经皮扩张气管切开术在心外科的临床应用价值

目的通过比较传统开放性气管切开术（open tracheostomy,OT）和经皮扩张气管切开术（percutaneous dilational tracheostomy,PDT）在心脏外科术后危重病人中的应用,评价PDT在心外科的临床应用价值。方法40例正中开胸心脏手术后危重患者,2002年1月～2003年7月为OT组,2003年8月～2008年2月为PDT组,各20例,观察手术时间、切口长度、愈合时间、术中出血、生命体征的波动及术后不良反应等情况。结果PDT组手术时间（8.8±2.2）min、切口长度（1.3±0.2）cm、切口愈合时间（3.9±0.9）d,与OT组的（21.5±5.3）min、（3.4±0.5）cm、（5.9±1.2）d相比,均有显著性差异（t=-9.897,-17.440,-5.963,P=0.000）;术中Ⅱ度出血PDT组明显少于OT组[1例（5%）vs 13例（65%）,χ^2=15.824,P=0.000];术中平均动脉压、心率、脉搏血氧饱和度的波动PDT组明显小于OT组[1～5（中位数2）mm Hg vs 1～20（中位数3.5）mm Hg,Z=-2.959,P=0.003;3～12（中位数5.5）次/min vs 7～70（中位数10）次/min,Z=-3.956,P=0.000;0～4%（中位数2%）vs 0～31%（中位数3.5%）,Z=-3.548,P=0.000];不良反应切口溢痰的发生率PDT组明显低于OT组[1例（5%）vs 8例（40%）,χ2=5.161,P=0.023];总并发症发生率PDT组明显低于OT组[1例（5%）vs 12例（60%）,χ2=13.789,P=0.000）。结论PDT具有快速、创伤小、手术操作精确、易掌握、成功率高、并发症少等优势,是心血管术后危重病人气管切开的较好选择。     

应用不同品牌机械瓣行主动脉瓣置换术患者的血流动力学变化

目的 探讨应用不同品牌19 mm机械瓣行单纯主动脉瓣置换术后早期血流动力学变化情况。 方法回顾性分析2007年1月至2012年1月北京安贞医院116例单纯主动脉瓣狭窄患者行主动脉瓣置换术后血流动力学变化,其中男61例、女55例,年龄（52±13） 岁。根据使用的瓣膜品牌将患者分为3组： SJ.Regent瓣膜组,38例（33%）,男20例、女18例,平均年龄（52±15） 岁; Carbomedics瓣膜组,40例（34%）,男21例、女19例,平均年龄（51±17） 岁。On-X瓣膜组,38例（33%）,男20例、女18例,平均年龄（55±16） 岁。比较患者术前和术后左心室收缩期末内径、左心室舒张期末内径、射血分数（EF）值、室间隔厚度、左心室壁厚度、主动脉瓣瓣上流速、跨瓣压差以及术后有效瓣口面积指数（EOAI）。 结果 三组患者术前及术后的左心室收缩期末内径、左心室舒张期末内径、EF值、室间隔厚度、左心室壁厚度差异均无统计学意义 （P＞0.05）。主动脉瓣瓣上流速和跨瓣压差术前、术后有差异有统计学意义。SJ.Regent瓣膜组和Carbomedics瓣膜组患者较On-X瓣膜组患者的术后主动脉瓣瓣上流速 ［（244.30±33.67） cm/s vs. （249.69±79.13） cm/s vs. （294.83±52.05） cm/s］和跨瓣压差［（27.77±3.33） mm Hg vs. （33.58±18.90） mm Hg vs. （38.56±13.21） mm Hg］明显偏小,其差异有统计学意义。 结论 运用19 mm机械瓣进行主动脉瓣置换术,SJ.Regent和Carbomedics瓣膜较On-X瓣膜有更好的血流动力学效果。     

