ECMO在肺动脉高压肺移植病人围术期的护理

终末期肺病需要行肺移植的病人常伴有肺动脉高压。体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)能在进行呼吸支持治疗时保证病人的氧合,并能提供血流动力学支持。我院2006年7月—2009年7月对30例特发性肺动脉高压及终末期肺病伴继发性肺动脉高压病人实施了ECMO辅助下     

体外膜肺氧合辅助肺移植术治疗对终末期肺病患者预后的影响及相关因素分析

目的 探讨体外膜肺氧合(ECMO)辅助肺移植术治疗对终末期肺病患者预后的影响及相关因素。方法 回顾性分析2020年4月至2022年6月我院开展的87例ECMO辅助肺移植术治疗的终末期肺病患者,其中44例行静脉-动脉(V-A)转流为VA-ECMO组,43例行静脉-静脉(V-V)转流为VV-ECMO组,比较两组患者临床资料、手术相关指标、术后并发症及预后,分析影响终末期肺病患者预后的危险因素。结果 VA-ECMO组平均肺动脉压及重度动脉压占比显著高于VV-ECMO组(P<0.05);手术时间显著高于VV-ECMO组,ECMO流转时间显著低于VV-ECMO组(P<0.05);两组术后PGD率、术后72 h内休克率、再次气管插管或气管切开率、术后6个月生存率比较,差异无统计学意义(P>0.05);多因素Logistic回归分析显示,肺动脉压、ECMO转流时间、术后PGD、再次气管插管或气管切开是影响终末期肺病患者预后的危险因素(P<0.05)。结论 ECMO辅助肺移植术治疗终末期肺病采用V-A转流和V-V转流患者短期预后比较无显著性差异,而肺动脉压、ECMO转流时间、术...     

心脏移植术后患儿行体外膜肺氧合的护理

目的总结心脏移植术后患儿行体外膜肺氧合的护理经验。方法对2例心脏移植术后行体外膜肺氧合患儿,做好监测血流动力学变化、严格控制入量、改善右心功能、肺动脉高压的处理、预防感染等护理措施。结果 2例患儿体外膜肺氧合辅助时间74~115 h,各项生命体征平稳,血气参数正常,痊愈出院。结论加强对低心排综合征、右心功能不全和肺动脉高压的预防和护理,对提高体外膜肺氧合辅助效果和确保手术成功,具有重要意义。     

体外膜肺氧合技术支持治疗期间患者血乳酸浓度及其预后

目的:探讨体外膜肺氧合支持治疗患者血乳酸浓度的变化和预后。方法:于2004-12/2006-09在中国医学科学院阜外心血管病医院因脱离体外循环困难的心脏外科术后患者、扩张性心肌病和冠状动脉粥样硬化性心脏病发生心源性休克的患者共40例进行了体外膜肺氧合支持治疗,按年龄和存活预后分为4组:成人存活组、成人死亡组、儿童存活组、儿童死亡组。分析4组的治疗效果,分别抽取各组患者体外膜肺氧合建立时、体外膜肺氧合运转6h、运转中间时点、停机前6h、停机时的血乳酸浓度。结果:①体外膜肺氧合支持治疗患者40例,成人组26例,20例脱机,16例生存,10例死亡,脱机率76.9%,生存率61.5%;儿童组14例,7例脱机,5例生存,9例死亡,脱机率50.0%,生存率35.0%。②成人或儿童存活组的乳酸浓度都与死亡组有明显差别,存活组血乳酸浓度明显低于死亡组,其中建立和运转6h、中间时点的差异有显著性意义(P<0.05),其余2个时点的差异有非常显著性意义(P<0.001)。组内与建立时比较,中间时点、停止前6h、停止时差异均有显著性意义(P<0.001),血乳酸浓度逐渐降低。结论:经体外膜肺氧合支持治疗的患者,血乳酸浓度明显下降,脱机时血乳酸仍高的患者预后不良。     

