复杂先心病矫治术后低心排体外膜肺氧合支持一例报告

现结合我科进行的1例复杂先心矫治术后呼吸循环功能支持病例,对有关体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)过程中的情况进行回顾性分析.     

体外膜肺氧合用于心死亡供肝的初步经验

目的 总结体外膜肺氧合(ECMO)保护心死亡供肝的初步经验.方法 回顾分析2009年7月至2011年5月期间广州军区总医院肝移植中心施行的17例心死亡肝移植供者临床资料,了解供者原发病和有关指标、供者捐献与获取流程、ECMO使用方法.结果 17例供者均先诊断脑死亡然后等待心脏停跳,属于脑心双死亡供者(DBCD).在心死亡过程全部应用了ECMO,ECMO时间51～380(平均187)min.所有供者均成功获取了供肝并用于受者.受者全组无手术死亡.术后肝功能恢复满意,未发生原发性移植肝无功能并发症.术后1个月内因肺部感染死亡1例,其余16例顺利康复出院并随访至今,随访最长时间为29个月.结论 DBCD是我国公民心死亡供体的特殊类型.ECMO可以控制DBCD热缺血损伤且没有伦理学争议,对我国公民心死亡器官捐献有着十分重要的作用.     

体外膜肺氧合用于成人心脏外科术后26例临床分析

目的总结我院心脏术后患者体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)使用经验,综合分析影响患者预后的危险因素,讨论ECMO治疗过程中的并发症及预防管理经验。方法回顾性分析2012年1月至2017年9月在复旦大学附属中山医院接受心脏手术后因心肺功能不全等原因行ECMO支持且辅助时间8 h的26例患者的临床资料,其中男19例、女7例,年龄24~80(58.0±13.9)岁。结果 26例中成功脱机12例,6例存活出院。其中行VA ECMO(veno-arterial ECMO)总共24例,包括心脏移植术后5例,心脏瓣膜术后9例,成功脱机3例。7例瓣膜术后患者因难治性低心排血量综合征(low cardiac output syndrome,LCOS),术后48 h内ECMO插管;主动脉手术后8例,其中3例脱机;冠状动脉旁路移植术及其他心脏术后4例。VA ECMO除2例大血管术后患者行股静脉-腋动脉置管外,其余均行经股静脉-股动脉插管。VV ECMO患者均行股静脉-颈静脉插管。ECMO支持后出血10例,成功脱机5例。所有患者在辅助期间均有不同程度的输血治疗,ECMO支持后出现感染7例;所有患者中发生远端肢体严重缺血4例。存活与死亡患者中乳酸等在ECMO支持前后差异均无统计学意义,但存活病例中血清乳酸的下降速度始终比死亡患者快,术后前6 h下降趋势最显著。结论 ECMO是治疗心脏术后LCOS和顽固性低氧血症的重要支持手段之一,患者所接受手术类型、置管时机的选择是ECMO成功的关键因素。ECMO插管方式的不同、ECMO期间对出血的预防与控制、乳酸等代谢产物水平的监测及管理、抗感染措施的使用都是ECMO成功的重要因素。     

法洛四联症术后低心排血量综合征发生因素探讨

低心排血量综合征（ｌｏｗｃａｒｄｉａｃｏｕｔｐｕｔｓｙｎｄｒｏｍｅ,ＬＣＯＳ）仍是法洛四联症（ｔｅｔｒａｌｏｇｙｏｆＦａｌｏｔ,ＴＯＦ）根治术后主要并发症和死亡原因［１～３］。我们对１９８３年１月～１９９６年１２月的ＴＯＦ根治术资料进行分析,探讨术后...     