ProSeal喉罩对老年患者腹腔镜手术循环和通气功能的影响

目的比较ProSeal喉罩和气管插管对老年患者腹腔镜手术循环和通气功能的影响。方法择期行腹腔镜手术60例,ASAⅠ－Ⅱ级。按手术时间顺序分为2组,喉罩组（LMA组,n=30）和气管插管组（ET组,n=30）。比较2组患者麻醉诱导前（T0）、诱导后（T1）、插入喉罩/气管导管后即刻（T2）及插入喉罩/气管导管后3 min（T3）、拔管前（T4）、拔管即刻（T5）、拔管后3 min（T6）MAP、HR、SpO2;记录间歇通气5 min（T7）、15 min（T8）、30 min（T9）的分钟通气量（MV）、气道峰压（Ppeak）、潮气量（VT）和PETCO2;同时记录不良反应。结果ET组在T2、T3、T5、T6时点的MAP（109±13）,（102±12）,（99±11）,（96±10）mm Hg显著高于LMA组（83±10）,（81±9）,（83±9）,（81±7）mm Hg（t=-8.683,P=0.000;t=-7.668,P=0.000;t=-6.166,P=0.000;t=-6.731;P=0.000）;ET组在T2、T3、T4、T5、T6时点HR（99±11）,（95±10）,（75±7）,（97±11）,（91±10）次/min显著高于LMA组（81±7）,（79±7）,（69±9）,（71±7）,（74±8）次/min（t=-7.562,P=0.000;t=-7.179,P=0.000;t=-2.882,P=0.000;t=-10.922,P=0.000;t=-7.271,P=0.000）;其他时点2组MAP、HR差异无统计学意义（P〉0.05）。SpO2均维持在95%-100%。2组T7-T8时点MV、VT、Ppeak差异无统计学意义（P〉0.05）,LMA组在T9时点Ppeak（19.0±5.0）mm Hg显著高于ET组（13.0±3.0）mm Hg（t=5.636,P=0.000）;LMA组在T9时点PETCO2（44.7±3.1）mm Hg显著高于ET组（34.1±1.9）mm Hg（t=15.968,P=0.000）。LMA组5例发生不良反应,显著低于ET组13例（χ^2=3.774,P=0.052）。结论ProSeal喉罩可安全用于腹腔镜手术老年患者,通气可靠,对血液动力学影响轻微,并且不良反应发生率低。     

喉罩通气麻醉在高龄患者内镜逆行胰胆管造影中的应用

目的观察喉罩通气麻醉在高龄患者内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)中的应用价值。方法对60例实施ERCP的老年患者(70~85岁),随机分为喉罩通气麻醉(LMA组,n=30)和传统面罩吸氧通气麻醉(M组,n=30),2组患者均静脉注射地佐辛5 mg,丙泊酚1.5 mg·kg~(-1),LMA组待患者入睡睫毛反射消失,下颌松弛后即置入喉罩行辅助呼吸,M组用面罩辅助呼吸。2组均根据检查时间和患者体动情况追加丙泊酚。记录手术开始前(T0),检查镜通过咽喉后(T1),手术开始10 min(T2),术毕(T3)4个时点患者血压(MAP)、心率(HR)、脉搏血氧饱和度(Sp O2)、术中患者呛咳、体动和缺氧情况、术者满意度等。结果 LMA组在T1、T2时点MAP显著低于M组[T1:(98.7±13.6)mm Hg vs.(120.0±9.6)mm Hg,t=-6.928,P=0.000;T2:(99.6±13.3)mm Hg vs.(117.4±12.3)mm Hg,t=-7.649,P=0.000]。LMA组在T1、T2时点HR显著低于M组[T1:(81.6±14.0)次·min~(-1)vs.(92.5±15.0)次·min~(-1),t=-2.887,P=0.005;T2:(80.7±10.8)次·min~(-1)vs.(92.1±16.3)次·min~(-1),t=-3.177,P=0.002];LMA组Sp O2在T1、T2、T3时点显著高于M组[T1:(99.6±0.6)%vs.(94.7±7.2)%,t=3.715,P=0.000;T2:(99.6±0.6)%vs.(93.5±6.2)%,t=5.365,P=0.000;T3:(99.0±2.3)%vs.(95.1±4.7)%,t=4.070,P=0.000]。LMA组ERCP操作时间明显短于M组时间[(47.7±10.4)min vs.(55.8±14.6)min,t=-2.461,P=0.017],但苏醒时间较M组明显延长[(7.5±4.9)min vs.(4.6±3.2)min,t=2.682,P=0.010]。LMA组患者术中呛咳和低氧血症发生率更低(呛咳:0例vs.7例,P=0.005;低氧血症:0例vs.5例,P=0.024),术者满意度更高[(1.0±0.1)分vs.(0.8±0.3)分,t=3.459,P=0.001]。结论喉罩通气麻醉用于高龄病人的ERCP可取得满意效果,且安全性更高。     