体外膜式氧合支持治疗患者血乳酸浓度的变体

背景:体外膜肺氧合的核心部分膜肺采用了肝素涂层氧合器,是在人工材料表面与肝素一端的黏多糖进行共价键结合,使人工材料部分模拟人体血管内皮功能,减少乳酸的产生,增加材料的生物相容性,避免血栓的形成及减轻术后炎症反应.目的:探讨应用了肝素涂层氧合器的体外膜肺氧合支持治疗后,患者血乳酸浓度变化及其与预后的关系.设计:按年龄及存活预后分组,自身对照临床实验.单位:中国医学科学院阜外心血管病医院体外循环科.对象:选择2004-12/2006-09在中国医学科学院阜外心血管病医院40例进行体外膜肺氧合支持治疗的患者,入组条件为脱离体外循环困难的心脏外科术后患者、扩张性心肌病发生心源性休克的患者、冠心病心源性休克的患者.按年龄和存活预后分为4组:成人存活组、成人死亡组、儿童存活组、儿童死亡组.方法:所有患者采用静脉-动脉体外膜肺氧合灌注系统支持治疗,体外膜肺氧合灌注系统由离心泵、变温水箱、肝素涂层氧合器(Jorstra Novalung,德国)及配套管道(Bioline Coating,德国,批号是:SFDA(I)20063450801)等组成.主要观察指标:抽取各组患者体外膜肺氧合建立时、运转6 h、运转中间时点、停机前6 h、停机时患者的血乳酸浓度.结果:①成人组26例,20例脱机,16例生存,10例死亡,脱机率76.9%,生存率61.5%;儿童组14例,7例脱机,5例生存,9例死亡,脱机率50.0%,生存率35.7%.②2个存活组的乳酸浓度均明显低于死亡组(P＜0.05或0.001).组内比较,中间时点、停止前6h、停止时的乳酸浓度低于体外膜肺氧合建立时(P＜0.01),血乳酸浓度逐渐降低.结论:①经体外膜肺氧合治疗的患者血乳酸浓度明显下降.②撤机时血乳酸仍高的患者预后不良.     

1例体外膜肺氧合联合肺移植救治百草枯中毒病人的护理

介绍1例因百草枯中毒后行体外膜肺氧合(ECMO)治疗过渡,成功等待供体进行双肺移植并顺利康复出院病人的护理。进行肺移植前后做好体外膜肺氧合治疗时的相关护理,做好肺移植前无菌环境及用物的准备;肺移植术后做好循环系统、呼吸系统的监测及护理等以及排斥反应的观察、预防感染等护理。病人经过上述护理干预结合后续的康复治疗后顺利出院。     

1例房间隔缺损合并重度肺动脉高压剖宫产术后行肺移植手术患者的护理

报告了1例房间隔缺损合并重度肺动脉高压行剖宫产术后第11天进行肺移植治疗患者的护理经验。护理要点包括:体外膜肺氧合护理,围产期护理,心功能维护,心理护理。患者肺移植术后第30天病情明显好转,转入胸外科病房继续治疗。     

体外膜肺氧合支持下危重患者院内转运管理

总结10例行体外膜肺氧合治疗的危重患者院内安全转运的管理体会。组建专业的转运团队,制定转运流程及突发事件应急预案,转运前充分评估病情并做好仪器和用物准备,转运途中做好患者及仪器的安全管理,转运后做好再查工作,均是体外膜肺氧合支持下危重患者院内安全转运的重点。经以上转运方法,6例急性心肌梗死经皮冠状动脉介入治疗术后患者完成ICU与导管室间的转运,3例重症肺炎合并急性呼吸窘迫综合征患者顺利完成CT检查,1例重症肺部感染合并心源性休克心搏骤停患者在急诊科紧急建立体外膜肺氧合后安全转运至ICU。     

