体外膜肺氧合

体外膜肺氧合 ( ECMO)是一种呼吸循环支持技术 ,其原理是经导管将静脉血引到体外 ,在血泵的驱动下 ,经过膜式氧合器氧合 ,再输回患者体内。对呼吸衰竭的患者 ,将大部分血在体外氧合 ,有利于低氧血症的纠正和肺部病变的恢复 ;对循环衰竭患者 ,心肺转流可降低肺动脉高压和右心室负荷 ,减少左心室的充盈和射血 ,对双侧心室的功能恢复有益。 ECMO的实施需要内外科医师、灌注师、呼吸治疗师、营养师、药剂师、护士等的密切配合 ,是一个反映医院综合水平的系统工程。ECMO的适应症 :1患者心肺功能损害可逆 ,预期在 2～3周恢复 ;2急性呼吸衰竭…     

体外膜肺氧合支持治疗39例心肺功能衰竭患者的临床经验

目的:回顾性总结阜外心血管病医院39例心肺功能衰竭患者应用体外膜肺氧合(ECMO)支持治疗的临床经验。方法:2004年12月至2006年6月,对本院39例终末期心脏病和心脏术后需心肺支持的患者进行ECMO支持治疗,所有患者均采用静脉到动脉的ECMO辅助方式。婴幼儿采用右心房—升主动脉插管,成人应用右心房—股动脉插管或股动—静脉插管,肝素用量5~20U/(kg.h),激活全血凝固时间(ACT)维持120~160s。辅助期间流量在40~220ml/(kg.min)。结果:25例患者顺利撤离ECMO装置,其中21例患者康复出院(总出院率为53.8%,21/39),4例患者术后死亡。25例患者ECMO平均辅助时间(91±57)h。其余14例患者因适应证的选择、严重并发症(其中3例与ECMO技术有明确关系)等原因而放弃治疗最终死亡,ECMO平均辅助时间(112±101)h。共18例死亡,ECMO平均辅助时间(116±103)h。39例患者ECMO平均辅助时间(99±62)h,共用膜肺44个,平均膜肺使用时间(91±47)h。ECMO并发症:主要有出血和渗血、肾功能衰竭、感染、血栓形成、神经系统并发症、肢体缺血坏死等。结论:ECMO支持是一种有效的循环呼吸衰竭机械辅助治疗方法,也可以作为心脏移植患者等待供体期间的桥梁过渡。应用ECMO的时机和适应证是ECMO成功的关键。     

超声心动图在体外膜肺氧合对心脏支持的应用价值

目的：探讨超声心动图在体外膜肺氧合(ECMO)支持辅助中对心脏的监测作用。方法：2004年12月～2005年8月间连续10例因低心排接受 Veno-Aterial ECMO 支持,其中心脏外科术后8例,心肌病急性心力衰竭拟心脏移植的2例患者,年龄13～60岁,平均(44±12)岁。仪器为 Philips iE33和 sonos 5500彩超仪,均在床旁进行检查,分别在 ECMO 安置前、ECMO 辅助后(撤机前30 min 内流量减至最低)前后观察患者左心室射血分数(INEF)、左心室舒张末前后径(LVEDD)等指标,结合患者临床资料(心率、血压、左心房压及血氧饱和度)对比。并观察并发症情况。结果：10例患者 ECMO 辅助后的 LVEF、LVEDD、心率、血压、左心房压及动脉血氧饱和度均有改善。并发症的检出：机械瓣异常、左心房血栓、心包血凝块、二尖瓣狭窄未纠正各1例。结论：彩色多普勒超声心动图可无创实时评价 ECMO 辅助前后心脏结构及功能变化,及时发现其并发症。     

体外膜肺氧合支持下重症患者的呼吸介入治疗

部分重症患者的呼吸介入治疗在常规局麻或全麻下风险极高,体外膜肺氧合（ECMO）可以提供有效的呼吸和（或）循环支持,预防或克服围手术期致命的低氧血症和高碳酸血症,保障手术顺利进行。文章结合目前发表的短期ECMO支持下重症患者呼吸介入治疗的病例报道,针对ECMO支持下呼吸介入治疗的应用时机、适用人群和ECMO管理细节（如工作模式、抗凝治疗、撤机和并发症等）等方面进行概述和探讨,以期能为更好开展ECMO支持下呼吸介入治疗提供指导。     