哌替啶复合氟哌利多在无痛人流术中的应用

目的观察哌替啶复合氟哌利多在无痛人流中的麻醉效果和安全性。方法 400例无痛人流的早孕患者根据麻醉用药的不同分为2组,A组152例采用丙泊酚麻醉,B组248例采用哌替啶复合氟哌利多麻醉,2组患者均在静脉注射药物前应用1%利多卡因行宫颈旁阻滞。比较2组收缩压(systolic blood pressure,SBP)、舒张压(diastolic blood pressure,DBP)、心率(heart rate,HR)、呼吸频率(respiratory rate,RR)、脉搏血氧饱和度(pulse oxygen saturation,Sp O2)、Ramsay镇静评分、麻醉起效时间、术后离床时间、术后留观时间、镇痛效果和术后恶心呕吐等不良反应的发生情况。结果麻醉后A组收缩压、舒张压及呼吸频率显著低于B组[(90.3±10.7)mm Hg vs.(100.6±12.0)mm Hg,t=-8.677,P=0.000;(69.9±7.5)mm Hg vs.(78.8±10.5)mm Hg,t=9.119,P=0.000;(16.7±2.7)次/min vs.(18.6±3.2)次/min,t=-6.107,P=0.000]。A组镇静评分显著高于B组[(6.0±0.1)分vs.(3.4±1.4)分,t=22.850,P=0.000];A组术后离床时间和术后留观时间显著长于B组[(11.0±3.3)min vs.(3.5±1.6)min,t=30.442,P=0.000;(118.8±1.1)min vs.(30.5±2.9)min,t=359.722,P=0.000]。结论复合应用宫颈局部麻醉,2种麻醉方法均可满足手术需要,但哌替啶复合氟哌利多的麻醉效果更符合基层医院的实际情况。     

新型主动脉旁与主动脉内球囊反搏对羊重度急性心力衰竭辅助的实验研究

目的比较新型主动脉旁反搏装置（paraaortic counterpulsation device,PACD）与主动脉内球囊反搏（intraaortic balloon pump,IABP）装置对羊重度急性心力衰竭的辅助效果。方法选成年小尾寒羊8只,将自制PACD（每搏量为55 ml）的无瓣人工血管吻合于降主动脉,同时于降主动脉内植入IABP（每搏量为40 ml）进行反搏辅助。结扎冠状动脉分支建立重度急性心力衰竭动物模型,观察PACD和IABP辅助对重度急性心力衰竭辅助后的血流动力学变化;实验结束后观察PACD辅助和羊主要器官的变化。结果成功建立了8只羊心力衰竭模型,心力衰竭后心排血量（CO）、肺毛细血管楔压（PCWP）、平均动脉压（MAP）和左心室舒张期末压（LVEDP）与基础值比较差异均有统计学意义（t=-8.466,34.083,25.767,-5.219,P=0.000）。应用IABP和PACD辅助后,平均动脉舒张压（MADP）较辅助前不明显或明显增高（38.34±7.13 mm Hg vs.38.42±6.81 mm Hg,P=0.418;38.34±7.13 mmHg vs.54.14±10.13 mm Hg,P=0.001）,IABP与PACD比较差异有统计学意义（P=0.010）;而LVEDP较辅助前无明显降低（7.43±2.54 mm Hg vs.7.32±2.14 mm Hg,P=0.498;7.43±2.54 mm Hg vs.6.53±1.91 mm Hg,P=0.821）,IABP与PACD比较差异无统计学意义（P=0.651）;冠状窦血流量（CSF）较辅助前不明显或明显增加（86.63±7.71 ml/min vs.87.04±6.53 ml/min,P=0.981;86.63±7.71 ml/min vs.110.52±11.03 ml/min,P=0.000）,IABP与PACD比较差异有统计学意义（P=0.000）;IABP辅助后,左侧颈动脉流量（LCAF）较辅助前无明显降低（131.07±21.26 ml/min vs.128.36±20.38 ml/min,P=0.689）,而PACD辅助后较辅助前增加（131.07±21.26 ml/min vs.151.29±18.37 ml/min,P=0.008）,IABP与PACD比较差异有统计学意义（P=0.002）。PACD后血囊、人工血管内及动物心脏、肝、肾、肺等器官未见血栓、栓塞和缺血坏死;病理切片在光学显微镜下观察未见明显异常。结论 IABP对羊重度急性心力衰竭无辅助作用,而PACD辅助明显提高了MADP,增加了冠状窦血流量,改善了脑灌注流量,对重度心力衰竭具有良好的循环辅助效果。     