静脉-静脉体外膜肺氧合支持治疗对体外循环心脏手术后难治性低氧血症患者预后的影响

目的 观察体外循环心脏手术后发生难治性低氧血症患者行静脉-静脉体外膜肺氧合(veno-venous extracorporeal membrane oxygenation, VV-ECMO)支持的疗效,探讨其发生院内死亡的影响因素。方法 体外循环心脏手术后发生难治性低氧血症患者12例,均行VV-ECMO支持治疗,治疗时间均≥24 h,观察患者VV-ECMO治疗期间发生插管处出血、术区出血、鼻出血、泵功能障碍、肺部感染等并发症发生情况及VV-ECMO撤机成功情况;比较VV-ECMO治疗前与治疗24 h后氧合指数、血浆乳酸水平、心率、平均动脉压、血管活性药物指数。根据患者存活出院情况分为死亡组4例和生存组8例,比较2组年龄、VV-ECMO治疗前急性生理学与慢性健康评估(Acute Physiology and Chronic Health EvaluationⅡ, APACHEⅡ)评分、VV-ECMO治疗24 h氧合指数等临床资料;采用多因素logistic回归分析体外循环心脏手术后难治性低氧血症患者行VV-ECMO治疗后发生院内死亡的影响因素。结果 12例患者VV-ECMO治疗时间为(1...     

甲流型重症肺炎继发肺纤维化超常期体外膜肺氧合辅助下行双肺移植1例的护理

总结1例甲流型重症肺炎继发肺纤维化超常期体外膜肺氧合辅助下行双肺移植患者的护理。护理要点为超常期体外膜肺氧合维护,双肺移植术后精细化管理严格控制液体,实现感染全面预防策略,落实重症患者早期康复策略,实现最佳的呼吸训练,最大化维护发挥移植肺功能,依托多学科团队合作全面管理患者。通过治疗护理,患者情况稳定,住院64 d康复出院。     

肺移植围术期的并发症处理(附18例报告)

目的观察肺移植围术期患者重症监护室(ICU)监测与治疗手段对并发症的影响。方法于2002年9月—2005年4月,江苏省无锡市第五人民医院有18例肺移植患者,其中肺气肿9例,肺纤维化5例,矽肺、支气管扩张、肺血管平滑肌瘤病及室间隔缺损(室缺)合并艾森曼格综合征患者各1例。手术方式:左肺移植9例,右肺移植5例,室缺修补加右肺移植1例,双肺移植3例。术后带管进入ICU行机械通气、免疫抑制治疗,并预防感染和再灌注损伤等并发症的出现。术前常规心脏超声监测肺动脉收缩压并通过动脉血气分析监测动脉血二氧化碳分压(PaCO2),计算氧合指数(动脉血氧分压/吸入氧浓度,PaO2/FiO2)。结果术后机械通气平均脱机时间(7.39±4.89)d,平均ICU停留时间为(9.72±8.32)d。术后1周通过SwanGanz导管测得患者的肺动脉收缩压较术前有明显下降(48.94±14.45)mmHg比(39.59±7.45)mmHg,1mmHg=0.133kPa,P<0.05;PaO2/FiO2明显改善(263.89±82.09)mmHg比(345.56±92.18)mmHg,P<0.05;PaCO2明显下降(63.29±22.56)mmHg比(38.37±9.19)mmHg,P均<0.05。术后短期内有3例患者死亡,其中1例于术后15d死于急性排斥,1例于术后28d死于真菌感染,1例术后36d死于肺梗死。15例恢复良好出院,最长生存达32个月。结论肺移植是治疗终末期肺病患者的最佳选择,而肺移植术后围术期并发症的处理是肺移植手术成功和长期生存的关键。     

