体外膜式氧合在成人心脏病患者中的应用

Objective To explore the experience on venoarterial extracorporeal membrane oxygenation (ECMO) in adult patients with cardiac failure. Methods From February 2005 to June 2008, 45 patients (male 34, female 11) undergoing cardiogenic shock required temporary ECMO support. Average age was (49.0±14.1) years. Average body weight was (67.0±12.8) kg. Coronary heart disease occupied in 21 cases, valve disease occupied in 8 cases, and cardiomyopathy occupied in 7 cases. All the patients could be divided into 3 groups: post-cardiotomy (group 1, n=31), post-transplantation (group 2, n=5), decompensate of chronic heart failure (group 3, n=9). Fourteen patients need cardiac resuscitation before ECMO support. ECMO implantation was performed through the femoral vessels or axillary artery or through the right atrium and ascending aorta. Results Average support duration of ECMO was (126.7± 104.3) h. Twenty-seven patients could be successfully weaned from support (60.0%), additionally, 5 were bridged to heart transplantation. The in-hospital mortality was 42. 2% (19/45). Twenty-six patients (57.8%) could be successfully discharged. The discharge rate was 58. 1% in group 1,4/5 in group 2 and was 4/9 in group 3. Twelve patients were re-operated for hemostasia. Three patients need femoral arterial thrombectomy because of ischemia of lower extremity. Additional intra-aortic balloon pumps were used in 11 patients, with 6 patients successfully discharged. The mortality rate for patients with acute renal failure treated by continuous renal replacement therapy under ECMO support was obviously high (7/9). The dominant mode of death was multisystem organ failure (9/19). Conclusion Early indication, control of complications, and paying attention to the treatment after ECMO support could improve our results with increasing experience.     

体外膜肺氧合辅助后高胆红素血症的临床意义

Objective The incidence of post-operative hyperbilimbinemia, which is associated with poor outcomes in patients, was reported to be increased in recent years though it has been a rare complication for cardiac operations. Post-opera-tive impairment of liver function is highlighted. We evaluated the incidence and prognosis of post-operative hyperbiliruhinemia in adult patients who underwent cardiotomy with extracorporeal membrane oxygenation (ECMO) support. Methods Sixty-five adult patients who had received ECMO support after cardiac surgery from 2004 to 2008 were enrolled and evaluated retrospec-tively. Post-oporative hypethilirubinemia was defined as the serum level of the total bilirubin more than 51.3 μmol/L during postoperative period. Demographic and clinical data included gender, age, types of surgery, perioperative hemodynamic param-eters, biochemical variables, duration of the ventilation support, ICU stay and outcomes. Results The mean age of the pa-tients was (50.1 ± 13.9) years, forty-six patients(70.8%) were male. The main cardiac procedures were heart transplanta-tion for 9 patients, coronary artery bypass grafting and/or valve operations for 47 patients, congenital heart disease correction for 4 patients and other operations for 5 patients. Among all patients, fifty-one patients(78.5%) were weaned from ECMO succeas-fully and thirty-thrce patients were discharged from hospital. The overall mortality rate was 49.2%. Overall incidence of post-operative hyperbilirubinemia was 55.4%. In patients with postoperative hyperbilirubinemia, the mean peak value for serum to-tal bilirubin was 104.8 (68.5-156.7) μmol/l. The hospital mortality in the hyperbilirubinemia group was significantly higher than that in the non-hyperbilirubinemia group(66.7% vs. 27.6%, P <0.01). Moreover, postoperative hypethilirubinemia (adds ratio = 3. 895, 95% confidence interval, 1.088 - 13.947 ; P = 0.037) and SOFA score (odds ratio = 1.214, 95% confidence interval, 0.987 - 1.494, P = 0.047) and APACHE Ⅲ score (odds ratio = 1.096, 95% confidence interval, 1.028 - 1.169 ; P = 0.004) were associated with hospital mortality after adjusting for preoperative levels of the total bilirubin, direct bilirubin, gender and age. Conclusion Postoperative hyperbilirubinemia is one of the complications in adult patients who undergo cardiotomy with ECMO support, and is associated with increased hospital mortality.     

