中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

体外膜肺氧合用于成人心脏外科术后 26 例临床分析

查看全文

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,患者年龄 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(venous-artery ECMO)总共 24 例,包括心脏移植术后 5 例,心脏瓣膜术后患者 9 例,成功脱机 3 例。7 例瓣膜术后的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;大血管术后患者 7 例,其中 3 例脱机;冠脉旁路术及其他心脏术后患者 3 例。V-A ECMO 患者除 2 例大血管术后的患者行股静脉-腋动脉置管外,其余均行经股静脉-股动脉插管。V-V ECMO 患者均行股静脉-颈静脉插管。ECMO 支持后出现出血患者 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 支持后出现感染患者 8 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 支持前后均无显著性差异,但存活病例中血清乳酸的下降速度始终比死亡患者更快,术后前 6 h 下降趋势最为显著。 结论 ECMO 是治疗心脏术后低心排血量综合征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。

Objective To summarize the clinical experience of extracorporeal membrane oxygenation (ECMO) in adult patients with cardiac surgery, analyze the risk factors associated with the mortality and other severe complications and to discuss prevention methods of complications during ECMO treatment. Methods The clinical data of 26 patients with cardiac surgery, who underwent ECMO in Zhongshan Hospital, Fudan University from 2012 January to 2017 September, was retrospectively analyzed. There were 19 males and 7 females aged 24–80 (58.0±13.9) years. Results Twelve (42.3%) patients successfully weaned from ECMO and six (23.1%) was discharged from hospital. Except two patients received VV ECMO, all patients received VA ECMO. Five patients underwent heart transplantation, all of whom underwent VA ECMO, and were successfully weaned from ECMO, and two patients were discharged. Nine patients after valve surgery underwent VA ECMO, three patients were successfully weaned support, and only one patient after AVR was discharged. Eight patients underwent aorta surgery, three were weaned ECMO support, and two of them were discharged. Four patients underwent coronary artery bypass grafting and other cardiac surgical procedures, and one patient weaned from ECMO. All patients underwent RBC transfusion during ECMO. After ECMO 10 of 26 patients suffered hemorrhage from different parts. Infection was confirmed in 8 of 26 patients and including 2 fungal infection. Four patients had severe ischemia in distal limbs. There was no significant difference between discharged and death patients in blood lactate and other indications, such as creatinine, hemoglobin, alanine aminotransferase. But we found that blood lactate of discharged patients always decreased faster than others, especially on first 6 hours after ECMO. Conclusion ECMO is one of the significant treatments for low cardiac output syndrome and refractory hypoxemia after cardiac surgery. The type of cardiac surgery and the timing of catheter placementare key factors for the success of ECMO. The different ways of ECMO intubation, prevention and control of bleeding during ECMO, monitoring and management of internal environment and the strategies of anti-infection are all important for success of ECMO.

关键词: 体外膜肺氧合; 心脏手术; 并发症; 低心排血量综合征; 预后

Key words: Extracorporeal membrane oxygenation; cardiac surgical procedures; low cardiac output syndrome; complications; prognosis

