【作者】 袁媛；

【导师】 龙村； 黑飞龙； 李景文； 于坤；

【作者基本信息】 中国协和医科大学 ， 麻醉学， 2009， 博士

【摘要】 研究目的回顾性总结阜外医院107例心肺功能衰竭患者应用体外膜肺氧合(ECMO)支持治疗的临床经验,分析早期及中长期预后及其影响因素。研究方法2004年12月至2008年12月,对本院107例终末期心脏病和心脏术后需心肺支持的患者行ECMO支持治疗,ECMO系统的氧合器及离心泵内膜均采用全肝素涂抹技术,婴幼儿采用右心房—升主动脉插管,成人应用右心房-股动脉插管或股动-静脉插管,辅助期间流量范围在40～220 ml/(kg·min)。研究结果107例患者,男71例(66.4%),女36例(33.6);年龄出生5天～76岁,平均(28.86±25.20)岁;体重3.2～100 kg,平均(43.49±29.04)kg。97例(90.7%)心脏术后安装ECMO;10(9.3%)例内科心肺复苏后安装ECMO(终末期心肌病6例,冠心病2例,主动脉瓣置换术后心衰1例,暴发型心肌炎1例)。辅助时间为12～504h,平均(128.86±86.64)h。康复出院62例(57.9%,62/107),ECMO平均时间(118.08±69.58)h;45例患者院内死亡(42.1%,45/107),ECMO平均时间(143.71±104.79)h;其中6例为顺利撤除ECMO装置后死亡。总撤机率63.6%。由于脱离CPB困难直接转为ECMO辅助的患者及因肺动脉高压需要ECMO支持治疗的患者出院率较高。出院患者体重明显大于死亡患者(P=0.001),ECMO前平均动脉压(MAP)显著高于死亡组(P=0.038);死亡患者ECMO辅助时间显著延长(P=0.009),ECMO前血乳酸水平显著增高(P=0.005)。出血、肾功能衰竭、感染、氧合器渗漏等是ECMO重要并发症。与死亡率显著性相关的并发症为出血、肾衰、溶血、感染、远端肢体缺血坏死、MSOF、DIC、氧合器渗漏及更换氧合器。62例出院患者电话随访至2009年3月31日,其中6例由于电话号码为空号缺失,随访率为90.3%;其余56例患者中7例死亡,平均存活时间97.0±80.0d,余49例患者存活,占全部出院患者的79.0%。存活患者中有5例股动脉插管侧腿部感不适,轻微影响活动;1例冠脉搭桥患者出院14个月后因心绞痛再次入院5d;1例冠脉搭桥患者出院后因胸闷再次入当地医院治疗。所有存活小儿患者生长发育正常,正常上学。结论ECMO支持是一种有效的循环呼吸衰竭辅助支持治疗方法,尽早对心肺衰竭患者使用ECMO支持治疗,避免重要脏器不可逆损伤,对提高治疗效果有积极的帮助。ECMO期间及术后并发症直接威胁患者的生命,如何进一步提高ECMO辅助效果,减少和避免并发症,需要ECMO工作者更加深入研究,同时提高对严重并发症的治疗效果也是提高ECMO临床效果的有力保障。研究目的回顾性总结分析阜外医院45例小儿体外膜肺氧合(extracorporeal membraneoxygenation,ECMO)支持治疗的临床结果和经验。研究方法2004年12月至2008年12月共实施小儿ECMO病例45例,所有患儿均行静脉-动脉ECMO辅助,激活凝血时间维持140～180秒,肝素用量5～20U/(kg·h)。辅助期间平均流量在40～220ml/(kg·min)。研究结果45例心脏术后小儿患者,男25例,女20例。平均年龄2.9±4.3岁(5天～16岁);平均体重13.0±12.5 Kg(3.2～50 Kg);平均ECMO辅助时间152.04±93.14h(16～504 h)。22例患者成功撤离ECMO,撤机率为48.9%;20例患者出院,出院率为44.4%。2例成功撤离ECMO后死亡,其中1例存活5d后死于MSOF,1例存活9d后死于感染性休克。23例不能撤离ECMO,终止治疗,院内死亡。出院患儿ECMO支持时间为16～268h,平均(64.21±14.36)h,死亡患儿ECMO支持时间为25～504h,平均(109.88±21.98)h,存在统计学差异(P=0.05);出院组与死亡组的平均年龄、体重有显著差异(P=0.000);并发症中肾功能不全、感染及氧合器渗漏的患儿死亡率显著上升;多因素回归分析结果显示肾功能不全与死亡率显著相关。20例出院患儿电话随访至2009年3月31日,2例由于电话号码为空号缺失,随访率为90.0%;余18例患儿中,1例出院后1天死亡,1例出院后57天死亡;余16例患儿存活至今,生长发育正常,正常上学。结论ECMO支持治疗在小儿复杂先天性心脏病术后循环呼吸衰竭的治疗中是一种有效的机械辅助方法。手术畸形矫正满意,尽早对心肺衰竭的患儿使用ECMO支持治疗,避免重要脏器的不可逆损伤是ECMO成功的关键。研究目的总结17例终末期心脏病患者应用体外膜肺氧合(ECMO)支持治疗的临床经验。研究方法自2005年7月至2008年12月,对17例终末期心脏病患者行ECMO支持治疗,男13例,女4例,年龄15～67岁,平均(40.53±16.73)岁;体重42.5～100 Kg,平均(63.94±16.83)kg。其中终末期心肌病13例,冠心病2例,瓣膜置换术后行心脏移植术2例。所有患者在ECMO支持治疗前都伴有难以控制的心源性休克和/或急性呼吸衰竭。