The Mount Sinai School of Medicine, New York, NY, USA.
J Cardiothorac Vasc Anesth. 2010 Aug;24(4):681-90. doi: 10.1053/j.jvca.2009.10.032. Epub 2010 Jan 8.
In this review, the authors discussed criteria for diagnosing ALI; incidence, etiology, preoperative risk factors, intraoperative management, risk-reduction strategies, treatment, and prognosis. The anesthesiologist needs to maintain an index of suspicion for ALI in the perioperative period of thoracic surgery, particularly after lung resection on the right side. Acute hypoxemia, imaging analysis for diffuse infiltrates, and detecting a noncardiogenic origin for pulmonary edema are important hallmarks of acute lung injury. Conservative intraoperative fluid administration of neutral to slightly negative fluid balance over the postoperative first week can reduce the number of ventilator days. Fluid management may be optimized with the assistance of new imaging techniques, and the anesthesiologist should monitor for transfusion-related lung injuries. Small tidal volumes of 6 mL/kg and low plateau pressures of < or =30 cmH2O may reduce organ and systemic failure. PEEP may improve oxygenation and increases organ failure-free days but has not shown a mortality benefit. The optimal mode of ventilation has not been shown in perioperative studies. Permissive hypercapnia may be needed in order to reduce lung injury from positive-pressure ventilation. NO is not recommended as a treatment. Strategies such as bronchodilation, smoking cessation, steroids, and recruitment maneuvers are unproven to benefit mortality although symptomatically they often have been shown to help ALI patients. Further studies to isolate biomarkers active in the acute setting of lung injury and pharmacologic agents to inhibit inflammatory intermediates may help improve management of this complex disease.
在这篇综述中，作者讨论了诊断 ALI 的标准；发病率、病因、术前危险因素、术中管理、降低风险策略、治疗和预后。麻醉师需要在胸外科围手术期保持对 ALI 的怀疑指数，特别是在右侧肺切除术后。急性低氧血症、弥漫性浸润的影像学分析和检测非心源性肺水肿是急性肺损伤的重要标志。在术后第一周保持中性至轻度负平衡的保守术中液体管理可以减少呼吸机使用天数。新的影像学技术可以帮助优化液体管理，麻醉师应监测输血相关的肺损伤。小潮气量 6ml/kg 和低平台压 < =30cmH2O 可能减少器官和全身衰竭。PEEP 可以改善氧合并增加无器官衰竭天数，但没有显示出对死亡率的益处。在围手术期研究中没有显示出最佳的通气模式。为了减少正压通气引起的肺损伤，可能需要允许性高碳酸血症。不建议将 NO 作为治疗方法。虽然支气管扩张剂、戒烟、类固醇和复张手法等策略在症状上经常被证明对 ALI 患者有帮助，但它们对死亡率的影响尚未得到证实。进一步研究分离急性肺损伤中活性的生物标志物和抑制炎症介体的药物可能有助于改善这种复杂疾病的管理。
