ECMO联合IABP辅助治疗高危冠心病介入治疗的护理

目的探讨应用体外膜肺氧合（ECMO）和主动脉内球囊反搏（LABP）辅助治疗高危冠心病介入治疗的护理效果。方法对2012年1月～12月7例高危冠心病介入患者,行ECMO联合IABP辅助治疗的临床护理资料进行分析。结果7例患者经治疗后均顺利脱管,脱机率100％,治疗期间发生3例并发症,拔管后因并发症死亡1例。结论ECM0和IABP联合应用为高危冠心病介入治疗患者提供了有效的心脏支持,为心脏的恢复争取时间,严密监护和有效护理是保证ECMO联合IABP辅助治疗高危冠心病介入治疗成功的重要环节。     

体外膜肺氧合应用于心脏术后呼吸循环衰竭患者的护理

目的探讨体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)应用于心脏术后呼吸循环衰竭患者的护理方法。方法回顾性分析并总结2014年6月至2015年12月南京大学医学院附属鼓楼医院心胸外科应用ECMO救治的10例心脏术后呼吸循环衰竭患者的临床资料。结果本组10例患者均顺利停机并撤除ECMO,其中5例患者治愈出院,2例患者因经济问题放弃治疗,2例患者死于多器官功能衰竭综合征(multiple organ disfunction syndrome,MODS),1例撤机后死于严重心力衰竭。结论合适的应用时机、严密的监测和观察、专业的ECMO管理、精细的护理支持,是心脏术后呼吸循环衰竭应用ECMO患者康复的保证。     

体外膜肺氧合用于急危重症患者的临床观察

目的 总结8例危重心肺疾病患者实施体外膜肺氧合(ECMO)的方法和效果,时实施病例的适应证、时机及结局进行回顾性分析,为危重患者ECMO的支持适应证及时机选择提供一些可靠经验.方法 对8例不同病因及不同时机患者实施ECMO,年龄26～82岁,体重57～87 kg,采用静脉-动脉转流,辅助流量40～70 ml/(kg·min);ACT 160～200 s.并对8例患者支持适应证、时机选择及结局进行总结分析.结果 ECMO时间9.5～84.1 h.1例未能脱机死亡;2例脱机后38、6 h后死亡;5例成功脱机,康复出院.结论 ECMO是抢救危重心肺功能衰竭、复苏中支持及心脏手术心功能支持的有效方法,其适应证及时机的选择对实施结局有重要影响.     

体外膜肺氧合应用于危重症患者的初步探讨

目的 探讨体外膜肺氧合(ECMO)在危重症患者呼吸、循环衰竭支持中的作用.方法 回顾分析2007年10月1日至2009年12月26日北京大学第三医院及北京地坛医院重症监护病房(ICU)使用ECMO支持治疗的危重症患者的临床资料.结果 9例ECMO治疗患者中男性3例,女性6例;平均年龄(26.8±7.0)岁;体质指数(28.3±9.1) kg/m2.2例因循环衰竭行静脉-动脉(V-A)治疗模式辅助心功能,治疗开始后血管活性药物剂量明显减少,心功能指标均显著改善;另7例因感染2009新型甲型H1N1流感伴严重急性呼吸窘迫综合征(ARDS),常规机械通气治疗无效行静脉-静脉(V-V)模式辅助肺功能,治疗后呼吸机支持条件显著降低,同时动脉血氧饱和度(SaO2)、动脉血二氧化碳分压(PaCO2)、血pH值均明显改善.全部患者中5例发生急性肾功能不全,6例出现高胆红素血症,4例发生导管相关性血行感染.最终5例成功脱机(其中4例存活出院,1例死亡),2例治疗过程中死亡,2例放弃治疗.9例患者平均输注悬浮红细胞(15.1±9.9)U,ICU住院时间(18.9±15.7)d.结论 ECMO能迅速减轻危重症患者心肺工作负荷,改善心肺功能,并为其提供休息及自行恢复的机会.减少相关并发症的发生是成功实施ECMO、改善患者预后的关键.     