体外膜肺氧合的临床应用现状和发展趋势

体外膜肺氧合原理和现状体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)是将血液从体内引到体外,经膜肺氧合再用泵将血灌入体内,可进行长时间心肺支持。ECMO治疗期间,心脏和肺得到充分休息,全身氧供和血流动力学处在相对稳定状态。此时膜式氧合器     

体外膜肺氧合转流在肺移植术中的应用

目的探讨肺移植术中应用体外膜肺氧合（ECMO）转流的效果。方法对23例终末期肺疾病患者行肺移植术（单肺移植16例,序贯式双肺移植7例）,麻醉诱导气管插管后常规行右侧股动、静脉穿刺置管,行ECMO转流辅助,转流期间维持激活凝血时间（ACT）160～200 s,流量控制在1.8～2.5 L/（m2.min）,转流时间3.5～8.2 h。监测转流前后动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）、肺动脉压（PAP）、肺泡气—动脉血氧分压差（PA-aO2）。结果移植术顺利,麻醉全程生命体征平稳,ECMO转流后PAP及PaCO2明显下降,PaO2显著升高。术后未出现ECMO相关并发症。术后3个月因多器官功能衰竭、移植肺功能丧失、支气管吻合口裂开而死亡各1例;术后1 a内急性排斥反应发生率为34.8%（8/23）;死于重症排斥反应及严重感染分别为1、2例。受者术后3个月、1 a及3 a存活率分别为86.9%、73.9%和52.2%,中位存活时间49个月,肺功能改善明显,生活质量显著提高。结论 ECMO转流应用于肺移植术中效果确切,可有效控制肺动脉高压,提高肺移植术的成功率及受者的存活率。     

体外膜肺氧合治疗ARDS的实验研究

目的：探讨体外膜肺氧合（ECMO）治疗ARDS的有效性和可行性。方法：采用油酸注入法制备犬ARDS模型,将15只犬随机分为3组：对照组（n=5）、模型组（n=5）及V-VECMO治疗组,通过监测血气指标、血流动力学指标、血管外肺水含量及肺顺应性指标,评价V-VECMO疗效。结果：V-VECMO明显提高了动脉和混合静脉血氧分压,增加氧供,增加心排血量,降低肺血管阻力,减轻肺水肿,肺功能明显改善。结论：ECMO治疗ARDS有效和可行,为临床治疗ARDS提供了新思路。     

107例体外膜肺氧合并发症回顾分析

目的:总结阜外心血管病医院107例应用体外膜肺氧合(ECMO)支持治疗患者的并发症发生情况,探讨ECMO并发症的发生和防治,提高ECMO救治水平。方法:阜外医院2004年12月至2008年12月共对107例患者行ECMO支持治疗,回顾性分析总结其临床资料,探讨其并发症发生情况、原因、防治及并发症对ECMO结果的影响。结果:ECMO机械并发症主要有氧合器渗漏(28.4%)、氧合器置换(27.5%)及管路血栓(20.6%)等;机体并发症主要有出血和渗血(32.7%)、肾功能不全(28.3%)、溶血(14.0%)、感染(14例;13.1%)、神经系统并发症(11.2%)、肢体远端缺血(9例;8.4%)及多器官功能衰竭(6例;5.6%)等。肾衰、肢体缺血坏死、多器官功能衰竭(MSOR)及DIC等并发症影响患者预后。结论:ECMO并发症较多,危害较大,应尽量减少和避免并发症,对其积极治疗,进一步提高ECMO的救治水平。     

体外膜肺氧合用于危重经皮冠状动脉介入治疗

目的总结体外膜肺氧合（ECMO）在危重患者经皮冠状动脉介入治疗（PCI）中应用的经验。方法 2012年1月至2013年3月6例危重冠心病患者在PCI术中使用ECMO辅助,回顾性分析其临床资料,调查患者基本情况、辅助原因、辅助时间、并发症及预后。结果 6例患者均在ECMO辅助下顺利完成PCI术,辅助时间34~96 min,术中血流动力学平稳,平均动脉压（MAP）70~90mm Hg,术中未出现心室颤动、呼吸心搏骤停、心脏压塞等PCI术中严重并发症。6例患者分别置入支架2~4枚。1例患者因肾功能不全于PCI术毕通过ECMO管路连接超滤器行改良超滤以预防对比剂肾病。所有患者术后均顺利停机并撤除ECMO,术后1~3 d心力衰竭的症状得到控制,可平卧,无心绞痛发作。1例患者术前合并肺部感染,因感染加重于术后1个月死亡,其余5例患者康复出院。结论 ECMO可以为危重PCI患者提供有效支持治疗,但需充分评估病情,及时适度应用。     

急性重症呼吸衰竭与体外膜肺氧合

急性重症呼吸衰竭（severe acute respiratory failure）是由于肺外或肺内的严重疾病引起肺损伤导致气体交换障碍,产生严重的低氧血症和／或高碳酸血症,其病情较重,病死率高。尽管在呼吸危重病治疗方面已取得一些进展,但由于急性肺损伤／急性呼吸窘迫综合征（acute lung injury／acute respiratory distress syndrome,ALI／ARDS）病因复杂,     

Nosocomial infections in adult patients undergoing extracorporeal membrane oxygenation.

