静脉-动脉模式体外膜肺氧合机械辅助在心脏外科手术围术期的应用

目的:总结心脏外科手术围术期采用静脉-动脉模式体外膜肺氧合(VA-ECMO)辅助支持治疗患者的救治经验。方法:回顾分析中国医学科学院阜外医院2004年12月至2019年12月307例心脏外科手术围术期使用VAECMO支持治疗患者的临床资料。根据使用VA-ECMO的适应证及不同年龄段应用的患者分析总结,对比使用主动脉内球囊反搏(IABP)联合VA-ECMO辅助患者的临床转归差异。结果:307例患者中,177例(57.7%)为成年患者,男性211例(68.7%),平均VA-ECMO辅助时间为(119.2±72.7)h,209例(68.4%)成功脱机,158例(51.5%)恢复后顺利出院。VA-ECMO机械辅助并发症最为常见的是急性肾功能不全(51.1%)、肺部感染(36.8%)和出血(30.2%)。联合应用IABP者较不用IABP者VA-ECMO辅助时间未能缩短,但呼吸机机械通气时间(131.5 h vs.158.6 h,P=0.013)以及入住重症监护病房(ICU)时间(119.0 h vs.153.2 h,P=0.002)明显缩短,急性肾功能不全(40.0%vs.64.0%,P=0.035)以及胃肠道并发症发生率(7.6%vs.24.0%,P=0.044)明显降低。在术中建立VA-ECMO辅助循环的心脏外科手术患者较ICU床旁建立VA-ECMO者脱机率(77.8%vs.57.9%)和出院后30 d生存率(66.0%vs.35.2%)更高(P均<0.05),急性肾功能不全发生率更低(37.0%vs.66.9%,P<0.05)。结论:VA-ECMO可为心脏外科手术围术期出现循环呼吸功能衰竭的患者提供有效的辅助支持,IABP搏动性血流对于VA-ECMO辅助过程中外周器官灌注有积极作用,早期及时应用VA-ECMO有助于获得更优的短期辅助疗效。

Experience on the Application of Veno-arterial Extracorporeal Membrane Oxygenation Support During Perioperative Period of Cardiac Surgery

Objectives:This study aims to report the treatment experience of veno-arterial extracorporeal membrane oxygenation(VA-ECMO)support during perioperative period of cardiac surgery.Methods:We retrospectively analyzed the clinical data of 307 patients who underwent VA-ECMO support treatment during perioperative period of cardiac surgery in Fuwai Hospital from 2004 to 2019.Results:Among the 307 patients,177(57.7%)were adult patients,and 211(68.7%)were male.The average VA-ECMO assistance time was(119.2±72.7)h,209(68.4%)patients were successfully weaned,and 158(51.5%)patients recovered smoothly and were discharged.The most common complications of VA-ECMO were acute renal insufficiency(51.1%),lung infection(36.8%),and bleeding(30.2%).The combined application of intra-aortic balloon pump(IABP)failed to reduce the time of VA-ECMO assistance compared with those without IABP.However,IABP significantly reduced the time of mechanical ventilation(131.5 h vs.158.6 h,P=0.013)and the time of admission to the intensive care unit(ICU)(119.0 h vs.153.2 h,P=0.002),which also reduced the incidence of concurrent acute renal insufficiency(40.0%vs.64.0%,P=0.035)and the incidence of gastrointestinal complications(7.6%vs.24.0%,P=0.044).The weaning rate(77.8%vs.57.9%)and the 30-day survival rate(66.0%vs.35.2%)of cardiac surgery patients with VA-ECMO established in the operating roon after cardiac surgery are better than that of VA-ECMO established at the ICU bedside(all P<0.05).The incidence of major complications,such as the incidence of acute renal insufficiency(37.0%vs.66.9%,P<0.05),was better in the former group.Conclusions:VA-ECMO can provide effective support to patients with circulatory and respiratory failure during perioperative period of cardiac surgery.IABP has a positive effect on peripheral organ perfusion during ECMO assistance through the pulsatile blood flow.Early and timely application of VA-ECMO is associated with better outcomes for patients supported with VA-ECMO after cardiac surgery.