体外膜肺氧合治疗急性心肌梗死合并心源性休克的临床研究

目的 总结体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)治疗急性心肌梗死(acute myocardial infarction,AMI)合并心源性休克的临床经验.方法 回顾南京医科大学第一附属医院急诊中心2016年3月至2020年10月收治的37例采用ECMO治疗的A...     

急诊体外膜肺氧合辅助下危重心肌梗死的介入治疗

目的 探讨体外膜肺氧合(ECMO)辅助下对急性危重心肌梗死(AMI)患者行急诊经皮冠状动脉介入治疗(PCI)的疗效.方法 回顾分析2003-01-2007-12期间住院的25例诊断AMI并心搏骤停、严重心律失常、心功能衰竭的患者在ECMO支持下行急诊PCI治疗,分析其临床疗效.结果 25例患者均在ECMO支持下血流动力学稳定,并成功行PCI,梗死相关动脉全部再通,20例血流达到TIMI 3级,5例患者发生慢血流或无复流(血流TIMI 0～2级).急诊介入术中无一例死亡,介人治疗术后住院期内死亡7例,住院期间总的死亡率为28%(7/25).结论 ECMO支持使高危AMI患者血流动力学稳定,为高危患者进行PCI提供了必备的前提条件,为冠状动脉血运重建赢得了时间,明显提高了危重AMI患者的存活率.     

Pulmonary embolectomy in high-risk acute pulmonary embolism: The effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support

Objectives

To investigate the effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support (ECLS) in high-risk acute pulmonary embolism (aPE) treated with pulmonary embolectomy.

Materials and methods

This retrospective study included 25 consecutive patients of aPE treated with pulmonary embolectomy in a single institution between June 2005 and July 2012. All patients had high-risk aPE identified by computed tomographic angiography and were not suitable for thrombolytic therapy. High-risk aPE here was defined as aPE with (1) hemodynamic instability, (2) a pulmonary artery obstruction index (PAOI) ≥ 0.5, (3) a diameter ratio of right ventricle-to-left ventricle (RV-to-LV) ≥ 1.0, or (4) right heart thrombi. Once the eligibility was confirmed, a 3-staged therapeutic algorithm was adopted to perform an aggressive preoperative resuscitation, an expeditious pulmonary embolectomy with multidisciplinary postoperative care, and a thorough surveillance for recurrence.

Results

Among the 25 patients, 24 had a PAOI ≥ 0.5 and 23 had a RV-to-LV diameter ratio ≥ 1.0. Four patients had right heart thrombi. Sixteen patients developed preoperative instability requiring inotropic and/or mechanical support. Eight in the 16 had a preoperative cardiac arrest (CA) and six of these were bridged to surgery on ECLS. Three in the 6 patients weaned ECLS after surgery and survived to discharge. The overall in-hospital mortality was 20% (n = 5). A preoperative CA (Odds ratio [OR]: 16, 95% confidence interval [CI]: 1.4–185.4, p = 0.027, c-index: 0.80) and a postoperative requirement of ECLS (OR: 36, 95% CI: 2.1–501.3, p = 0.008, c-index: 0.85) was the pre- and postoperative predictor of in-hospital mortality. No late deaths or re-admission for recurrence were found during a median follow-up of 19 months (interquartile range: 8–29).

Conclusion

Pulmonary embolectomy was an effective intervention of high-risk aPE. However, the occurrence of preoperative CA still carried a high mortality in spite of the assistance of ECLS.     

急诊体外膜肺氧合辅助下重症心肌梗死的介入治疗

目的 探讨体外膜肺氧合辅助下对急性重症心肌梗死(AMI)患者中的行急诊经皮冠状动脉介入治疗(PCI)的疗效. 方法 回顾分析2003年1月至2007年12月期间中山大学附属中山医院住院的25例诊断急性心肌梗死合并心脏骤停、严重心律失常或心功能衰竭的患者,在体外膜肺氧合(ECMO)支持下行急诊PCI治疗的临床疗效观察. 结果 25例患者均在ECMO支持下血流动力学稳定,并成功行PCI,梗死相关动脉全部开通,20例患者血流达到TIMI 3级,5例患者发生慢血流或无复流(血流TIMI 0～2级).急诊介入手术中无一例死亡,介入治疗术后住院期内死亡7例,住院期间总的死亡率为28%(7/25). 结论 ECMO支持下,能促进重症AMI患者血流动力学恢复稳定,为重症患者进行PCI提供了必备的前提条件;为冠状动脉血运重建赢得了时间,从而提高了重症AMI患者的存活率.     