零平衡超滤对冠状动脉旁路移植术后患者肺功能的影响

目的探讨零平衡超滤对改善体外循环（CPB）冠状动脉旁路移植术（CABG）患者术后肺功能的临床效果。方法选择2006年6月至2008年12月在中国医科大学附属第一医院接受CABG患者40例,按照采用的不同超滤方法分为两组,试验组（n=20）：男14例,女6例;年龄65.43±8.31岁;于CPB开始后行零平衡超滤及常规超滤;对照组（n=20）：男15例,女5例;年龄66.51±7.62岁;仅于复温后施行常规超滤。术前常规检测两组患者肺功能和动脉血气分析;分别于CPB前、CPB结束时、术后6 h和12h测定两组患者气道阻力（Raw）、氧合指数（OI）和肺泡-动脉血氧分压差[P（A-a）O2],记录术后呼吸机辅助通气时间。结果两组患者术前肺功能和动脉血气指标比较差异均无统计学意义（P〉0.05）。两组患者CPB前Raw、OI和P（A-a）O2比较差异无统计学意义（P〉0.05）,而术后6 h和12 h试验组的Raw显著低于对照组[2.22±0.31 cm H2O/（L.s）vs.2.94±0.42 cm H2O/（L.s）,F=0.061,P〈0.05;1.89±0.51 cm H2O/（L.s）vs.2.52±0.29 cm H2O/（L.s）,F=0.096,P〈0.05];术后6 h和12 h试验组P（A-a）O2显著低于对照组（86.74±7.63 mm Hg vs.111.66±7.49 mm Hg,F=0.036,P〈0.05;74.82±5.67 mm Hg vs.95.23±6.78 mm Hg,F=0.059,P〈0.05）;术后6 h和12 h试验组OI显著高于对照组（384.33±30.67 vs.324.63±31.22,F=0.033,P〈0.05;342.24±23.43 vs.293.67±25.44,F=0.047,P〈0.05）;术后呼吸机辅助通气时间试验组短于对照组（15.44±3.93 h vs.20.68±5.77 h,P〈0.05）。结论零平衡超滤可以改善CABG患者术后肺功能、缩短术后机械通气时间。     

轻中度慢性阻塞性肺疾病患者行腹腔镜与开腹胃癌根治性手术的安全性比较

目的评估轻中度慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)患者行腹腔镜辅助胃癌根治术的安全性及可行性。方法回顾性分析我院2011年1月~2014年6月112例胃癌合并轻中度COPD患者的临床资料,按患者意愿分组,腹腔镜组44例,开腹组68例,比较2组术中呼气末CO2分压(PETCO2)、动脉血CO2分压(Pa CO2)、术后恢复及并发症。结果腹腔镜组术中PETCO2和Pa CO2均高于开腹组[(37.63±4.00)mm Hg vs.(34.72±2.85)mm Hg,t=4.491,P=0.000;(44.51±4.08)mm Hg vs.(41.95±5.24)mm Hg,t=2.747,P=0.007]。2组手术时间差异无显著性(P0.05)。腹腔镜组术中出血量、术中及术后输血率、术后镇痛次数、肛门排气时间、下床活动时间、术后住院时间均少于开腹组[(136.4±66.4)ml vs.(241.4±69.6)ml,t=-7.671,P=0.000;11.4%(5/44)vs.29.4%(20/68),χ2=5.019,P=0.025;(2.1±0.9)次vs.(3.2±0.9)次,t=-5.151,P=0.000;(2.5±0.9)d vs.(3.4±1.0)d,t=-4.635,P=0.000;(3.3±0.9)d vs.(4.4±1.0)d,t=-5.876,P=0.000;(13.9±7.9)d vs.(17.4±8.6)d,t=-2.060,P=0.042]。2组术后肺部并发症、其他并发症发生率差异无显著性[27.3%(12/44)vs.29.4%(20/68),χ2=0.060,P=0.807;13.6%(6/44)vs.14.7%(10/68),χ2=0.025,P=0.874]。结论轻中度COPD患者行腹腔镜辅助下胃癌根治术是安全可行的。     

丙泊酚靶控输注对鼻内镜手术病人应激反应的影响

目的观察丙泊酚靶控输注对鼻内窥镜手术病人应激反应的影响。方法40例ASA分级为Ⅰ-Ⅱ级行鼻内镜手术的病人,按随机数字表法分为A组（丙泊酚静脉注射2.5mg.kg^-1）和B组（丙泊酚靶控输注靶浓度4μg.ml^-1）,手术全部在全凭静脉麻醉下完成。手术前,手术后30min和气管拔管后60min,抽取外周静脉血检测皮质醇和血糖,并记录心率（heart rate,HR）和平均动脉压（mean artery pressure,MAP）。结果A组病人手术开始后30min心率（73±8）次/min明显高于B组病人（65±13）次/min（t=2.344,P=0.024）,MAP（74±7）mm Hg明显高于B组病人（68±7）mm Hg（t=2.711,P=0.010）,血糖（6.28±0.11）mmol/ml明显高于B组病人（5.31±0.15）mmol/ml（t=23.321,P=0.000）,皮质醇（125.3±11.5）ng/ml明显高于B组病人（89.6±9.9）ng/ml（t=10.521,P=0.000）。气管拔管后60min A组病人MAP（79±6）mm Hg显著高于B组病人（73±8）mm Hg（t=2.683,P=0.011）,血糖（6.18±0.09）mmol/ml明显高于B组病人（5.62±0.16）mmol/ml（t=10.082,P=0.000）,皮质醇（169.1±16.3）ng/ml明显高于B组病人（149.5±15.3）ng/ml（t=3.921,P=0.000）。结论丙泊酚靶控输注能较为有效地抑制鼻内镜手术刺激引起的应激反应。     