心脏移植术后体外膜肺氧合支持治疗的监护

总结了10例心脏移植术后应用体外膜肺氧合(ECMO)支持治疗的护理经验。10例心脏移植术后出现急性供心衰竭行ECMO辅助治疗,术后监测心电图、血流动力学变化、体温、尿量、引流液、活化凝血时间(ACT)、肝肾功能、游离血红蛋白、胶渗压情况。9例痊愈出院,病死1例,ECMO辅助时间40-824h,床旁超声心动图(UCG)评价心功能得到恢复,移植术后ECMO辅助100h顺利撤除,远期随访结果满意。ECMO支持治疗期间加强心肺功能监护,合理调整呼吸机参数,加强肺部及呼吸道护理,加强心律失常、出血、栓塞、感染、压疮等并发症的防治,可明显降低心脏移植术后危重症患者的病死率。     

Extracorporeal membrane oxygenation as a bridge to liver transplantation for acute respiratory distress syndrome-induced life-threatening hypoxaemia aggravated by hepatopulmonary syndrome

Introduction

Combined with massive lung aeration loss resulting from acute respiratory distress syndrome, hepatopulmonary syndrome, a liver-induced vascular lung disorder characterized by diffuse or localized dilated pulmonary capillaries, may induce hypoxaemia and death in patients with end-stage liver disease.

Methods

The case of such a patient presenting with both disorders and in whom an extracorporeal membrane oxygenation was used is described.

Results

A 51-year-old man with a five-year history of alcoholic cirrhosis was admitted for acute respiratory failure, platypnoea and severe hypoxaemia requiring emergency tracheal intubation. Following mechanical ventilation, hypoxaemia remained refractory to positive end-expiratory pressure, 100% of inspired oxygen and inhaled nitric oxide. Two-dimensional contrast-enhanced (agitated saline) transthoracic echocardiography disclosed a massive right-to-left extracardiac shunt, without patent foramen ovale. Contrast computed tomography (CT) of the thorax using quantitative analysis and colour encoding system established the diagnosis of acute respiratory distress syndrome aggravated by hepatopulmonary syndrome. According to the severity of the respiratory condition, a veno-venous extracorporeal membrane oxygenation was implemented and the patient was listed for emergency liver transplantation. Orthotopic liver transplantation was performed at Day 13. At the end of the surgical procedure, the improvement in oxygenation allowed removal of extracorporeal membrane oxygenation (Day 5). The patient was discharged from hospital at Day 48. Three months after hospital discharge, the patient recovered a correct physical autonomy status without supplemental O₂.

Conclusions

In a cirrhotic patient, acute respiratory distress syndrome was aggravated by hepatopulmonary syndrome causing life-threatening hypoxaemia not controlled by standard supportive measures. The use of extracorporeal membrane oxygenation, by controlling gas exchange, allowed the performing of a successful liver transplantation and final recovery.     

Intraoperative care of elderly patients with COVID-19 undergoing double lung transplantation: Two case reports

BACKGROUNDLung transplantation is considered an effective method for treating patients with end-stage coronavirus disease 2019 (COVID-19). The nurses play a pivotal role in lung transplantation for COVID-19 patients.CASE SUMMARYTwo elderly patients were admitted to the emergency department due to cough, and the nucleic acid test was positive. The patients were preliminarily diagnosed with COVID-19. The chest computed tomography scan revealed massive lung consolidation, and the patients did not improve after treatment with antiviral drugs, glucocorticoids, antibiotics, and other drugs. Under the support of pure oxygen in extracorporeal membrane oxygenation, the patients’ oxygen levels were still poor, indicating that they were in the terminal stage of viral pneumonia. The patients underwent double-lung transplantation and received intraoperative care. The extracorporeal membrane oxygenation device was removed within a week of the surgical procedure, and the respiratory circulation of the patients were stabilized.CONCLUSIONHigh-quality care for COVID-19 patients undergoing lung transplantation ensures patient safety during operation while protecting the safety of the medical staff.     