体外膜肺氧合在心肺脑复苏中的应用

目的 探讨体外膜肺氧合(extlacorporeal membrane oxygenation,ECMO)在心脏骤停患者中的治疗作用及应用价值.方法 回顾分析2002年6月至2007年6月期间,本院急诊和重症监护室应用体外膜肺氧合(ECMO)治疗的心脏骤停15例患者,按照美国心脏学会<2005年心肺复苏和心血管急救国际指南>的标准诊治方案进行救治,同时行体外膜肺氧合(ECMO)治疗.采用治疗前后自身对照的方法,监测ECMO治疗前、ECMO治疗后10 min、1 h、6 h、12 h、24 h,患者的心率、平均动脉压、中心静脉压(eve);并抽取桡动脉血检测动脉血氧分压、二氧化碳分压、血氧饱和度、酸碱度、动脉血乳酸含量等指标;统计数据以((x)±s)表示,采用SPSS 10.0统计软件包进行t检验,以P<0.05为差异具有统计学意义;同时就患者的神经性后遗症进行了观察和描述.结果 平均动脉压在ECMO治疗后10min比ECMO治疗前明显升高(P<0.01),ECMO治疗后1 h比ECMO治疗后10 min有所升高(P<0.05);CVP在ECMO治疗后10 min比ECMO治疗前,ECMO治疗后1 h比ECMO治疗后10 min有所降低(P<0.05);经ECMO治疗后10 min动脉血氧分压、血氧饱和度较ECMO治疗前明显上升(P<0.01),pH明显升高(P<0.01),动脉血乳酸含量明显降低(P<0.01).15例患者中,11例康复出院,其中5例完全康复,没有后遗症,2例有部分记忆障碍,无躯体后遗症;2例有精神障碍,2例有肢体偏瘫.结论 ECMO治疗可辅助心脏维持有效的血液循环,明显改善低氧血症,为大脑提供稳定的氧合血灌流,对心肺脑复苏有利.     

Resuscitative extracorporeal membrane oxygenation for in hospital cardiac arrest: A Canadian observational experience

Background

Among patients with reversible conditions who sustain cardiac arrest, extracorporeal membrane oxygenation (ECMO) may support end organ perfusion while bridging to definitive therapy.

Methods

A single center retrospective review (February 2008–September 2013) of adults receiving ECMO for cardiac arrest ≥15 min duration refractory to conventional management (E-CPR) or profound cardiogenic shock following IHCA (E-CS) was conducted. The primary outcome was 30-day survival with good neurologic function defined as a cerebral performance category (CPC) of 1–2. Secondary outcomes included intensive care unit (ICU) and hospital length of say, duration of mechanical ventilation, and univariate predictors of 30-day survival with favorable neurologic function.

Results

Thirty-two patients (55 ± 11 years, 66% male) were included of which 22 (69%) received E-CPR and 10 (31%) received E-CS following return of spontaneous circulation (ROSC). Cardiac arrest duration was 48.8 ± 21 min for those receiving E-CPR and 25 ± 23 min for the E-CS group. Patients received ECMO support for 70.7 ± 47.6 h. Death on ECMO support occurred in 7 (21.9%) patients, while 7 (21.9%) were bridged to another form of mechanical circulatory support, and 18 (56.3%) were successfully decannulated. ICU length of stay was 7.5 [3.3–14] days and ICU survival occurred in 16 (50%) of patients. 30-Day survival was 5 (50%) in the E-CS group, 10 (45.4%) in the E-CPR group, and 15 (47%) overall. All survivors had CPC 1–2 neurologic status.

