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。     

Septal Myectomy in Hypertrophic Cardiomyopathy: National Outcomes of Concomitant Mitral Surgery

Objectives

To assess the frequency and implications of mitral valve (MV) surgery at the time of septal myectomy (SM) for hypertrophic cardiomyopathy (HCM) in a national cohort.

Pediatric sand aspiration managed using bronchoscopy and extracorporeal membrane oxygenation

Sand aspiration is a rare but potentially fatal occurrence to consider in near-drownings, accidental burials or cave-ins. Optimal management is not well defined.     

When is it safe to exercise mechanically ventilated patients in the intensive care unit? An evaluation of consensus recommendations in a cardiothoracic setting

Rationale

Consensus recommendations have been developed to guide exercise rehabilitation of mechanically ventilated patients in the intensive care unit.

Prediction of chronic lung disease,survival and need for ECMO therapy in infants with congenital diaphragmatic hernia: Additional value of fetal MRI measurements?

Introduction

The lung-to-head ratio (LHR), measured by ultrasound, and the fetal lung volume (FLV), measured by MRI, are both used to predict survival and need for extra corporeal membrane oxygenation (ECMO) in infants with congenital diaphragmatic hernia (CDH). The aim of this study is to determine whether MRI measurements of the FLV, in addition to standard ultrasound measurements of the LHR, give better prediction of chronic lung disease, mortality by day 28 and need for ECMO.

Materials and methods

Patients with unilateral isolated CDH born between January 2002 and December 2008 were eligible for inclusion. LHR and FLV were expressed as observed-to-expected values (O/E LHR and O/E FLV). Univariate and multivariate analyses were performed. Receiver operating characteristic curves were constructed and areas under the curve (AUC) were calculated to determine predictive values.

Results

90 patients were included in the analysis. Combined measurement of the O/E LHR and O/E FLV gave a slightly better prediction of chronic lung disease (AUC = 0.83 and AUC = 0.87) and need for ECMO therapy (AUC = 0.77 and AUC = 0.81) than standard ultrasound measurements of the O/E LHR alone. Combined measurement of the O/E LHR and O/E FLV did not improve prediction of early mortality (AUC = 0.90) compared to measurement of the O/E LHR alone (AUC = 0.89). An intrathoracal position of the liver was independently associated with a higher risk of early mortality (p < 0.001), chronic lung disease (p = 0.007) and need for ECMO therapy (p = 0.001).

Discussion

Chronic lung disease and need for ECMO therapy are slightly better predicted by combined measurement of the O/E LHR and the O/E FLV. Early mortality is very well predicted by measurement of the O/E LHR alone.

Conclusion

Clinical relevance of additional MRI measurements may be debated.     

Neonatal Myocardial Infarction: Case Report and Review of the Literature

Myocardial infarction in a neonate is rare. We describe the case of a full‐term male who presented with respiratory distress. A chest radiograph demonstrated cardiomegaly. An electrocardiogram revealed ST segment changes suggestive of ischemia. Cardiac enzymes were elevated and an echocardiogram revealed a regional wall motion abnormality. Cardiac catheterization was performed demonstrating occlusion of the ramus intermedius branch of the left main coronary artery. The patient decompensated, requiring extracorporeal membrane oxygenation (ECMO). The infant was able to be decannulated from ECMO support in 5 days and was ultimately discharged on hospital day 25. We review this case as well as the literature on neonatal myocardial infarction.     

Vasoactive Inotropic Score as a Predictor of Mortality in Adult Patients With Cardiogenic Shock: Medical Therapy Versus ECMO

Introduction and objectives

This study investigated whether the vasoactive inotropic score (VIS) is independently predictive of mortality in cardiogenic shock (CS).

湖北省5例人禽流感病例临床分析

目的:分析湖北省5例人禽流感病例的临床表现、实验室结果、影像学特征、治疗及预后。方法:回顾性分析5例人禽流感病例的临床资料。结果:5例患者中男3例,女2例(其中孕妇1例)。年龄21~50岁。病例高度分散,发病时间集中于3~5月份。部分病例发病前有禽流感环境暴露史。具有发热(并非均是高热,仅有1例超过39℃)、中毒症状、肺部感染、急性呼吸窘迫综合征(ARDS)、多脏器功能损害/衰竭的病情经过。早期有外周血白细胞和淋巴细胞减少或在正常值低限。病情进展迅速,出现ARDS和多器官功能障碍综合征(MODS),病程中、后期常合并多种细菌或真菌感染。2例死亡,康复3例,其中2例接受体外膜肺氧合(ECMO)治疗的患者存活。结论:人禽流感病例以青壮年居多,病死率高。应早期识别和确诊,尽早行奥司他韦抗病毒治疗以及多器官功能支持治疗,ECMO可以降低病死率。     

Arterial Pulsatility and Circulating von Willebrand Factor in Patients on Mechanical Circulatory Support

BackgroundThe main risk factor for bleeding in patients with continuous-flow mechanical circulatory support (CF-MCS) is the acquired von Willebrand factor (VWF) defect related to the high shear-stress forces developed by these devices. Although a higher bleeding rate has been reported in CF-MCS recipients who had reduced pulsatility, the relation between pulsatility and the VWF defect has never been studied.ObjectivesThe purpose of this study was to investigate the relation between pulsatility and VWF under CF-MCS.MethodsWe assessed the effect of 2 CF-MCS on VWF multimer degradation in a mock circulatory loop (model 1). Using these devices, we investigated in a dose-effect model (model 2) 3 levels of pulsatility in 3 groups of swine. In a cross-over model (model 3), we studied the effects of sequential changes of pulsatility on VWF. We reported the evolution of VWF multimerization in a patient undergoing serial CF-MCS and/or pulsatile-MCS.ResultsWe demonstrated the proteolytic degradation of VWF multimers by high shear CF-MCS in a circulatory loop without pulsatility. We observed both in swine models and in a patient that the magnitude of the VWF degradation is modulated by the pulsatility level in the high shear-stress level condition, and that the restoration of pulsatility is a trigger for the endothelial release of VWF.ConclusionsWe demonstrated that the VWF defect reflects the balance between degradation induced by the shear stress and the endothelial release of new VWF triggered by the pulsatility. This modulation of VWF levels could explain the relationship between pulsatility and bleeding observed in CF-MCS recipients. Preservation of pulsatility may be a new target to improve clinical outcomes of patients.