体外膜肺氧合辅助后高胆红素血症的临床意义

Objective The incidence of post-operative hyperbilimbinemia, which is associated with poor outcomes in patients, was reported to be increased in recent years though it has been a rare complication for cardiac operations. Post-opera-tive impairment of liver function is highlighted. We evaluated the incidence and prognosis of post-operative hyperbiliruhinemia in adult patients who underwent cardiotomy with extracorporeal membrane oxygenation (ECMO) support. Methods Sixty-five adult patients who had received ECMO support after cardiac surgery from 2004 to 2008 were enrolled and evaluated retrospec-tively. Post-oporative hypethilirubinemia was defined as the serum level of the total bilirubin more than 51.3 μmol/L during postoperative period. Demographic and clinical data included gender, age, types of surgery, perioperative hemodynamic param-eters, biochemical variables, duration of the ventilation support, ICU stay and outcomes. Results The mean age of the pa-tients was (50.1 ± 13.9) years, forty-six patients(70.8%) were male. The main cardiac procedures were heart transplanta-tion for 9 patients, coronary artery bypass grafting and/or valve operations for 47 patients, congenital heart disease correction for 4 patients and other operations for 5 patients. Among all patients, fifty-one patients(78.5%) were weaned from ECMO succeas-fully and thirty-thrce patients were discharged from hospital. The overall mortality rate was 49.2%. Overall incidence of post-operative hyperbilirubinemia was 55.4%. In patients with postoperative hyperbilirubinemia, the mean peak value for serum to-tal bilirubin was 104.8 (68.5-156.7) μmol/l. The hospital mortality in the hyperbilirubinemia group was significantly higher than that in the non-hyperbilirubinemia group(66.7% vs. 27.6%, P <0.01). Moreover, postoperative hypethilirubinemia (adds ratio = 3. 895, 95% confidence interval, 1.088 - 13.947 ; P = 0.037) and SOFA score (odds ratio = 1.214, 95% confidence interval, 0.987 - 1.494, P = 0.047) and APACHE Ⅲ score (odds ratio = 1.096, 95% confidence interval, 1.028 - 1.169 ; P = 0.004) were associated with hospital mortality after adjusting for preoperative levels of the total bilirubin, direct bilirubin, gender and age. Conclusion Postoperative hyperbilirubinemia is one of the complications in adult patients who undergo cardiotomy with ECMO support, and is associated with increased hospital mortality.     

Cerebral state index versus Glasgow coma scale as a predictor for in-hospital mortality in brain-injured patients

Objective：To compare the value of Glasgow coma scale （GCS） and cerebral state index （CSI）on predicting hospital discharge status of acute braininjured patients.Methods：In 60 brain-injured patients who did not receive sedatives,GCS and CSI were measured daily during the first 10 days of hospitalization.The outcome of prognostic cut-off points was calculated by GCS and CSI using receiver operating characteristic （ROC） curve regarding the time of admission and third day of hospitalization.Sensitivity,specificity and other predictive values for both indices were calculated.Results：Of the 60 assessed patients,14 patients had mild,13 patients had moderate and 33 patients had severe injuries.During the course of the study,17 patients （28.3％） deteriorated in their situation and died.The mean GCS and CSI in patients who deceased during hospitalization was significantly lower than those who were discharged from the hospital.GCS＜4.5 and CSI＜64.5 at the time of admission was associated with higher mortality risk in traumatic brain injury patients and GCS was more sensitive than CSI to predict in-hospital death in these patients.For the first day of hospitalization,the area under ROC curve was 0.947 for GCS and 0.732 for CSI.Conclusion：GCS score at ICU admission is a good predictor of in-hospital mortality.GCS＜4.5 and CSI＜64.5 at the time of admission is associated with higher mortality risk in traumatic brain injury patients and GCS is more sensitive than CSI in predicting death in these patients.     

Diabetes patients and non-diabetic patients intensive care unit and hospital mortality risks associated with sepsis