Conclusion

In this single center experience, the use of resuscitative ECMO was associated with neurologically favorable 30-day survival in 47% of patients with prolonged IHCA (H2012:172).     

急诊体外膜肺氧合在心脏骤停中的应用研究

目的探讨急诊体外膜肺氧合（extraeorporeal membrane oxygenation，ECMO）在心搏骤停患者中的治疗作用及应用价值。方法2002年6月至2007年7月，应用急诊体外膜肺氧合（ECMO）治疗心搏骤停患者16例，患者男10例，女6例，均采用股动、静脉插管技术，应用离心泵和肝素涂敷管道。ECMO辅助8～73h，平均19h。监测治疗前后动脉血压及血气分析等指标。结果平均动脉压在ECMO后10min比ECMO前明显升高（P〈0．01），ECMO后1h比ECMO后10min有所升高（P〈0.05），CVP在ECMO后10min比ECMO前有所降低，ECMO后1h比ECMO后10min又有所降低（P〈0.05）。经ECMO辅助治疗后低氧血症均迅速改善，动脉血氧分压、血氧饱和度较转流前明显上升（P〈0．05），动脉血乳酸含量明显降低（P〈0．05）。结论ECMO治疗可辅助心脏维持有效的血液循环，明显改善低氧血症，改善机体氧代谢，为大脑提供稳定的氧合血灌流，对心肺复苏有利。     

体外膜肺氧合对心脏骤停患者神经功能预后的影响

目的探讨体外膜肺氧合（ECMO）对心脏骤停患者神经功能预后的影响因素。 方法纳入2012年1月至2020年6月因心脏骤停入住浙江大学医学院附属杭州市第一人民医院重症医学科且行ECMO治疗的22例患者。以脑功能分类（CPC）量表评价患者出院时神经功能情况,并将其分为CPC良好组（12例,CPC 1 ~ 2分）和CPC不佳组（10例,CPC 3 ~ 5分）。比较两组患者的一般资料、心脏骤停病因、基础疾病、疾病严重程度、心脏骤停相关情况、神经系统相关情况、ECMO相关情况及肌钙蛋白I、白蛋白等生化指标。采用二分类Logistic回归分析ECMO治疗心脏骤停患者对其神经功能预后的影响因素。 结果22例接受ECMO治疗的心脏骤停患者中,14例存活出院且12例神经功能良好。CPC不佳组患者肌钙蛋白I[47.0（26.8,80.0）μg/L vs. 13.6（3.3,32.6）μg/L,U = 20.000,P = 0.017]水平较CPC良好组显著升高,白蛋白[（27 ± 7）g/L vs.（33 ± 6）g/L,t = 2.485,P = 0.022]水平较CPC良好组显著降低。此外,CPC不佳组患者第3天ECMO流量[（3.6 ± 0.8）L/min vs.（3.0 ± 0.7）L/min,t = 2.091,P = 0.050]高于CPC良好组,但两组比较差异无统计学意义。Logistic回归分析结果显示,较低的白蛋白浓度[优势比（OR）= 0.755,95%置信区间（CI）（0.576,0.990）,P = 0.042]是ECMO治疗心脏骤停患者神经功能预后不佳的独立危险因素。 结论较低的白蛋白浓度是ECMO治疗的心脏骤停患者神经功能预后不佳的独立危险因素。     

超声在急性呼吸窘迫综合征围静脉-静脉体外膜氧合期中的应用价值

目的探讨经胸超声心动图、血管超声及腹部超声在急性呼吸窘迫综合征(ARDS)患者围静脉-静脉体外膜氧合(V-V ECMO)期的临床应用价值。方法选取我院拟行V-V ECMO支持治疗的ARDS患者13例,分析超声在插管前对患者基本情况的评估结果,以及在插管过程中、V-V ECMO支持治疗期间和脱机后对心脏及血管相关并发症监测情况。结果行V-V ECMO支持治疗的13例ARDS患者中,12例存活至脱机,8例存活至康复出院。V-V ECMO插管过程中,7例在超声引导下调整套管末端位置;V-V ECMO支持治疗期间,2例在超声引导下调整套管末端位置。并发症发生情况:V-V ECMO支持治疗期间血管超声提示2例套管周围血栓形成,腹部超声提示1例腹腔出血;脱机后超声心动图提示1例下腔静脉附壁血栓形成,血管超声提示1例插管同侧下肢深静脉血栓形成。围V-V ECMO期无严重不良事件发生。结论超声在V-V ECMO插管过程中、支持治疗期间及监测并发症方面均具有重要价值。     