The use of extracorporeal membrane oxygenation (ECMO) for adult patients has increased in recent years. A retrospective cohort study of adult patients undergoing ECMO was performed between 19 February 1985 and 10 October 1995 to evaluate nosocomial infections. Seventy-one evaluable patients underwent ECMO for a total of 799 days. Forty-six infections were identified in 32 (45%) of 71 patients. There were 15 bloodstream infections, 13 lower respiratory infections, 11 urinary tract infections, and 7 miscellaneous infections. The rates of bloodstream infection (18.8 cases per 1,000 ECMO days) and urinary tract infection (13.8 cases per 1,000 ECMO days) were significantly higher than those reported through the Centers for Disease Control and Prevention / National Nosocomial Infection Surveillance System (P < .0001 and P < .001, respectively). The rate of bloodstream infection increased with the duration of ECMO cannulation. This study highlights the increased risk for nosocomial infections in this patient population. Infection may not be apparent, and increased physician awareness of infection risk is imperative.     

Incidence of nosocomial infections in adult patients undergoing extracorporeal membrane oxygenation

Introduction

Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) are at increased risk for developing nosocomial infections owing to their underlying disease process along with numerous invasive monitoring devices.

心胸外科术后使用体外膜肺氧合治疗重度心肺功能不全23例临床分析

目的 分析我院成人心胸外科术后患者应用体外膜肺氧合(ECMO)治疗的临床资料,总结ECMO治疗经验及其相关并发症的防治措施.方法 回顾性分析2016年1月至2020年6月在上海交通大学医学院附属新华医院心胸外科术后因心肺功能不全行ECMO治疗的23例患者的临床资料,其中男性16例、女性7例,年龄(64.5±8.9)岁....     

A comparison of existing risk prediction models in patients undergoing venoarterial extracorporeal membrane oxygenation

BackgroundPatients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA-ECMO) require an immediate risk profile assessment in the setting of incomplete information. A number of survival prediction models for critically ill patients and patients undergoing elective cardiac surgery or institution of VA-ECMO support have been designed. We assess the ability of these models to predict outcomes in a cohort of patients undergoing institution of VA-ECMO for cardiogenic shock or cardiac arrest.MethodsFifty-one patients undergoing institution of VA-ECMO support were retrospectively analyzed. APACHE II, SOFA, SAPS II, Encourage, SAVE, and ACEF scores were calculated. Their ability to predict outcomes were assessed.ResultsIndications for ECMO support included postcardiotomy shock (25%), ischemic etiologies (39%), and other etiologies (36%). Pre-ECMO arrest occurred in 73% and 41% of patients underwent cannulation during arrest. Survival to discharge was 39%. Three survival prediction model scores were significantly higher in nonsurvivors to discharge than surivors; the Encourage score (25.4 vs 20; p = .04), the APACHE II score (23.6 vs 19.2; p = .05), and the ACEF score (3.1 vs 1.8; p = .03). In ROC analysis, the ACEF score demonstrated the greatest predictive ability with an AUC of 0.7.ConclusionsA variety of survival prediction model scores designed for critically ill ICU and VA-ECMO patients demonstrated modest discriminatory ability in the current cohort of patients. The ACEF score, while not designed to predict survival in critically ill patients, demonstrated the best discriminatory ability. Furthermore, it is the simplest to calculate, an advantage in the emergent setting.     