体外膜肺氧合用于困难气道的研究进展

体外膜肺氧合(ECMO)是一套体外循环系统,通过对患者引出的血液进行体外氧合后回输,可以有效代替患者的心肺功能。作为一种辅助手段,ECMO常用于重症心肺功能衰竭患者的急救以及心肺手术的体外循环。而对于合并困难气道的患者,在常规氧合方法无法提供有效氧合的情况下,ECMO可以满足氧合需求。鉴于ECMO的诸多优势,建议将其纳入气道管理指南。本文就近年来ECMO用于困难气道患者的研究进展做一综述。     

心脏移植术后体外膜肺氧合支持一例

体外膜肺氧合(ECMO)是一种可暂时性替代心肺功能的新型抢救技术,已被成功用于多种心脏围手术期循环、呼吸支持.心脏移植术后ECMO支持国内报道罕见[1].我院于2006年12月15日为1例扩张性心肌病患者实施原位心脏移植,术后ECMO支持5 d使受者存活.现将本例报告如下.     

法乐四联症根治术后低心排综合征诊断标准探讨

法乐四联症根治术后低心排综合征诊断标准探讨石艳芬梁平宁寿葆林其珊我们通过严密的观测，对法乐四联症（ＴＯＦ）根治术后各项生命体征的动态变化，应用超声心动图连续监测心脏指数，以建立ＴＯＦ根治术后低心排综合征（ＬＣＯ）的定性定量诊断标准。报告如下：临床资料...     

边缘性供心移植术中采用体外膜肺氧合技术四例

目的 研究体外膜肺氧合(ECMO)技术用于边缘性供心移植的临床效果.方法 4例患者心脏移植时采用ECMO技术,其供心的冷缺血时间长达4.8～8.0 h.术中采用ECMO技术代替体外循环,全流量控制在4.5～5.0 L/min,术后流量降到1/2左右时,改为经典的ECMO心脏辅助管路的连接方式,带ECMO辅助回到重症监护室,随后在合适的时机撤除ECMO的辅助.结果 4例手术均顺利完成,主动脉开放后心脏自动复跳.术中阻断时间为(90±3)min,转机(136±14)min,转流时的主动脉流量为50～70 ml·kg-1·min-1,氧流量为2～4 L/min.4例患者均于术后第2天撤除ECMO,术后ECMO辅助时间为(16±4)h.2例术后出现出血,1例右下肢出现淋巴漏和神经过敏,经过积极治疗后好转,无右心衰竭和三尖瓣明显返流现象.4例患者恢复顺利,出院时左心室舒张末径为37～43 mm,左心室射血分数为56 %～64 %,三尖瓣无返流或仅有轻度返流,心功能均为Ⅱ级.结论 以ECMO代替体外循环技术可以有效地保护供心,有利于经历长时间缺血的供心恢复功能.     

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.     

成人体外膜肺氧合循环支持19例

目的总结成人临床应用体外膜肺氧合（ECMO）的经验、教训。方法2004年12月至2006年4月对19例成人实施ECMO，男14例，女5例；年龄19～72岁，平均48．8岁；体重37～100kg，平均69．2kg。内科急性心肺衰竭4例，术后心肺衰竭15例。使用Medtmnic成人ECMO配套系统，经股动、静脉插管行心肺辅助。结果10例（52．6％）顺利出院，9例（47．4％）死亡，其中6例未能脱机，EC2V10成功脱机13例（68．4％），其中3例脱机后未能得到进一步有效治疗而死亡。EC2V10支持11～196h，平均83．3h。单一膜肺使用寿命40～134h。结论EC2V10可以作为临床难治性心肺衰竭的有效辅助手段，使危重症病人度过危险期，为进一步治疗争取宝贵的时间。     

体外膜肺氧合用于肺移植术患者围术期的效果

体外膜肺氧合(ECMO)作为一种体外呼吸、循环支持的手段,广泛应用于早产儿和新生儿呼吸功能不全、成人呼吸窘迫综合征的治疗及心脏外科手术.ECMO在肺移植围术期中也得到了广泛的应用,用于治疗移植肺功能异常及再灌注损伤[1-2],还用于伴肺动脉高压的终末期肺疾病患者肺移植围术期的支持治疗.本院于2005年11月至2010年6月对45例肺移植患者围术期行ECMO,取得了较为理想的效果,现将经验总结如下.     