Extracorporeal membrane oxygenation in adult acute respiratory distress syndrome

The role of extracorporeal membrane oxygenation (ECMO) in supporting adult refractory respiratory failure continues to evolve. Technical advances and the clinical challenges of H1N1 associated severe ARDS have spurred a resurgence of interest in ECMO. Published systematic review and pooled analyses point out the limitations of available studies, however, a growing body of evidence suggest potential for benefit. Referral to a specialized center with ECMO experience should be considered early after the initiation of high-level ventilator support in adult patients with severe ARDS.     

Assessment of outcomes and differences between in- and out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal life support

Aim

Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) for in-hospital cardiac arrest (IHCA) patients has been assigned a low-grade recommendation in current resuscitation guidelines. This study compared the outcomes of IHCA and out-of-hospital cardiac arrest (OHCA) patients treated with ECLS.

Methods

A total of 77 patients were treated with ECLS. Baselines characteristics and outcomes were compared for 38 IHCA and 39 OCHA patients.

Results

The time interval between collapse and starting ECLS was significantly shorter after IHCA than after OHCA (25 (21-43) min versus 59 (45-65) min, p < 0.001). The weaning rate from ECLS (61% versus 36%, p = 0.03) and 30-day survival (34% versus 13%, p = 0.03) were higher for IHCA compared with OHCA patients. IHCA patients had a higher rate of favourable neurological outcome compared to OHCA patients, but the difference was not statistically significant (26% versus 10%, p = 0.07). Kaplan-Meier analysis showed improved 30-day and 1-year survival for IHCA patients treated with ECLS compared to OHCA patients who had ECLS. However, multivariate stepwise Cox regression model analysis indicated no difference in 30-day (odds ratio 0.94 (95% confidence interval 0.68-1.27), p = 0.67) and 1-year survival (0.99 (0.73-1.33), p = 0.95).

Conclusion

CPR with ECLS led to more favourable patient outcomes after IHCA compared with OHCA in our patient group. The difference in outcomes for ECLS after IHCA and OHCA disappeared after adjusting for patient factors and the time delay in starting ECLS.     

Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock: Treatment strategies and predictors of short-term and midterm survival

Background

Postcardiotomy extracorporeal life support (ECLS) is a resource-demanding therapy with varied results among institutions. An organized protocol was necessary to improve the effectiveness of this therapy.

Methods and results

A total of 110 patients received ECLS due to refractory postcardiotomy cardiogenic shock between January 2003 and June 2009, and were eligible for inclusion in this retrospective study. Preoperative, perioperative, and postoperative variables were collected, including the European system for cardiac operative risk evaluation (EuroSCORE) and markers of ECLS-related organ injuries. All variables were analyzed for possible associations with mortality in hospital, and after hospital discharge. The mean age, additive EuroSCORE, and left ventricular ejection fraction (LVEF) for all patients was 60 (±14) years, 9 (±6), and 43% (±20%) respectively. Sixty-seven patients were weaned from ECLS and 46 survived to hospital discharge. The mean duration of ECLS support was 143 h (±112 h). Multivariate analysis revealed that an age of >60 years, a necessity for postoperative continuous arteriovenous hemofiltration, a maximal serum total bilirubin >6 mg/dL, and a need for ECLS support for >110 h were independent predictors of in-hospital mortality. In addition, persistent heart failure with LVEF <30% was an independent predictor of mortality after hospital discharge. A risk-predicting score for in-hospital mortality associated with postcardiotomy ECLS was developed for clinical application.