腹腔镜与开腹手术治疗卵巢良性肿瘤2141例临床分析

目的探讨腹腔镜手术治疗卵巢良性肿瘤的临床价值。方法回顾分析2010年1月～2011年9月2141例行腹腔镜（770例）或开腹（1371例）手术治疗的卵巢良性肿瘤患者的临床资料,其中384例行患侧附件切除,1757例行肿瘤剔除。比较两组围手术期情况及住院费用。结果术后病理诊断为卵巢良性畸胎瘤899例,卵巢单纯性囊肿124例,卵巢囊腺瘤1070例,卵巢纤维瘤48例。与开腹组相比,腹腔镜组患者年轻[（32.7±9.4）岁vs.（39.7±13.8）岁,t=-12.499,P=0.000],肿瘤小[（6.03±1.85）cm vs.（6.83±2.37）cm,t=-8.085,P=0.000]。腹腔镜组手术时间早[（61.5±8.5）min vs.（72.5±7.1）min,t=-32.084,P=0.000],术中出血少[（75.0±10.5）ml vs.（105.5±9.0）ml,t=-70.796,P=0.000],术后排气早[（10.5±4.1）h vs.（33.0±9.6）h,t=-62.046,P=0.000],下床活动早[（12.5±1.8）h vs.（36.7±10.9）h,t=-61.010,P=0.000],术后住院时间短[（4.7±1.2）d vs.（8.9±2.3）d,t=-46.904,P=0.000];但住院费用高[（15 172±2876）元vs.（11 576±2851）元,t=27.919,P=0.000]。结论对卵巢良性肿瘤实施腹腔镜手术较之开腹手术治疗,手术出血少,术后恢复快,有较大的应用价值,值得推广。     

Establishing extracorporeal membrane oxygenation in a university clinic: case series

OBJECTIVES: Although extracorporeal membrane oxygenation (ECMO) is well established for respiratory failure in neonates, application in adults is still considered controversial. The survival of patients with acute respiratory distress syndrome and ECMO therapy is 50% to 70%. DESIGN: A retrospective analysis of 10 patients, who were placed on ECMO from September 2004 to December 2005, was performed. SETTING: University clinic. INTERVENTIONS: Venoarterial ECMO was established in 7 patients, venovenous ECMO in 2 patients, and combined venoarterial and venovenous ECMO in 1 patient. MEASUREMENTS AND MAIN RESULTS: Indications were pneumonia, acute respiratory distress syndrome, near drowning, pericardial tamponade with shock lung, right-heart failure after heart transplantation, shock lung after cardiopulmonary resuscitation, and right-heart failure in chronic thromboembolic pulmonary hypertension. Median maintenance of ECMO therapy was 56.5 hours (range, 36-240). The median Murray score was 3.3 for survivors and 4 for nonsurvivors. Overall mortality was 30%; 70% were weaned from ECMO and survived until discharge. Median pre-ECMO risk for fatal outcome according to Hemmila was 0.43 for survivors and 0.92 for nonsurvivors (p < 0.02). In 2 cases, surgical reintervention was necessary because of bleeding in one, and a side switch of the cannulae had to be performed because of femoral venous thrombosis in the other. CONCLUSIONS: ECMO has been shown to be a successful therapy for acute respiratory distress syndrome when conventional strategies have failed. Pre-ECMO risk assessment may be useful in the evaluation of patients.     

Combination of continuous renal replacement therapies (CRRT) and extracorporeal membrane oxygenation (ECMO) for advanced cardiac patients

BACKGROUND: The critically ill patients may require mechanical ventilation, cardiac mechanical support, and other types of critical support. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy, which provides good cardiopulmonary and end-organ support. Continuous renal replacement therapies (CRRT) exhibit important advantages in terms of clinical tolerance and blood purification. This investigation aims to evaluate the acute renal failure in cardiac patients under ECMO, and assess the effect of combining these two technologies, ECMO and CRRT. METHODS: Between December 1998 and June 2001, 10 adult cardiac patients were treated on ECMO. Five of them were treated with both ECMO and CRRT. The clinical outcomes were retrospectively analyzed. RESULTS: Of the 10 patients studied, five were men and five were women. The mean age of survivors and non-survivors was 37.00 +/- 14.54 years and 46.17 +/- 7.41 years, respectively. The overall mortality rate was 60%. Survivors did not differ significantly from non-survivors in age or gender. The APACHE II scores on the first day of ECMO support between survival and non-survival were 19.00 +/- 9.38 and 24.67 +/- 3.50 (P value = 0.392) (Table 2), which demonstrates no significant differences too. The cause of death in most patients was related to organ system failure during the 24 h immediately before ECMO started. Five patients with acute renal failure treated by CRRT were eventually died. The median and mean survival in this group on CRRT was 40.50 +/- 18.07 h and 92.60 +/- 60.50 h. CONCLUSION: We conclude that mortality rate for acute renal failure in cardiac patients under ECMO continues to be high. Our data suggest that acute renal failure is generally a part of multiorgan failure. This unique form of acute renal failure, causes generalized edema and fluid overload despite still low serum creatinine and azotemia, and deteriorates rapidly to death. From this study shows, advanced cardiac failure may need more aggressive and early initiation of ECMO support before acute renal failure develops. Acute renal failure in advanced heart failure under ECMO support means a grave sign, need aggressive heart transplantation therapy as soon as possible. Combination of CRRT and ECMO might serve an alternative therapy bridging the temporary replacement treatment and heart transplantation in advanced cardiac patients.     