登录后 ,请手动点击刷新查看全文内容。 没有账号,
登录后 ,请手动点击刷新查看图表内容。 没有账号,
1. 龙村, 赵举, 侯晓彤. ECMO/体外膜肺氧合. 第2版. 北京: 北京人民卫生出版社, 2016.
2. Thiagarajan RR, Barbaro RP, Rycus PT, et al. Extracorporeal Life Support Organization Registry International Report 2016. ASAIO J, 2017, 63(1): 60-67.
3. Lafç G, Budak AB, Yener Aü, et al. Use of extracorporeal membrane oxygenation in adults. Heart Lung Circ, 2014, 23(1): 10-23.
4. Pellegrino V, Hockings LE, Davies A. Veno-arterial extracorporeal membrane oxygenation for adult cardiovascular failure. Curr Opin Crit Care, 2014, 20(5): 484-492.
5. Rao V, Ivanov J, Weisel RD, et al. Predictors of low cardiac output syndrome after coronary artery bypass. J Thorac Cardiovasc Surg, 1996, 112(1): 38-51.
6. Rudiger A, Businger F, Streit M, et al. Presentation and outcome of critically ill medical and cardiac-surgery patients with acute heart failure. Swiss Med Wkly, 2009, 139(7-8): 110-116.
7. Balderas-Muñoz K, Rodríguez-Zanella H, Fritche-Salazar JF, et al. Improving risk assessment for post-surgical low cardiac output syndrome in patients without severely reduced ejection fraction undergoing open aortic valve replacement. The role of global longitudinal strain and right ventricular free wall strain. Int J Cardiovasc Imaging, 2017, 33(10): 1483-1489.
8. Gattinoni L, Carlesso E, Langer T. Clinical review: Extracorporeal membrane oxygenation. Crit Care, 2011, 15(6): 243.
9. Wang L, Wang H, Hou X. Clinical Outcomes of Adult Patients Who Receive Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth, 2018, 32(5): 2087-2093.
10. 杜中涛, 杨峰, 江春景, 等. 体外膜肺氧合在成人心外科术后心源性休克应用早期死亡率及临床结果危险因素分析. 中国体外循环杂志, 2014, 12(4): 210-214.
11. Rastan AJ, Dege A, Mohr M, et al. Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. J Thorac Cardiovasc Surg, 2010, 139(2): 302-311.
12. Khorsandi M, Dougherty S, Bouamra O, et al. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg, 2017, 12(1): 55.
13. Fukuhara S, Takeda K, Garan AR, et al. Contemporary mechanical circulatory support therapy for postcardiotomy shock. Gen Thorac Cardiovasc Surg, 2016, 64(4): 183-191.
14. Lazzeri C, Cianchi G, Bonizzoli M, et al. Pulmonary vascular dysfunction in refractory acute respiratory distress syndrome before veno-venous extracorporeal membrane oxygenation. Acta Anaesthesiol Scand, 2016, 60(4): 485-491.
15. Taghavi S, Zuckermann A, Ankersmit J, et al. Extracorporeal membrane oxygenation is superior to right ventricular assist device for acute right ventricular failure after heart transplantation. Ann Thorac Surg, 2004, 78(5): 1644-1649.
16. Aziz F, Brehm CE, El-Banyosy A, et al. Arterial complications in patients undergoing extracorporeal membrane oxygenation via femoral cannulation. Ann Vasc Surg, 2014, 28(1): 178-183.
17. Bisdas T, Beutel G, Warnecke G, et al. Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. Ann Thorac Surg, 2011, 92(2): 626-631.
18. Chen H, Yu RG, Yin NN, et al. Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill patients: a systematic review. Crit Care, 2014, 18(6): 675.
19. Kilburn DJ, Shekar K, Fraser JF. The Complex Relationship of Extracorporeal Membrane Oxygenation and Acute Kidney Injury: Causation or Association? Biomed Res Int, 2016, 2016: 1094296.
20. Lee SW, Yu MY, Lee H, et al. Risk factors for acute kidney injury and in-hospital mortality in. patients receiving extracorporeal membrane oxygenation. PLoS One, 2015, 10(10): e0140674.
21. Roussel A, Al-Attar N, Khaliel F, et al. Arterial vascular complications in peripheral extracorporeal membrane oxygenation support: a review of techniques and outcomes. Future Cardiol, 2013, 9(4): 489-495.
22. Bonizzoli M, Lazzeri C, Cianchi G, et al. Serial Lactate Measurements as a Prognostic Tool in Venovenous Extracorporeal Membrane Oxygenation Support. Ann Thorac Surg, 2017, 103(3): 812-818.
23. Park SJ, Kim SP, Kim JB, et al. Blood lactate level during extracorporeal life support as a surrogate marker for survival. J Thorac Cardiovasc Surg, 2014, 148(2): 714-720.