单肺移植治疗伴有肺动脉高压的终末期肺病

目的观察单肺移植治疗对伴有肺动脉高压的终末期肺病患者的疗效。方法2002年9月—2005年11月我院22例单肺移植患者,其中肺气肿10例、肺纤维化10例、矽肺1例、肺淋巴管平滑肌瘤病1例。受体肺移植术前评估肺动脉压均显示有不同程度的升高。手术方式:左肺移植10例,右肺移植12例。术前常规心脏超声监测肺动脉收缩压,并通过动脉血气分析计算氧合指数(PaO2/FiO2)。结果术后1周用Swan-Ganz导管测定患者平均肺动脉收缩压,较术前有明显下降,从(50.00±13.00)mmHg(1mmHg=0.133kPa)降至(39.50±7.36)mmHg(P<0.05);PaO2/FiO2明显改善,从(241.26±79.54)mmHg升到(348.23±99.31)mmHg(P<0.05)。结论单肺移植是治疗伴肺动脉高压终末期肺病的有效和可选方法。     

Transesophageal echocardiography monitoring in the intensive care department: the management of hemodynamic instability secondary to thoracic tamponade after single lung transplantation.

A 65-year-old woman with pulmonary fibrosis had hemodynamic instability develop after single lung transplantation. Transesophageal echocardiography was useful in determining the cause of hemodynamic instability, which was secondary to thoracic tamponade. Furthermore, transesophageal echocardiography monitoring was important in the decision to initiate extracorporeal membrane oxygenation to evaluate adequate positioning of the cannula and in the extracorporeal membrane oxygenation weaning process.     

肺移植围术期处理

肺移植术（LTX）是治疗终末期肺疾病的一种有益选择。由于我国供体肺紧缺以及大量终末期肺疾病患者没能及时进行肺移植评估,导致这些患者需要在重症医学科（ICU）内行生命支持的同时进行LTX等待及评估;而且这些患者的术后并发症也较多。这样ICU医生对肺移植受体围术期评估和支持能力面临着巨大的挑战。本文就在ICU内LTX受体的围术期管理,包括术前评估,术后并发症以及体外膜氧合（ECMO）技术的应用,根据国外的文献结合本中心的经验进行综述。     

Infantile pulmonary alveolar proteinosis with interstitial pneumonia: bilateral simultaneous lung lavage utilizing extracorporeal membrane oxygenation and steroid therapy.

An infant with refractory pulmonary alveolar proteinosis (PAP) associated with severe interstitial pneumonia is described. Although she was treated by bilateral simultaneous lung lavage utilizing extracorporeal membrane oxygenation and steroid therapy, she died of progressive respiratory failure 28 days after admission. Histologic examination of lung autopsy specimen showed only partial alveolar spaces to be filled with a dense PAS positive granular eosinophilic material and showed severe interstitial pneumonia with marked fibrosis of alveolar walls and interstitium. The lung lavage seemed to be effective for PAP because the effluent fluid sufficiently became clear and the PAS positive material was detected only in partial alveoli. The full venoarterial cardiopulmonary bypass with extracorporeal membrane oxygenation seemed to be very useful to support bilateral lung lavage for small infants. The refractory symptoms and failure of treatment were resulted from the association of severe interstitial pneumonia. In neonates or infants with PAP and severe interstitial pneumonia with poor response for steroid therapy, the lung transplantation should be considered.     

体外膜肺氧合在严重肺挫伤中的应用

目的 探讨体外膜肺氧合（ECMO）对严重肺挫伤患者的治疗效果及应用价值。方法 应用ECMO治疗严重肺挫伤患者17例，均采用颈内静脉、股静脉插管技术，应用离心泵和肝素涂敷管道。ECMO辅助27-94h，平均62h。监测治疗前后血流动力学及氧代谢指标。结果 行ECMO治疗后，静脉血氧分压、静脉血氧饱和度、动脉血氧分压、血氧饱和度明显上升（P〈0．01）；氧供明显增加，氧耗也随之有所增加（P〈0．05）；动脉血乳酸含量明显降低（P〈0．01）；氧摄取率有所上升（P〈0．05）。ECMO前后血流动力学无明显变化。结论 ECMO治疗能明显改善低氧血症，从而改善机体氧代谢，提高组织氧摄取率，为治疗原发病赢得时间。