AIM:To compare mortality risks associated with known diabetic patients to hyperglycemic non-diabetic patients.METHODS:PubMed data base was searched for patients with sepsis,bacteremia,mortality and diabetes.Articles that also identified new onset hyperglycemia (NOH) (fasting blood glucose125 mg/dL or random blood glucose199 mg/dL) were identified and reviewed.Nine studies were evaluated with regards to hyperglycemia and hospital mortality and five of the nine were summarized with regards to intensive care unit (ICU) mortality.RESULTS:Historically hyperglycemia has been believed to be equally harmful in known diabetic patients and non-diabetics patients admitted to the hospital.Unexpectedly,having a history of diabetes when admitted to the hospital was associated with a reduced risk of hospital mortality.Approximately 17% of patients admitted to hospital have NOH and 24% have diabetes mellitus.Hospital mortality was significantly increased in all nine studies of patients with NOH as compared to known diabetic patients (26.7%±3.4% vs 12.5% ±3.4%,P0.05;analysis of variance).Unadjusted ICU mortality was evaluated in five studies and was more than doubled for those patients with NOH as compared to known diabetic patients (25.3%±3.3% vs 12.8%±2.6%,P0.05) despite having similar blood glucose concentrations.Most importantly,having NOH was associated with an increased ICU and a 2.7-fold increase in hospital mortality when compared to hyperglycemic diabetic patients.The mortality benefit of being diabetic is unclear but may have to do with adaptation to hyperglycemia over time.Having a history of diabetes mellitus and prior episodes of hyperglycemia may provide time for the immune system to adapt to hyperglycemia and result in a reduced mortality risk.Understanding why diabetic patients have a lower than expected hospital mortality rate even with bacteremia or acute respiratory distress syndrome needs further study.CONCLUSION:Having hyperglycemia without a history of previous diabetes mellitus is a major independent risk factor for ICU and hospital mortality.     

体外膜肺氧合在肺移植围手术期的应用30例

目的 总结体外膜肺氧合(ECMO)在肺移植围手术期应用的经验.方法 30例原发性终末期肺病伴继发性肺动脉高压的患者在肺移植术中应用了ECMO,其中单肺移植18例,不横断胸骨序贯式双肺移植12例.在术前使用ECMO维持者2例,分别维持19 d和6 d;其他患者在麻醉完成后开始置ECMO管道.受者在氧合和血流动力学平稳后撒除ECMO.结果所有受者均顺利完成移植.27例于移植术后顺利撤除ECMO;3例术后继续使用ECMO,其中2例分别于术后36 h和7 d时顺利撤除,另1例未能撤除ECMO,术后5 d出现急性肾功能衰竭,术后2周时死于多器官功能衰竭.发生股动、静脉切口感染并发症者2例,股动脉血栓形成(中度)者1例,经治疗后均好转.结论 体外膜肺氧合可应用于伴有原发性或继发性肺动脉高压患者的肺移植手术,其并发症的发生可能与患者病情较重、血流动力学不稳定等因素有关,早期发现和积极有效地治疗可以改善患者的预后.

Abstract：

Objective To explore the perioperative application of extracorporeal membrane oxygenation (ECMO) in lung transplantation. Methods Thirty patients with primary and end-stage pulmonary disease accompanied by pulmonary hypertension were subjected to operation under the accessory of ECMO. Eighteen patients received single-lung transplantation and 12 patients bilateral sequential lung transplantation without sternal division in our hospital from November 2005 to July 2009. In 2 patients ECMO was given before operation and maintained for 19 days and 6 days respectively. In the remaining patients, ECMO pipeline was placed after anesthesia. After lung trarnsplantation,ECMO was removed after the recipients' oxygen saturation and hemodynamics were stable. Results In all recipients lung transplantation was successfully done. ECOM was removed in 27recipients after operation, and the rest 3 recipients were supported by ECMO after operation: the ECMO was removed at 36th h and 7th day after lung transplantation in two patients respectively,and another one was supported by ECMO for 5 days after operation and suffered acute kidney failure, and died of multiple organ failure 2 weeks post-transplantation. Two recipients were infected in thigh arteriovenous cut and one suffered femoral artery thrombosis, but all of them got better and discharged from hospital after treatment. Conclusion ECMO can be used for lung transplantation on patients with primary and secondary pulmonary hypertension. The complications may be associated with patients'serious condition and unstable hemodynamics. Early detection and active and effective treatment can improve patient's prognosis.     

Laparoscopic complete mesocolic excisions for colonic cancer in the last decade:Five-year survival in a single centre

AIM To analyse clinical and long-term oncologic results after laparoscopic complete mesocolic excision(CME) for colonic cancer over a 10-year period.METHODS Consecutive patients who received laparoscopic CME at our hospital from 2007 to 2017 were prospectively registered and retrospectively analysed. In total, 341 patients were included with tumour-nodal-metastasis(TNM) stages 0-Ⅲ.RESULTS The mean age of the patients was 71.9 years. The median length of stay was 5 d. The mean lymph node harvest was 17.8. The mortality rate was 1.2%. Fifteen patients were reoperated on for anastomotic leaks. The local recurrence rate was 2.3%. Five-year TTR and cancer-specific survival CSS were 83.1% and 90.3%. The location of the tumour was not a significant variable for survival in unadjusted and adjusted survival analysis. TNM stage and anastomotic leaks were significant variables with respect to survival.CONCLUSION Laparoscopic CME results in acceptable complication rates and long-term oncologic results. It is important to avoid anastomotic leaks because of their negative effect on survival.     