体外膜肺氧合在终末期心脏病围手术期严重心力衰竭中的应用

目的 观察体外膜肺氧合(ECMO)对终末期心脏病围手术期心力衰竭患者的治疗效果,总结临床经验.方法 选择本院2007年6月至2010年7月6例终末期心脏病围手术期心力衰竭行ECMO支持治疗的患者,观察ECMO期间患者的血流动力学及转归情况.结果 ECMO支持时间为23～168 h,平均78 h;患者的血流动力学明显改善[平均动脉压(MAP,mm Hg,1 mm Hg=0.133 kPa):78.13±8.01比47.75±5.21,中心静脉压(mm Hg):11.03±3.21比19.36±4.51,心排血量(L/min):4.93±1.01比3.50±0.81,心排血指数(L·min-1·m-2):2.71±0.51比1.91±0.40,肺动脉楔压(mm Hg):12.72±6.52比20.22±6.91,静脉血氧饱和度:0.66±0.13比0.54±0.07],正性肌力药物使用量也显著减少[多巴胺(μg·kg-1·min-1):5.05±0.85比14.20±5.05,肾上腺素(μg·kg-1·min-1):0.05±0.01比0.24±0.04,均P＜0.05].6例患者均顺利脱机.3例康复出院,出院率50%;3例脱机后因多器官功能衰竭(MOF)死亡.主要并发症为出血、弥散性血管内凝血、感染、栓塞.结论 ECMO可对终末期心脏病围手术期严重心力衰竭患者提供有效的支持治疗,但需正确掌握适应证,合理选择患者.     

成人法洛四联征的外科治疗

目的:探讨成人法洛四联征患者的手术方法和效果。方法:对成人法洛四联征18例行右室流出道疏通重建,并以合适大小心包外衬涤纶片加宽(6例行肺动脉跨环补片),其中8例行肺动脉瓣成型,3例三尖瓣反流患者行三尖瓣成型术。结果:18例患者1例因术后低心排和肾衰于术后第3 d死亡,1例因固定胸骨的钢丝刺破右乳内动脉,术后再次大量出血开胸止血,17例顺利康复出院,术后心功能都得到有效的恢复。结论:成人法洛四联征只要得到合理的手术矫正,同样可以取得较好的治疗效果。     

1例体外膜肺氧合辅助非体外循环下患儿行冠状动脉去顶手术的护理配合

总结1例体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）辅助非体外循环下患儿行冠状动脉去顶手术的护理配合经验。护理要点如下:术前病情讨论、手术间准备、ECMO下患儿的院内转运,术中护理配合和应急预案制订以及术后管理。该例患儿成功完成心脏手术,术后继续ECMO支持,14 d后顺利脱机,术后27 d出院。     

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。     

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。     

体外膜肺氧合在重症心脏病患者术后的护理管理体会

总结了8例重症心脏病患者术后应用体外膜肺氧合(ECMO)治疗的护理管理体会。患者均采用动-静模式,选择股动静脉置管。治疗期间通过护理专案小组严格加强血液动力学、呼吸道、活化凝血时间、皮肤及下肢血运的管理,做好氧合器及管道的护理,同时加强原发病的护理、积极预防并发症发生。最终6例患者脱机继续机械通气治疗后顺利痊愈出院,2例插管期间因并发症死亡。认为ECMO治疗是重症心脏术后患者有效的生命支持手段,精细护理和护理专案管理是其成功的重要环节,能够增加重症心脏病患者后续治疗生存的几率。     

Therapeutic plasma exchange performed in parallel with extra corporeal membrane oxygenation for antibody mediated rejection after heart transplantation

We report on the feasibility, safety, and efficacy of performing therapeutic plasmapheresis (TPE) in parallel with extracorporeal membrane oxygenation (ECMO) to alleviate antibody mediated rejection (AMR) after heart transplantation. Two pediatric and one adult patient presented with severe congestive heart failure and respiratory distress after heart transplantation and required ECMO support. TPE was initiated to treat AMR while patients remained on ECMO. Each patient received three to five procedures either every day or every other day. One equivalent total plasma volume (TPV) was processed for each procedure (patient TPV + ECMO extracorporeal TPV). A total of 13 TPE procedures were performed with 12 procedures completed without complications or adverse events; one procedure was terminated before completion because of cardiac arrhythmia. Anti-HLA antibody titers decreased after TPE in all three patients. Ventricular function improved and ECMO was discontinued in 2 of 3 patients. Performing large volume TPE with a processed volume up to 2.5 times the patient's TPV is well tolerated in both pediatric (< or = 10 kg) and adult patients. TPE in parallel with ECMO is feasible, safe, and may be measurably effective at reducing anti-HLA antibodies and should be considered as part of the treatment for patients with early AMR after heart transplantation.     