Clinical evaluation of two different extracorporeal membrane oxygenation systems: a single center report

Refinements in extracorporeal membrane oxygenation (ECMO) equipment, including heparin-coated surfaces, centrifugal pump, membrane oxygenator, and more biocompatible pump-oxygenator circuits, have reduced procedure-related complications and have made ECMO a safe and effective therapy for critical patients. The aim of this study was to evaluate the performance of two different ECMO circuit systems in a clinical setting and compare their outcomes. From December 2004 to December 2009, 121 patients required ECMO for primary or postcardiotomy cardiogenic shock at our heart center. We used the Medtronic circuit system in our earlier series (Group M, n = 64), and from July 2007, ECMO was carried out mainly with the Quadrox D PLS circuit system (Group Q, n = 56). We retrospectively summarized and analyzed the data of these patients. The evaluation was based on the comparison between properties of the membrane oxygenators and pumps, anticoagulation therapy, circuit-related complications, and clinical outcomes. Support pump flow rates, platelet counts, and trans-membrane pressure drops (TMPDs) of preoxygenator and postoxygenator pressures were compared between two groups at the time of support established (T1) and support established for 24 h (T2). There were no significant differences between the two groups with regard to patient characteristics and pre-ECMO data. The support pump flow rates and platelet counts at different times were comparable in the two groups. The cannulation technique, ECMO duration, and mean heparin dosage were similar in both groups. There were also no significant differences between the groups in mortality or complications related to bleeding and organ dysfunction. Compared with the M group, the Q group experienced less mechanical failure of the ECMO circuit. The Quadrox PLS circuit system showed less circuit thrombus formation (P < 0.045), less plasma leakage (P < 0.001), and less need for replacement of oxygenators (P < 0.001). Furthermore, frequency of hemolysis during ECMO was significantly lower (P < 0.045). In addition, at T1 and T2, TMPDs were significantly lower in the Q group. Our results suggest that both ECMO circuit systems provide similar effects for safe clinical application, but the Quadrox PLS ECMO circuit system demonstrated partially improved biocompatibility in terms of improved cell preservation, lower TMPDs, less plasma leakage, and thrombus formation.     

The impact of extracorporeal membrane oxygenation on survival in pediatric patients with respiratory and heart failure: review of our experience

Extracorporeal membrane oxygenation (ECMO) is widely used for circulatory support in pediatric cardiac patients with low cardiac output and hypoxemia. We retrospectively evaluated the efficacy of ECMO support for respiratory and heart failure in infants and children. From April 2002 to February 2011, 14 patients aged 19 days to 20 years old (average 44 months), with body weight 2.6 kg to 71 kg (median 14.1 kg), underwent ECMO support for failing cardiac function, hypoxemia, and low cardiac output syndrome. In 12 patients, ECMO was introduced after operation for congenital heart disease (four with complete repair including Fontan circulation, and eight with palliative repair). In one patient, ECMO was introduced after partial pulmonary resection for congenital cystic adenomatoid malformation because of respiratory failure. ECMO was introduced in a patient with severe heart failure caused by fulminant myocarditis. Patients' demographics, duration of extracorporeal membrane oxygenation, additional support, and outcomes were analyzed. Ten patients (71%) were successfully weaned from ECMO, and eight patients (57%) were discharged from the hospital. The mean duration of ECMO support was 332 h (range 11–2030 h). Although management of the ECMO circuit, including anticoagulation (activated clotting time: 150–250), was conducted following the institutional practice guidelines, it was difficult to control the bleeding. Seven patients required renal replacement therapy during ECMO support using peritoneal dialysis or continuous hemodiafiltration. Five patients had additional operative procedures: systemic–pulmonary shunt in two, bidirectional Glenn takedown with right modified Blalock–Taussig shunt, total cavopulmonary connection takedown, and redo ECMO in one patient each. The patient who had the longest ECMO support for respiratory failure due to acute respiratory distress syndrome after lung surgery was successfully weaned from ECMO because high‐frequency oscillation (HFO) improved respiratory function. ECMO for heart and respiratory failure in infants and children is effective and allows time for recovery of cardiac dysfunction and acute hypoxic insult. The long‐term ECMO support for over 2000 h was very rare, but it was possible to wean this patient from ECMO using HFO.     