Type 2 diabetes is associated with a worse functional outcome of ischemic stroke

AIM: To assess whether ischemic stroke severity and outcome is more adverse in patients with type 2 diabetes mellitus(T2DM). METHODS: Consecutive patients hospitalized for acute ischemic stroke between September 2010 and June 2013 were studied prospectively(n = 482; 40.2% males, age 78.8 ± 6.7 years). T2 DM was defined as self-reported T2 DM or antidiabetic treatment. Stroke severity was evaluated with the National Institutes of Health Stroke Scale(NIHSS) score at admission. The outcome was assessed with the modified Rankin scale(m RS) score at discharge and with in-hospital mortality. Adverse outcome was defined as m RS score at discharge ≥ 2 or in-hospital death. The length of hospitalization was also recorded.RESULTS: T2 DM was present in 32.2% of the study population. Patients with T2 DM had a larger waist circumference, higher serum triglyceride and glucose levels and lower serum high-density lipoprotein cholesterol levels as well as higher prevalence of hypertension, coronary heart disease and congestive heart failure than patients without T2 DM. On the other hand, diabetic patients had lower low-density lipoprotein cholesterol levels and reported smaller consumption of alcohol than non-diabetic patients. At admission, the NIHSS score did not differ between patients with and without T2DM(8.7 ± 8.8 and 8.6 ± 9.2, respectively; P = NS). At discharge, the m RS score also did not differ between the two groups(2.7 ± 2.1 and 2.7 ± 2.2 in patients with and without T2 DM, respectively; P = NS). Rates of adverse outcome were also similar in patients with and without T2DM(62.3% and 58.5%, respectively; P = NS). However, when we adjusted for the differences between patients with T2 DM and those without T2 DM in cardiovascular risk factors, T2 DM was independently associated with adverse outcome [relative risk(RR) = 2.39; 95%CI: 1.21-4.72, P = 0.012]. Inhospital mortality rates did not differ between patients with T2 DM and those without T2DM(9.0% and 9.8%, respectively; P = NS). In multivariate analysis adjusting for the difference in cardiovascular risk factors between the two groups, T2 DM was again not associated with in-hospital death. CONCLUSION: T2 DM does not appear to affect ischemic stroke severity but is independently associated with a worse functional outcome at discharge.     

Efficacy of new scoring system for diagnosis of abdominal injury after blunt abdominal trauma in patients referred to emergency department

Purpose: The blunt abdominal trauma (BAT) is a common emergency and is significantly associated with morbidity and mortality. Our study was conducted to achieve the goal that a new scoring system could be used for the BAT patients. Methods: The statistical population of this study was 1000 patients with BAT referred to emergency department of Imam Hossein Hospital, Tehran, Iran. Sampling was carried out in a convenience nonrandom manner and continued to reach the required sample size. All the patients with BAT due to road traffic accidents, falls, and other direct blunt traumas such as punctures and kickbacks were included in the study. Exclusion criteria were after 3 months of pregnancy, under the age of 18, warfarin taking, no reliable medical history providing and penetrating trauma. The study questionnaire was based on BAT scoring system. The data were analyzed by SPSS V20 software. The receiver operating characteristic curve was used to analyze the effectiveness of the new scoring system in predicting the BAT patients’ outcome. Results: The mean age of the patients (n = 1000) was (35.79 ± 13.09) years. The mean score of patients was (6.29 ± 5.80). Based on this scoring system, the patients were divided into three categories. The first group was patients at low risk with score of less than 8, the second group was patients at moderate risk with score of 8e12 and the third group was patients at high risk with score of 12-24. The score of 661 (66.1%) patients were low, 109 (10.9%) were moderate and 230 (23%) had a high score. The association between hip fracture and abdominal tenderness with abdominal injury was significant (p < 0.001). Cronbach''s alpha was 0.76 showing the reliability of this questionnaire to predict the future of patients. Conclusions: The study tool has a sensitivity to predict the BAT patients’ outcome, and has a proper specificity that can be used to reduce the use of harmful modalities such as computed tomography scan.     

