞介素-6（IL-6）和肿瘤坏死因子-α（TNF-α）水平。术后评估患者肺血管阻力增加情况、双侧弥漫性肺泡浸润的影像学证据以及术后第一天（POD1）后对通气支持的需求。
BAL液的细胞计数显示，手术过程中中性粒细胞、淋巴细胞和含脂巨噬细胞（LLMAC）显著增加。细胞因子IL-6和TNF-α的浓度也随手术增加。BAL炎症细胞和细胞因子水平的升高与肺血管阻力增加以及机械通气需求呈正相关。
在A/P脊柱融合术后，患者有急性炎症性肺损伤的证据。这一发现存在多种病因，包括输血输液、肺部直接创伤、全身炎症反应以及脂肪和骨髓碎片的栓塞。这些患者肺部存在LLMAC以及需要最长时间通气支持的患者BAL中LLMAC计数最高这一发现表明，手术过程中从脊柱释放的脂肪和骨碎片栓塞可能至少部分导致了肺损伤。有必要对该手术过程中肺损伤的机制进行进一步研究。
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