心功能衰竭孕妇的分娩处理策略

目的探究妊娠晚期合并心功能衰竭患者的分娩期处理策略。方法回顾性分析2007年12月至2018年12月间我院心脏外科与妇产科联合治疗的23例妊娠晚期合并心功能衰竭(心功能Ⅲ~Ⅳ级)患者的临床资料,探讨心功能衰竭孕妇的分娩处理及临床急救策略。结果23例孕妇均以全身麻醉剖宫产术作为结束妊娠的方式。17例患者单纯行剖宫产术,顺利度过围产期,另择期行心脏手术或进行内科治疗。6例患者在剖宫产过程中出现心脏停搏或心室颤动,紧急插管,行外周型体外膜肺氧合转机并辅助循环:2例患者转机2 h内心脏恢复自主跳动;1例患者转机6 h心脏出现自主跳动;3例患者虽有自主心跳但室颤反复发作,其中2例剖宫产术后第3天分别行心脏瓣膜置换和室间隔封堵,1例严重心肌病患者体外膜肺撤机困难,转机12 d后死于肺部感染。结论心脏病患者妊娠晚期发生心功能衰竭是导致孕产妇死亡的主要原因之一,加强孕期保健及多学科合作,及时终止妊娠,可改善患者的预后。     

A review of a newly established ECMO program in a university affiliated cardiac center

Extracorporeal membrane oxygenation (ECMO) is an established rescue treatment option for severe respiratory and cardiac failure in infants and neonates and has recently become widely utilised in adults. ECMO support can be initiated rapidly in an emergency setting both by percutanous implantation and surgically; it allows transportation of patients in cardio-pulmonary collapse and bridging of critically ill patients to be recovered, other support measures or transplantation. The aim of this study was to report authors' initial experience after starting an ECMO program in a university-based cardiac center. The institutionally approved ECMO team bears responsibility for adjudication regarding indication and implementation of ECMO in all patients. Since the establishment of the ECMO team in October 2007, one elective and nine urgent patients in deep cardiogenic and/or ventilatory collapse were treated by ECMO support up to December 2008. Three patients suffered severe acute right heart dysfunction, two patients suffered postcardiotomy refractory cardiogenic shock, two patients had a cardiogenic shock due to postinfarction interventricular septal rupture, two patients experienced severe respiratory failure and one had elective ECMO implantation as a back-up support during high-risk percutaneous coronary intervention. Veno-arterial ECMO was used in eight cases and veno-venous in two cases of isolated respiratory failure. In nine patients, ECMO circuit was instituted by peripheral cannulation, in eight out of nine cases by percutaneous puncture. On one occasion central surgical cannulation was used. In urgent patients, immediate hemodynamic and oxygenation improvement was observed. Average support duration was 6.8 days (range 1-16 days). Five (50 %) patients were successfully weaned from ECMO and survived to hospital discharge. The illness severity in urgent patients defined by SOFA score ranged from 10 to 17, patients dying while on ECMO had higher SOFA scores (14.8±1.6 vs. 10.8±1.5; P=0.0065). Complications included mainly bleeding. ECMO support allows treatment of severely ill patients in imminent cardiovascular and/or ventilatory collapse. Therefore, establishment of an ECMO program in university affiliated cardiac center is fully justified. A multidisciplinary approach is essential. Despite adequate training and education of ECMO team members, this highly invasive therapeutic modality bears an inherent risk of complications.     

Venovenous perfusion in ECMO for newborn respiratory insufficiency. A clinical comparison with venoarterial perfusion.

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) has been successful in the treatment of newborns less than 1 week of age and greater than 2000 gm birthweight with respiratory failure resistant to current medical and surgical management. While VA ECMO supports the heart as well as the lungs, it has the disadvantage of requiring carotid artery ligation and the possibility of perfusing air bubbles or particles into the arterial tree. We have treated 11 newborns with respiratory failure with venovenous (VV) ECMO returning the oxygenated blood to a cannula in the distal iliac vein. We compared these patients with 16 patients treated during the same period of time with VA ECMO. Three of the 11 VV patients required conversion to VA ECMO because of inadequate oxygenation and unstable hemodynamic situations. Ten of the 11 VV patients survived. Eleven of the 16 VA patients survived. The better survival in these patients treated with VV ECMO is attributed to their more favorable initial condition compared to patients treated with VA ECMO. The disadvantages of VV ECMO include a longer operative time to place the cannulas, groin wound problems, and persistent leg swelling along with the necessity to convert some patients to VA ECMO. Although this experience demonstrates that newborns with severe respiratory failure can be supported with VV ECMO, the complications and lack of practical advantages over VA lead us to recommend VA ECMO for routine clinical use at present.     