小儿体外膜肺氧合支持治疗8例

目的 总结小儿先天性心脏病术后严重心力衰竭和暴发型心肌炎应用体外膜肺氧合(ECMO)支持治疗的经验.方法 8例中术后不能脱离CPB 7例、暴发型心肌炎1例.均使用离心泵,全部静脉-动脉模式;采用中心插管、右房-升主动脉7例,周围大血管插管、股静脉-股动脉模式1例.辅助65～498 h,辅助流量80～120ml·min-1·kg-1.结果 死亡5例;出院3例,生存率38%.并发症包括出血5例、血栓形成2例、溶血1例、DIC 1例、肝衰竭1例、营养不良2例、机械故障2例.结论 先心病术后无残余解削畸形,而出现严重心衰病例,往往因合并左、右心室并伴肺功能不全,宜及时施行ECMO支持治疗,而取代肺脏气体交换功能,减少呼吸器使用中的高浓度氧气和气道压的肺损伤,降低总体病死率;注意及时补充新鲜血小板、血浆等血制品;合理应用血管活性药物和肝素,根椐出血部位及量采用针对性措施,维持内环境稳定;加用超滤,减少机体特别是出血的并发症.应选用长期使用的肝素涂层膜肺,监测膜前后压力,注意血浆渗漏,减少机械并发症.

Abstract：

Objective The use of extracorporeal membrane oxygenation (ECMO) as a treatment for the failure of cardiopulmonary function after cardiac surgery is increasing and has been reported to be 3% to 5% in the cases with congenital heart disease. We reviewed our experience with ECMO in children who received heart surgery for congenital heart disease and complicated with severe heart failure postoperatively. Methods Eight patients received ECMO, seven was due to the failure to wean from bypass and one had fulminant myocarditis. Import membrane oxygenator,veno-arterial mode ECMO and right atriumascending aortic cannulation were used in 7 cases and peripheral cannulation via femoral veno-artery route was used in 1 case.Supportive intervention persisted from 65 to 498 hours, with flow rate maintained at 80 to 120 ml per minute per kilogram body weight. Results Five patients died, with a mortality of 62.5%, and 3 cases discharged, with a survival rate of 38%. Bleeding occurred in 5 cases, thrombosis occurred in 2 cases, hemolysis was identified in 1 case and DIC was observed in 1 case.One case had liver failure and 2 cases had malnutrition. Oxygenator plasma leakage occurred in 2 cases. Mean arterial blood pressure increased significantly after the establishment of ECMO as compared with that before the procedure [( 60.2 ± 7.8 )mmHg vs. (48. 1 ± 5.2 ) mmHg, P≤0.05]. The arterial concentration of lactate decreased significantly, from (5. 1 ± 0. 8 )mmol per liter before ECMO to ( 3.6 ±0. 5 )mmol per liter after ECMO, P ＜0.05. Conclusion For patients who survived the congenital heart surgery and no residual anatomic deformity, ECMO can be used as early as possible as a treatment for severe heart failure which resulted from coexistent of left and right ventricular and pulmonary insufficiency. An overall mortality may be decreased by ECMO technique as it plays a substitution role for gas exchange in the lung. As a result, the concentration of oxygen and the airway pressure used during ventilation, and the resultant lung injury can be reduced. Appropriate strategies involve transfusion of fresh platelet and packed red blood cells, replacement of frozen plasma and blood products, as well as rational use of vasoactive drugs and heparin, and maintaining a stable internal environment. Following strategies are also recommended: using continuous arterio-venous hemofiltration and durable heparin-coated membrne oxygenator, reducing hemorrhagic complications, monitoring pressure on both side of the film, identifying plasma leakage carefully and reducing the mechanical complications.     