体外膜肺装置替代体外循环的临床应用

目的 总结16例使用体外膜肺(ECMO)装置代替体外循环并术后为体外膜肺辅助的临床经验,探讨体外膜肺临床应用的新方法.方法 利用体外膜肺建立体外循环施行心脏直视手术,术后利用同一套装置为体外膜肺辅助.全组患者均使用美顿力体外膜肺机,CB4649离心泵;15例应用541T膜肺,1例应用CARMEDA涂层膜肺.术前均采用股动、静脉切开置管、A-V转流方式.结果 术中及术后转为体外膜肺过程顺利,无并发症发生.本组患者体外膜肺脱机率93.75%,病死率18.75%,出院率81.25%.结论 体外膜肺是治疗重症心、肺衰竭的有效手段.对于预计术后需心肺辅助的患者,术中使用体外膜肺装置建立体外循环,术后转为体外膜肺支持,能够提供术中、术后无间断的心肺辅助,降低炎性反应及血液成分破坏,降低治疗费用.     

Anticipatory use of venoarterial extracorporeal membrane oxygenation for a high-risk interventional cardiac procedure

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a valuable technique in the critical care of children with congenital heart disease who require mechanical cardiorespiratory support. The use of VA ECMO in cardiac patients has expanded from an extension of intraoperative cardiopulmonary bypass and now includes rescue therapy during cardiopulmonary resuscitation, temporary circulatory support for reversible heart failure, and bridge support preceding heart or heart/lung transplantation. In the majority of clinical applications VA ECMO is used in reaction to impending or ongoing cardiorespiratory failure and not in anticipation of an induced change in clinical status. We describe the anticipatory use of VA ECMO to prepare a patient with complex cyanotic congenital heart disease for a high-risk interventional cardiac catheterization. A 2.5 kg neonate with severe Ebstein's anomaly of the tricuspid valve and recurrent episodes of life-threatening supraventricular tachycardia was electively cannulated for VA ECMO in the cardiac intensive care unit. She underwent successful electrophysiologic mapping and transcatheter radiofrequency ablation of an accessory conduction pathway, resulting in termination of the tachycardia. Following an uncomplicated ECMO course she was decannulated in the cardiac intensive care unit and subsequently discharged home in stable condition. The case illustrates the proactive use of ECMO during a procedure in which severe hemodynamic instability could be predicted. We discuss this concept of ECMO use in the context of accepted indications for ECMO in cardiac patients and encourage an expanded role for its use to prevent cardiorespiratory collapse in planned interventions on compromised patients who are at risk of acute deterioration.     

体外心肺复苏技术在成人心搏骤停抢救中的应用

目的 回顾性总结应用体外心肺复苏(E-CPR)技术救治成人心搏骤停患者的临床经验.方法 2005年7月至2009年7月,有11例心源性心搏骤停成人患者(男7例,女4例,年龄24～71岁)经常规心肺复苏(CPR)抢救10～15 min无法有效恢复自主循环,而采用E-CPR技术抢救.7例心脏手术后患者在CPR抢救同时自原胸骨切口先建立升主动脉-右心房常规体外循环辅助,再转为体外膜肺氧合(ECMO)辅助;4例患者在CPR抢救同时直接经股动、静脉置管建立ECMO辅助.结果 11例患者CPR时间30～90 min,平均(51±14)min,10例患者可恢复自主心律.11例患者ECMO辅助时间2～223 h,中位时间126 h.6例患者成功撤离ECMO辅助,但存活出院率为36.4%(4/11).2例患者在ECMO辅助的同时加用主动脉内球囊反搏术(IABP),1例存活.3例患者因合并肾功能衰竭而需血液滤过治疗.结论 E-CPR为抢救危重的心搏骤停患者提供了一个新的手段.如何有效评估和选择病例,及时开始救治以提高成功率,值得进一步研究.     