Conclusion

Based on the abovementioned findings, a comprehensive protocol for postcardiotomy ECLS was designed. The primary objective was to achieve adequate hemodynamics within the first 24 h of initiating ECLS. Other objectives of the protocol included a consistent approach to safe anticoagulation while on ECLS, a process to make decisions within 7 days of initiating ECLS, and patient follow-up after hospital discharge.     

体外膜肺氧合治疗用于心肺复苏的临床研究

目的 总结体外膜肺氧合（ECMO）治疗对于常规心肺复苏（CPR）困难患者的临床治疗经验。方法 自2005-09-2006-05我院进行ECMO治疗37例患者，其中11例心脏骤停后实施电除颤和心脏按压等CPR措施无效或自主循环恢复后持续低心排而行ECMO循环辅助。结果 8例顺利停机，6例存活恢复出院，其中2例行心脏移植后康复出院。3例不能顺利撤机者在ECMO辅助期间由于循环功能恶化，最终因多器官功能衰竭死亡。顺利撤机和存活出院的患者治疗前乳酸水平较低。ECMO治疗后乳酸清除率较快（P〈0．05）。ECMO期间出现的并发症包括出血、神经精神系统异常、肢体缺血坏死和多脏器功能不全。4例患者因膜肺出现血浆渗漏而更换膜肺。结论 ECMO可为危重心脏病患者心脏骤停后复苏困难时提供心肺功能支持，提高危重心脏病患者CPR的存活率。CPR后动脉血乳酸值和ECMO治疗后乳酸清除率可以预测患者预后。     

体外膜肺氧合在抢救危重心脏病患者心搏骤停中的作用

目的观察体外膜肺氧合对危重心脏患者心搏骤停后常规心肺复苏困难者的治疗效果。方法本院自2005年9月至2006年5月行体外膜肺氧合(ECMO)治疗危重心脏病患者37例,回顾性分析其中11例发生心搏骤停实施常规心肺复苏无效或复苏后持续低心排而行ECMO循环辅助患者的病历资料。结果5例为心脏术后患者,其中3例心肺复苏(CPR)的同时紧急建立体外循环再次手术,之后因低心排而行ECMO。7例患者床旁建立ECMO,ECMO支持治疗(134．0±113．0)h。8例顺利停机,6例存活出院,其中2例经心脏移植后出院。3例不能顺利脱机者由于ECMO辅助期间循环功能恶化,并最终死于多器官功能衰竭。ECMO期间出现的并发症包括出血、神经精神系统异常、肢体缺血坏死和多脏器功能不全。结论ECMO可以为心搏骤停的患者提供最快的心肺功能支持,为赢得抢救时机和提高抢救质量提供了又一途径,在危重患者心肺复苏中具有良好的疗效。     

体外膜肺氧合治疗暴发性心肌炎的报道一例

心肌炎中以感染性心肌炎最为常见,普通心肌炎通常没有明显的临床症状,但暴发性心肌炎会出现心衰等循环不稳危及生命安全的情况。本文对我科应用体外膜肺氧合成功救治1例暴发性心肌炎患者进行个案报道。     

体外膜肺氧合在严重肺挫伤中的应用研究

目的　探讨体外膜肺氧合 (extracorporealmembraneoxygenation ,ECMO)在严重肺挫伤患者中治疗作用及应用价值。方法　 2 0 0 2年 6月至 2 0 0 4年 8月应用体外膜肺氧合 (ECMO)治疗严重肺挫伤患者 17例 ,患者男 11例 ,女 6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 2 7～ 94h ,平均 6 2h。监测治疗前后血流动力学及氧代谢指标。结果　行ECMO治疗后 ,混合静脉血氧分压、静脉血氧饱和度、动脉血氧分压、血氧饱和度明显上升 (P <0 0 1) ,氧供明显增加 ,氧耗也随之增加 (P<0 0 5 ) ,动脉血乳酸含量明显降低 (P <0 0 1) ,氧摄取率有所上升 (P <0 0 5 )。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