Five-year results of 121 consecutive patients treated with extracorporeal membrane oxygenation at Fu Wai Hospital

Since 2004, our institution has adopted venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for patients who otherwise could not be weaned from cardiopulmonary bypass and patients experiencing cardiogenic shock and/or pulmonary dysfunction unresponsive to conventional treatments. In this study, we reviewed our experience with ECMO support and tried to identify predictors of in-hospital mortality. We retrospectively analyzed the clinical records of 121 consecutive patients receiving ECMO. Patients were divided into adult and pediatric groups and analyzed separately. Demographics, clinical characteristics at the time of ECMO implantation, ECMO-related complications, and in-hospital mortality were collected. Logistic regression analyses were performed to investigate predictors of mortality. A P value ≤ 0.05 was accepted as significant. Sixty-eight adult patients and 53 pediatric patients were included in this study. In adult patients, 52 were weaned from ECMO and 43 survived upon discharge. After univariate analysis, ECMO setup location, receiving cardiopulmonary resuscitation before ECMO, leg ischemia, hemolysis, acute renal failure (ARF), neurological dysfunction, and multiple organ dysfunction syndrome were associated with in-hospital death. In multiple logistic regression analyses, leg ischemia (OR 14.68, 95% CI 1.67-129.1), ARF (OR 12.14, 95% CI 2.5-58.8), and neurological dysfunction (OR 49.0, 95% CI 2.28-1051.96) were risk factors associated with in-hospital mortality. Patients put on ECMO in the operating room had a better chance of survival (OR 0.078, 95% CI 0.013-0.417). In pediatric patients, 30 were weaned from ECMO and 26 survived upon discharge. After univariate analysis, age, weight, and eight ECMO complications were associated with in-hospital death. In multiple logistic regression analyses, ARF (OR 24.0, 95% CI 4.2-137.3) was a risk factor associated with in-hospital mortality. A P value of 0.921 and >0.99 was obtained by the Hosmer-Lemeshow test, and the area under the curve was 0.863 and 0.867 for adult and pediatric patients, respectively. The overall survival rate was 57%. ECMO is a justifiable alternative treatment for refractory cardiac and/or pulmonary dysfunction which could rescue more than 50% of carefully selected patients. Higher survival rates could be achieved by preventing ECMO complications.     

Effect of pulmonary support using extracorporeal membrane oxygenation for adult liver transplant recipients with respiratory failure

BackgroundAdult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation.MethodsFrom January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT.ResultsA venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO.ConclusionsECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.     

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.     

VA‐ECMO Support in Nonsurgical Patients With Refractory Cardiogenic Shock: Pre‐Implant Outcome Predictors

Refractory cardiogenic shock (RCS) is associated with a high mortality. Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly used as acute cardiopulmonary support but selection of VA‐ECMO candidates remains challenging. There are limited data on which pre‐VA‐ECMO variables that predict outcome. The aim of this study was to identify pre‐VA‐ECMO predictors of 90‐day mortality. We retrospectively analyzed 76 consecutive patients (median age 52; interquartile range [IQR]: 37–60) supported with VA‐ECMO due to RCS. The association between pre‐implant variables and all‐cause mortality at 90 days was analyzed with multivariable logistic regression. Main etiologies of RCS were acute myocardial infarction 51% and other AHF etiologies 49%. Cardiopulmonary resuscitation was performed in 54% of patients before initiation of VA‐ECMO. Median duration of VA‐ECMO was 5 days (IQR: 2–11). The 90‐day overall mortality was 49% and in‐hospital mortality was 50%; 46% died on VA‐ECMO, 37% were successfully weaned, 13% were bridged to heart transplantation, and 4% to left ventricular assist device. Multivariable logistic regression analysis identified arterial lactate (odds ratio [OR] per mmol/L: 1.15; 95% confidence interval [CI]: 1.06–1.24; P = 0.001) and number of inotropes and vasopressors (OR per agent: 2.14; 95% CI: 1.26–3.63; P = 0.005) as independent predictors of 90‐day mortality. In RCS patients arterial lactate level and number of inotropes and vasopressors were identified as independent pre‐VA‐ECMO predictors of 90‐day mortality. Thus, the severity of cardiogenic shock expressed as levels of lactate and vasoactive agents just before start of VA‐ECMO may be more predictive of outcome than the specific etiology of cardiogenic shock.     

Extracorporeal membrane oxygenation for cardiac failure after congenital heart operation.