Extracorporeal life support devices and strategies for management of acute cardiorespiratory failure in adult patients: a comprehensive review

Evolution of extracorporeal life support (ECLS) technology has added a new dimension to the intensive care management of acute cardiac and/or respiratory failure in adult patients who fail conventional treatment. ECLS also complements cardiac surgical and cardiology procedures, implantation of long-term mechanical cardiac assist devices, heart and lung transplantation and cardiopulmonary resuscitation. Available ECLS therapies provide a range of options to the multidisciplinary teams who are involved in the time-critical care of these complex patients. While venovenous extracorporeal membrane oxygenation (ECMO) can provide complete respiratory support, extracorporeal carbon dioxide removal facilitates protective lung ventilation and provides only partial respiratory support. Mechanical circulatory support with venoarterial (VA) ECMO employed in a traditional central/peripheral fashion or in a temporary ventricular assist device configuration may stabilise patients with decompensated cardiac failure who have evidence of end-organ dysfunction, allowing time for recovery, decision-making, and bridging to implantation of a long-term mechanical circulatory support device and occasionally heart transplantation. In highly selected patients with combined severe cardiac and respiratory failure, advanced ECLS can be provided with central VA ECMO, peripheral VA ECMO with timely transition to venovenous ECMO or VA-venous ECMO upon myocardial recovery to avoid upper body hypoxia or by addition of an oxygenator to the temporary ventricular assist device circuit. This article summarises the available ECLS options and provides insights into the principles and practice of these techniques. One should emphasise that, as is common with many emerging therapies, their optimal use is currently not backed by quality evidence. This deficiency needs to be addressed to ensure that the full potential of ECLS can be achieved.     

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。     

Extracorporeal membrane oxygenation following pediatric cardiac surgery: development and outcomes from a single-center experience

Extracorporeal membrane oxygenation (ECMO) has emerged as an effective mechanical support following cardiac surgery with respiratory and cardiac failure. However, there are no clear indications for ECMO use after pediatric cardiac surgery. We retrospectively reviewed medical records of 76 pediatric patients [mean age, 10.8 months (0-86); mean weight, 5.16 kg (1.16-16.5)] with congenital heart disease who received ECMO following cardiac surgery between January 1997 and October 2010. Forty-five patients were treated with an aggressive ECMO approach (aggressive ECMO group, April 2005-October 2010) and 31 with a delayed ECMO approach (delayed ECMO group, January 1997-March 2005). Demographics, diagnosis, operative variables, ECMO indication, and duration of survivors and non-survivors were compared. Thirty-four patients (75.5%) were successfully weaned from ECMO in the aggressive ECMO group and 26 (57.7%) were discharged. Conversely, eight patients (25.8%) were successfully weaned from ECMO in the delayed ECMO group and two (6.5%) were discharged. Forty-five patients with shunted single ventricle physiology (aggressive: 29 patients, delayed: 16 patients) received ECMO, but only 15 (33.3%) survived and were discharged. The survival rate of the aggressive ECMO group was significantly better when compared with the delayed ECMO group (p<0.01). Also, ECMO duration was significantly shorter among the aggressive ECMO group survivors (96.5 ± 62.9 h, p<0.01). Thus, the aggressive ECMO approach is a superior strategy compared to the delayed ECMO approach in pediatric cardiac patients. The aggressive ECMO approach improved our outcomes of neonatal and pediatric ECMO.     

Risk factors for mortality in 137 pediatric cardiac intensive care unit patients managed with extracorporeal membrane oxygenation

OBJECTIVE: To identify factors associated with mortality in children with heart disease managed with extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective chart review. SETTING: Tertiary care university-affiliated children's hospital. PATIENTS: All pediatric cardiac intensive care unit patients managed with ECMO between January 1, 1995, and June 30, 2001. INTERVENTIONS: None. RESULTS: During the study period, 137 patients were managed with ECMO in the pediatric cardiac intensive care unit. Of the 137 patients, 80 (58%) survived > or =24 hrs after decannulation, and 53 (39%) survived to hospital discharge. Patients managed with ECMO following cardiac surgery were analyzed separately from patients not in the postoperative period. Factors associated with an increased probability of mortality in the postoperative patients were age <1 month, male gender, longer duration of mechanical ventilation before ECMO, and development of renal or hepatic dysfunction while on ECMO. Single ventricle physiology and failure to separate from cardiopulmonary bypass were not associated with an increased risk of mortality. Cardiac physiology and indication for ECMO were not associated with mortality rate. Although longer duration of ECMO was not associated with increased mortality risk, patients with longer duration of ECMO were less likely to survive without heart transplantation. CONCLUSIONS: In a series of 137 patients managed with ECMO in a pediatric cardiac intensive care unit, survival to hospital discharge was 39%. In postoperative patients only, mortality risk was increased in males, patients <1 month old, patients with a longer duration of mechanical ventilation before initiation of ECMO, and patients who developed renal or hepatic failure while on ECMO.