Staged Wound Management with Mesh Closure in Patient with Intra-Abdominal Hypertension after Liver Transplantation: Evaluation and Critical Care

本文主要在探討在病患於肝臟移植術後併發腹內高壓或腹腔腔室症候群，接受使用人工網膜鋪以降低腹內壓之經驗及術後傷口護理照護。而肝臟移植術後引發腹內壓增加嚴重的因素有，1、在移植術中門脈阻斷導致腸腫脹，2、再灌注後的肝腫大，特別是marginal grafts，3、捐贈者與受贈者肝臟比例的不配合，4、腹內出血，手術後或是嚴重凝血不全。針對彰化基督教醫院器官統計西元2002年至2010年，肝臟移植總共完成65例，分別屍體肝臟移植為32例，及活體部分肝臟移植33例。4例病患（3例屍體肝臟移植，1例活體部分肝臟移植）。除第一例，在術後在加護病房，發生腹內高壓或腹腔腔室症候群，並導致急性腎臟衰竭或是呼吸衰竭（血中二氧化碳過高）之情況，緊急採取剖腹探查手術。第二、三、四例則，在手術後將關閉腹腔傷口時，發現肺內壓與中心靜脈壓力急遽上升，無法再繼續進行傷口關閉而直接使用人工網膜。目前本院人工網膜時機，在關閉傷口縫合時，若中心靜脈壓力上升超過＞5mmHg情形，介入使用。約在使用人工網膜後，七至十四天移除，原因為第一是等至病患之肝臟與腸腫脹減輕，第二是避免感染情況發生。本文運用人工網膜在肝臟移植術後併發腹內高壓的使用，來降低腹內壓的方式，提供移植外科醫師與加護病房團隊的經驗參考。

關鍵字

肝臟移植；腹內壓；腹腔腔室症候群；人工網膜在傷口處置

並列摘要

This paper aims to discuss the application of synthetic mesh in liver transplantation complicated by intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) with decreasing intra-abdominal pressure and postoperative nursing. Factors for liver transplantation complicated by IAH included: 1. recurrent intra-abdominal bleeding due to the severe postoperative coagulation disorder, 2. postreperfusion hepatic edema, especially marginal grafts, 3. donor/recipient graft size mismatch, 4. bowel edema after portal vein clamping during transplatation. According to patient's of Changhua Christian Hospital, from 2002 to 2010, there were 65 liver transplantations that had been completed; nine cases of IAH/ACS were observed. Among them, four patients received wound closure with a mesh. Currently, the hospital uses a synthetic mesh as an intervention at the time of wound closure when the central venous pressure increases more than 5mmHg. The timing for the synthetic mesh removal depends on the recovery condition (waist circumference and decreased intra-abdominal pressure) of hepatic and bowel edema after the transplantation; also, in order to prevent infections, the exploratory laparatomy procedure is performed 7-14 days after the surgery to remove the mesh. This paper records the keypoints for physiological evaluation and nursing to assist early detection and prevention of IAH/CAS symptoms, complications and infections. Patients received abdominal catheter drainage or emergency surgery to prevent further ogran failure or severe infections. The techniques and experiences are shared for transplant surgeon and intensive care unit (ICU) medical team's nursing reference.

並列關鍵字

Liver transplantation ； Intra-abdominal hypertension ； Abdominal compartment syndrome ； Mesh

國際替代計量

Staged Wound Management with Mesh Closure in Patient with Intra-Abdominal Hypertension after Liver Transplantation: Evaluation and Critical Care

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