Despite continuing improvement in myocardial protection and surgical technique, the repair of complex congenital heart lesions can result in cardiopulmonary compromise refractory to conventional therapy. In a 29-month period, 24 patients (aged 14 hours to 6 years) were treated with extracorporeal membrane oxygenation (ECMO) 28 times for profound cardiopulmonary failure. Four patients required ECMO after each of two cardiopulmonary bypass procedures. Seventeen patients required ECMO to be initiated in the operating room: 12 (71%) were weaned successfully from ECMO, and 8 (47%) survived. Seven patients had ECMO initiated in the intensive care unit: 6 (86%) were weaned, and 5 (71%) survived. Serial echocardiograms demonstrated substantial recovery of cardiac function in 18 of 21 instances (86%) of ventricular failure from myocardial dysfunction. Overall, 18 of 24 patients (75%) were successfully weaned from ECMO including all 4 who underwent 2 ECMO treatments. We conclude that ECMO can successfully salvage children who have serious cardiopulmonary failure immediately after a congenital heart operation and that long-term survival is possible after two ECMO treatments.     

Extracorporeal membrane oxygenation following Norwood stage 1 procedures at a single institution

Extracorporeal membrane oxygenation (ECMO) is an important circulatory assist for children with refractory cardiopulmonary dysfunction, but its role and indications after a stage 1 Norwood procedure are controversial. We assessed outcomes and risk factors in patients who underwent a Norwood palliation and ECMO at our institution. We retrospectively reviewed all patients who underwent a Norwood procedure and were supported with ECMO between January 1998 and January 2010. Of the 91 children who underwent a Norwood procedure during the study period, there were 15 postoperative runs of ECMO in 12 patients. The diagnoses of the patients included five with hypoplastic left heart syndrome, five with a hypoplastic left heart syndrome variant, and two with critical aortic stenosis. A total of four patients underwent bilateral pulmonary artery banding, and two patients underwent aortic valvuloplasty before the stage 1 Norwood procedure. The mean age of the patients was 28±30 days, and mean body weight was 2.6±0.5kg at the induction of ECMO. The indications for ECMO were low cardiac output in six children, circulatory collapse needing cardiopulmonary resuscitation in six children, and hypoxemia in three children. Five of the 12 patients were successfully weaned from ECMO. The significant risk factors for the inability to be weaned from ECMO were a history of circulatory collapse requiring cardiopulmonary resuscitation, and the induction of ECMO in the intensive care unit. Induction of ECMO may be considered earlier when hemodynamics are unstable in impaired patients following a stage 1 Norwood procedure to avoid circulatory collapse.     

体外膜肺氧合在边缘供心移植中的临床应用研究(英文)

目的探讨体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)用于长时间冷缺血(long cold ischemic time,LCIT)供心心脏移植术的临床疗效。方法 2005年2月至2009年4月,11例患者[ECMO环路(intraoperative ECMO,i-ECMO)组]接受LCIT超过7 h的供心移植,手术采用i-ECMO进行心肺分流术,术毕直接转为ECMO辅助。同期有11例患者[心肺分流术(stand-ard cardiopulmonary bypass,s-CPB)组,s-CPB组]行冷缺血少于7 h的心脏移植手术,术中常规s-CPB,术后接受了ECMO辅助。比较两组的ECMO的总体撤机率、ICU停留时间、浓缩红细胞输注量、左心室射血分数(LVEF)、住院费用、围手术期生存率、术后1年生存率,并了解ECMO相关并发症。结果 i-ECMO组和s-CPB组供心缺血时间分别为422～485(平均448)min、110～400(平均218)min,两组间比较差异有统计学意义(P0.01)。i-ECMO组中10例患者(91%)成功撤离EC-MO并无出院前死亡,1例死于术中大出血(与ECMO无关),s-CPB组中9例(82%)成功撤离EC-MO。心脏移植应用ECMO的总体撤机率为86%。两组术后30 d(围手术期)和术后1年的生存率分别为91%和82%、73%和64%,两组比较差异均无统计学意义(P0.05)。i-ECMO组的ICU停留时间、浓缩红细胞输注量以及住院花费均显著低于对s-CPB组(均为P0.05)。i-ECMO组的入院和出院LVEF分别为0.23±0.06、0.65±0.12,s-CPB组相应为0.25±0.10、0.66±0.06,两组出院时LVEF均较术前明显升高,但两组比较差异无统计学意义(P0.05)。ECMO相关并发症及处理:5例患者(23%)因低心排量而应用了主动脉内球囊反搏(IABP),其中3例为成功撤离ECMO的病人,2例为未能撤离ECMO者;6例(27%)患者由于肾功能不全接受了持续肾替代治疗(CRRT),其中2例为成功撤离ECMO,4例为未能撤离ECMO者。结论用边缘供心进行心脏移植术时,术中利用i-ECMO、术毕转为ECMO辅助可以为LCIT的供心提供早期、持续和有效的循环支持,从而在相当程度上改善此类边缘供心的移植成功率。同时,该研究方法还具有ICU停留时间短,浓缩红细胞输注量低和显著节省费用的优点。     

Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension

The use of extracorporeal membrane oxygenator instead of standard cardiopulmonary bypass during lung transplantation is debatable. Moreover, recently, the concept of prolonged postoperative extracorporeal membrane oxygenator (ECMO) support has been introduced in many transplant centers to prevent primary graft dysfunction (PGD) and improve early and long-term results. The objective of this study was to review the results of our extracorporeal life support strategy during and after bilateral sequential lung transplantation (BSLT) for pulmonary artery hypertension. We review retrospectively our experience in BSLT for pulmonary artery hypertension between January 2010 and August 2018. A total of 38 patients were identified. Nine patients were transplanted using cardiopulmonary bypass (CPB), in eight cases CPB was followed by a prolonged ECMO (pECMO) support, 14 patients were transplanted on central ECMO support, and seven patients were transplanted with central ECMO support followed by a pECMO assistance. The effects of different support strategies were evaluated, in particular in-hospital morbidity, mortality, incidence of PGD, and long-term follow-up. The use of CPB was associated with poor postoperative results and worse long-term survival compared with ECMO-supported patients. Predictive preoperative factors for the need of intraoperative CPB instead of ECMO were identified. The pECMO strategy had a favorable effect to mitigate postoperative morbidity and mortality, not only in intraoperative ECMO-supported patients, but even in CPB-supported cases. In our experience, ECMO may be considered as the first choice circulatory support for lung transplantation. Sometimes, in very complex cases, CBP is still necessary. The pECMO strategy is very effective to reduce incidence of PGD even in CPB-supported patients.     

Out-of-center extracorporeal membrane oxygenation for adult cardiogenic shock patients

Patients with cardiogenic shock refractory to conventional management require advanced mechanical circulatory support such as extracorporeal membrane oxygenation (ECMO). In hospitals lacking ECMO facilities, interhospital transportation is necessary for further patient management. Thirty-one adult cardiac patients, who were transported to our hospital by our ECMO transport team between January 1998 and July 2004, were enrolled in this study. The median transportation distance was 200 km (range: 3-300 km). During transportation, the ECMO circuit per se and the patients did not have complications. Of the 31 patients, 20 (64.2%) were weaned off ECMO or bridged to ventricular assist devices and 10 patients (32.1%) survived to discharge. Delayed transfer (>2 days) and high organ dysfunction score were associated with poor outcomes. The survival rate was similar to that of our in-hospital group (survival rate: 32.8%, n = 64). In conclusion, adult cardiogenic shock patients requiring interhospital ECMO transport had a reasonable chance of survival.     

Congenital diaphragmatic hernia, extracorporeal membrane oxygenation, and death: a spectrum of etiologies

Extracorporeal Life Support Organization (ELSO) registry data show increased mortality in congenital diaphragmatic hernia (CDH) infants compared with other extracorporeal membrane oxygenation (ECMO) indications. To test the hypothesis that death might be related to various clinical parameters, retrospective data collection was solicited on 175 ECMO-related CDH deaths from 41 American ECMO centers (ELSO Registry 1980 through 1989). Data capture forms were received on 100 of 175 infants representing 29 of 41 centers. After review of all available material, a predominant cause of death was assigned. Other diagnoses were given secondary status. We analyzed arterial blood gas values at 6, 3, and 1 hour pre-ECMO, as well as at the time of highest recorded PO2 (preductal and postductal) and lowest recorded PCO2, and correlated these findings with predominant cause of death. The relationship between individual variables and cause of death was assessed by t test. Multivariate analysis was performed by using a stepwise discriminate procedure. The most common predominant causes of death were brain death (29%), pulmonary hypertension (25%), and pulmonary hypoplasia (17%). Correlation of arterial blood gas values at 6, 3, and 1 hour pre-ECMO with predominant causes of death established the following statistically significant associations (P less than .05): (1) pulmonary hypoplasia and low PO2 at 6 hours pre-ECMO; (2) brain death and low pH at 1 hour pre-ECMO; and (3) pulmonary hypertension and high HCO3- at 1 hour pre-ECMO.(ABSTRACT TRUNCATED AT 250 WORDS)