体外膜肺氧合用于脑心双死亡供者器官获取的流程和方法

目的 总结体外膜肺氧合(ECMO)用于脑心双死亡供者(DBCD)器官获取的流程和方法.方法 回顾分析2009年1月至2012年12月完成的39例DBCD器官捐赠.39例供者中,男性30例,女性9例,年龄(28.1±10.2)岁,体质量指数为(21.3±2.5)kg/m2;原发病为重型脑外伤29例,脑血管意外8例,以及缺血缺氧性脑病2例.评估供者危险指数为1.27±0.28.39例供者在捐赠器官过程中均使用了ECMO支持.结果 ECMO使用时间为(161±77)min.ECMO起始流量为(3.14±0.24) L/min,平衡流量为(1.76±0.58)L/min,复灌流量为(3.10±0.48) L/min.供者器官热缺血时间均为0 min.供者评估时、ECMO使用前、器官获取前供者胆红素总量、丙氨酸转氨酶均无显著性差异,但获取前血清肌酐水平显著升高,尿量显著减少.共获取38个肝脏,78个肾脏,分别实施了37例肝移植、64例肾移植.1个肝脏因合并乙型肝炎病毒表面抗原阳性未匹配到合适受者而未使用,14个肾脏因肾功能不全、肾结石未使用.结论 供者家属和伦理委员会对使用ECMO没有争议,ECMO辅助DBCD器官获取可避免热缺血损伤,获得更满意的移植效果.     

1例体外膜肺氧合下巨大胸骨后甲状腺肿瘤切除术的护理配合

对1例巨大甲状腺肿瘤患者在体外膜肺氧合辅助下行肿瘤切除术,手术顺利,历时12.0 h,切除肿瘤500 g,住院23 d患者康复出院.提出术前充分评估患者状况、做好心理护理和器械物品准备,术中熟悉体外膜肺氧合的操作方法、积极配合手术、密切观察病情等,是获得良好手术效果的重要环节.     

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.     

体外膜肺氧合相关急性肾损伤研究进展

体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)正在被越来越多地应用于心肺功能衰竭的患者,ECMO期间并发的(acute kidney injury, AKI)与患者死亡率相关,是ECMO辅助中除血栓和出血以外的常见和高危并发症,但其相关机制及其早期检测和预后预测等却未得到明确.本文就ECMO辅助时肾损伤的病理生理变化、相关检测方法和连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)等研究进展作一综述.     

体外膜肺氧合辅助后高胆红素血症的临床意义

目的 探讨体外膜肺氧合(ECMO)辅助病人高胆红素血症的发病率及其对住院死亡的影响.方法 收集2005年至2008年65例应用ECMO辅助的成年病人资料,记录血流动力学、血牛化指标等以及临床转归.结果 51例成功脱离ECMO,脱机率为78.5%,33例生存出院,总病死率49.2%.55.4%的ECMO辅助病人发生高胆红素血症,其病死率明显高于非高胆红素血症组(P<0.01).Logis-tic回归分析显示,高胆红素血症明显增加病人住院死亡风险(OR=3.895,P<0.01).结论 高胆红素血症在ECMO辅助病人中的发病率较高,是增加术后病死率的影响因素之一,应及时处理,以改善病人的临床转归.     

体外膜肺氧合治疗重症急性呼吸窘迫综合征的护理

目的 总结体外膜肺氧合(ECMO)治疗重症急性呼吸窘迫综合征(ARDS)的临床护理策略.方法 对22例机械通气效果不佳的重症ARDS患者应用ECMO治疗,同时合理调配护理人员,加强病房环境管理及各项生命指标的监测等.结果 ECMO治疗24 h后,患者氧代谢情况明显改善;住院治疗25～43 d,治愈16例,死亡6例.结论 严密监测和有效的护理是ECMO治疗成功的重要保证.     

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.     

体外膜肺氧合治疗重症急性呼吸窘迫综合征的护理

目的总结体外膜肺氧合（ECMO）治疗重症急性呼吸窘迫综合征（ARDS）的临床护理策略。方法对22例机械通气效果不佳的重症ARDS患者应用ECMO治疗，同时合理调配护理人员，加强病房环境管理及各项生命指标的监测等。结果ECMO治疗24h后，患者氧代谢情况明显改善；住院治疗25～43d，治愈16例，死亡6例。结论严密监测和有效的护理是ECMt）治疗成功的重要保证。