体外膜肺氧合技术在心脏移植不同时期的应用

目的 探讨体外膜肺氧合技术(ECMO)在心脏移植术前辅助、术中替代体外循环及术后辅助治疗的临床应用效果.方法 对心脏移植术前过渡、术中代替常规体外循环以及术后心功能衰竭辅助治疗中使用ECMO技术患者的临床资料进行回顾分析.结果 3例等待心脏移植的患者术前应用ECMO 5～8 d,其中2例患者在等待供心的过程中发生多器官功能衰竭而死亡;1例患者成功接受心脏移植,术后顺利撤除了ECMO.12例在心脏移植术中应用了ECMO代替常规体外循环技术,均顺利完成手术,术后持续应用ECMO辅助的时间平均为(38±14)h,1例患者因发生多器官功能衰竭死亡,其余11例患者均痊愈,顺利出院,无患者发生右心功能衰竭和三尖瓣返流等心脏移植术后常见的并发症.心脏移植术后由于严重右心功能衰竭接受ECMO辅助治疗的患者有10例,起始时间为返回监护室后2 h至2 d,持续时间为43～176 h,其中7例患者痊愈,顺利出院,1例因发生严重感染而死亡,2例因发生多器官功能衰竭而死亡.以上死亡患者的死亡原因均与ECMO的出血或血栓形成等并发症无关.结论 尽早应用ECMO可以使等待心脏移植的心功能衰竭患者有效地过渡到心脏移植;术中应用ECMO替代常规体外循环技术可以更好地保护供心,有利于缺血时间较长供心的功能恢复,提高心脏移植手术成功率;术后患者出现右心功能衰竭时,应用ECMO有良好的辅助治疗效果.

Abstract：

Objective To investigate the clinical results of extracorporeal membrane oxygenation (ECMO) technique during the peri-operative heart transplantation. Methods The clinical data of heart transplantations supported by the ECMO were retrospectively analyzed, including during the bridge to transplant, working as routine bypass in the operation room, and supporting the heart failure after surgery. Results Three 3 cases were supported with ECMO to extend the waiting time: 2cases died of multi organ failure during the waiting, and the third one received the heart transplant and the ECMO was successfully removed. Totally 12 cases of heart transplantation received the modified open style ECMO techniques replacing the routine bypass. The ECMO was removed after assistance for (38 ± 14) h. All the recipients except one death recovered well without right ventricular failure or obvious tricuspid regurgitation which was common after heart transplantation. Ten cases received ECMO support for the heart failure after the transplant. The initial application time ranged from 2 h to 2 days and lasted 43～176 h. One died of infection and two died of multi organ failure nothing to do with ECMO application and other 7 discharged with NYHA Ⅰ/Ⅱ cardiac function. Conclusion Early use of ECMO could safely bridge the heart failure patients to the transplant. Replacing the routine with ECMO techniques in the heart transplantation could get good myocardial protection results even with long cold ischemic time and improve the cardiac function recovery. For the heart failure patients after the surgery the ECMO could afford good support effect.     

pH 48 h after onset of extracorporeal membrane oxygenation is an independent predictor of survival in patients with respiratory failure

Extracorporeal membrane oxygenation (ECMO) is a life-saving procedure in patients with severe respiratory failure, unresponsive to conventional therapy. We reviewed our series of 70 ECMO runs (April 1997 to December 2005) in patients with respiratory distress, refractory to standard ventilation. Survival at 90 days was 42.7%. Besides age, we found no statistical significant difference in patient demographics or preoperative patient data between survivors and nonsurvivors. Univariate analyses indicated that pH values at 24 and 48 h after onset of ECMO were significantly higher in survivors. In multivariate analysis, age and pH at 48 h remained independent predictors of survival. ECMO in respiratory failure saves lives. No other demographic or preoperative, patient-related parameter than age was identified as predictor of survival. Although there was no difference in pH at onset of ECMO, blood gas analysis at 48 h revealed pH as an independent predictor of survival.     

Current Status of Extracorporeal Membrane Oxygenation for Severe Respiratory Failure

Abstract: Extracorporeal membrane oxygenation (ECMO) for respiratory failure was reviewed. ECMO progressed from laboratory research to initial clinical trials in 1972. Following a decade of clinical research, ECMO is now standard treatment for neonatal respiratory failure refractory to conventional pulmonary support techniques worldwide. The application of neonatal ECMO has been extended with improved outcome to premature and low birth weight infants as well as older children and adults. As of July 1994, 9,258 neonates, 754 pediatric, and 130 adult patients with respiratory failure treated with ECMO were entered in the registry of the Extracorporeal Life Support Organization (ELSO). Overall survival rates were 81% in neonates, 49% in pediatric, and 38% in adult patients. Recently the adult and pediatric populations treated with ECMO have increased rapidly, and the outcome has improved significantly.