Changes of the cytokine profile in inflammatory bowel diseases

Cytokines are indispensable signals of the mucosa-associated immune system for maintaining normal gut homeostasis. An imbalance of their profile in favour of inflammation initiation may lead to disease states, such as that is observed in inflammatory bowel diseases (IBD). Although Crohn’s disease (CD) is often described as a prototype of T-helper 1-type diseases, and ulcerative colitis (UC) is traditionally viewed as a T-helper 2-mediated condition, the classic paradigm, which categorises cytokines into pro- and anti-inflammatory groups, has recently been changed. The inflammation regulatory pathways may not be mutually exclusive as individual cytokines can have diverse and even opposing functions in various clinical and immunological settings. None the less there are many common immunological responses in IBD that are mediated by cytokines. Although they regulate and influence the development, course and recurrence of the inflammatory process, the concrete pathogenic role of these small signaling molecules is sometimes not unambiguous in the subtypes of the disease. Our aim is to review the current information about pro- and anti-inflammatory effects of traditionally studied and recently discovered cytokines in the pathogenesis of UC and CD. The better understanding of their production and functional activity may lead to the development of new therapeutic modalities.     

无症状性脑梗死患者血清炎性因子和纤溶及抗纤溶活性的变化

目的观察无症状性脑梗死(silent cerebral infarction,SCI)患者血清炎性因子和纤溶及抗纤溶活性的变化。方法选择SCI患者53例(SCI组)和健康体检者55例(对照组),分别检测血清高敏C反应蛋白(hs-CRP)、血浆纤溶酶原活性(PLG:A)、纤溶酶活性(PLM:A)、组织型纤溶酶原激活物(t-PA)活性、D-二聚体(D-D)含量、_2α-纤溶酶抑制剂(α_2-PI)和纤溶酶原激活物抑制剂(PAI)活性。结果 SCI组hs-CRP水平明显高于对照组[(15.36±4.30)mg/L vs (10.26±2.61)mg/L,P<0.01],SCI组PLM:A、t-PA和D-D含量均明显低于对照组[(35.84±10.23)% vs (68.74±18.41)%,(0.11±0.01)U/ml vs (0.49±0.12)U/mL(0.36±0.14)mg/L vs (0.68±0.16)mg/L,P<0.01)],SCI组PLG:A与对照组比较差异无统计学意义(P>0.05),SCI组α_2-PI活性和PAI活性明显高于对照组[(128.46±23.75)% vs (96.36±19.34)%,(0.86±0.22)AU/ml vs (0.48±0.10)AU/ml.P<0.01]。结论炎症过程和纤溶及抗纤溶系统的功能失调与SCl的形成有关。     

不同体质量指数女性患者静-动脉体外膜肺氧合辅助的临床结局回顾性分析

目的:分析超重或肥胖对静脉-动脉体外膜肺氧合(VA ECMO)辅助的女性患者临床结局的影响。方法:总结2011年1月至2014年12月,在北京安贞医院接受VA ECMO辅助的女性患者48例,按体质量指数(BMI)高低分为未超重组(NOW),BMI<24/(kg/m~2),n=34和超重或肥胖组(OVO),BMI≥24/(kg/m~2),n=14,比较两组患者ECMO辅助前基本资料、ECMO辅助参数、并发症和患者的临床结局。结果:两组患者的年龄、相关基础病、ECMO辅助前心功能、是否心肺复苏及ECMO前乳酸水平均无明显差别。OVO组患者的出院生存率为42.9%,高于NOW组的14.7%(P<0.05),两组患者的ECMO辅助时间和输血量没有明显差别,住院时间、ICU(intensive care unit)时间、机械通气时间均无明显差异。结论:超重或肥胖的VA ECMO辅助女性患者出院生存率可能高于偏瘦的患者,应辩证看待肥胖对VA ECMO辅助的女性患者临床结局的影响。     

Sudden deafness in patients undergoing cardiac surgery with extracorporeal circulation

Between January 1974 and December 1986, 5,975 patients underwent open heart surgery at National Institute of Cardiology "Ignacio Chávez". We reviewed all open heart cases carried out at this Center. Eleven patients (1.8/1000) presented unilateral sudden hearing loss following cardiopulmonary bypass surgery. Pure tone audiograms, speech reception threshold, discrimination testing, tympanometry and stapedius reflex testing were carried out. We then studied the relationship between the auditory deficit and the type of surgical procedure, length of time on the pump, preexisting ear disease, coexistence of diabetes, use of ototoxic drugs and occurrence of hemodynamic complications. There are 3 possible causes for hearing loss in cardiopulmonary bypass: 1) Microembolism from the cardiopulmonary bypass pump to the arteries that supply only the cochlea. 2) Decreasing cerebral flow, or 3) Microhemorrhage of the internal ear. Ototoxic drugs are used frequently, but the hallmark of these drugs is bilateral toxicity, and all the cases under discussion have been unilateral. Unilateral sudden deafness after open heart surgery constitutes another complication, fortunately rare and benign in most cases. Further studies should be undertaken to clarify the pathophysiology of this entity.