所有患者均采用股动-静脉插管行ECMO支持治疗。ECMO期间镇静或清醒,维持血流动力学和血气指标稳定。研究结果ECMO辅助支持时间20～416h,平均(125.5±107.8)h。16例患者顺利脱离ECMO,成功撤机率94.1%;其中15例出院(2例为ECMO支持治疗过渡至心脏移植,11例为移植术后辅助,2例内科患者),总出院率88.2%。15例出院患者电话随访至2009年3月31日,无缺失病例,随访率为100%。1例内科患者2年前死亡,具体原因不详,存活时间为575天;1例移植患者出院不久死亡,存活时间为3天;其余患者存活,占全部出院患者的86.7%(13/15),2例患者出现股动脉插管侧腿部感不适,轻微影响活动。1例成功撤离ECMO5d后,由于感染死亡;1例患者不能脱机,家属放弃治疗死亡。结论ECMO可对终末期心脏病合并急性心肺功能衰竭患者提供有效的支持治疗,为心脏移植或心功能的恢复赢得时间,延长部分高危患者的生命。研究目的体外膜肺氧合(ECMO)期间的并发症可分为机械系统并发症和患者机体并发症,机械系统并发症包括氧合器功能衰竭、循环管道血栓以及驱动泵和热交换器功能异常;患者机体并发症包括出血、神经系统并发症、器官功能衰竭和感染等。本研究回顾性分析总结阜外心血管病医院107例应用ECMO支持治疗患者的并发症发生情况,探讨ECMO并发症的发生和防治,降低并发症的发生,提高ECMO救治水平。研究方法阜外医院2004年12月至2008年12月共107例患者行ECMO支持治疗,回顾性分析总结其临床资料,并发症发生情况、原因、防治及并发症对ECMO结果的影响。全套ECMO系统,包括插管、循环管道、膜肺及离心泵头均为肝素涂抹。所有患者均采用静脉到动脉的ECMO辅助方式(V-A ECMO)。激活凝血时间(ACT)维持于120～180秒,肝素用量为5～20U/(Kg·h)。流量根据患者病情及监测指标来调整,辅助期间流量范围在40～220 ml/(kg·min)。研究结果107例接受ECMO支持治疗的患者,68例(63.6%,68/107)顺利撤离ECMO装置,其中康复出院62例(89.9%,62/69);6例患者撤机后院内死亡。45例患者因多种原因不能脱机或放弃治疗。总出院率为57.9%。83例患者发生了各类并发症,24例患者未发生并发症,并发症发生率为77.6%。机械并发症主要有氧合器渗漏、氧合器及管路血栓等,发病率分别为30.8%及20.6%。患者机体并发症主要包括出血、肾功能不全、感染、神经系统并发症、多器官功能衰竭(MSOF)、肢体缺血坏死等,发病率分别为32.7%、28.3%、11.2%、7.48%、5.61%及8.41%。与死亡率显著性相关的并发症有:出血、肾衰、溶血、感染、远端肢体缺血坏死、MSOF、DIC、氧合器渗漏。结论ECMO并发症较多,危害较大。ECMO支持时间越长,其发生并发症的危险性就越大,出血是ECMO最主要的机体并发症,氧合器渗漏是最主要的机械并发症。ECMO开始后,应积极监测及预防并发症的发生,一旦出现并发症,应积极治疗以挽救患者生命。更多还原

【Abstract】 ObjectiveRetrospectively summarized and analyzed the early outcome and long-term outcome of 107 consecutive extracorporeal membrane oxygenation(ECMO) cases performed in Fuwai Hospital and determine specific predictors of survival.MethodsReviewed the clinical protocols of 107 ECMO from Dec.2004 to Dec.2008 in Fuwai Hospital.The inter-surface of the ECMO equipment system was completely coated by heparin-coating technique.All patients were applied veno-artery ECMO and activated clotting time(ACT) was maintained between 120～180 sec and heparin usage dose was 5～20U/(Kg·h).Mean blood flow was 40～220ml/(Kg·min) during ECMO assistant period.ResultsWe support 107 patients(age range 5days～76 years,median age 28.86±25.20 years;weight range 3.2～100 kg,medianweight 43.49±29.04 kg) with extracorporeal membrane oxygenation.The shortest ECMO time was 12 hrs and the longest was 504 hrs with mean time was 128.86±86.64 hrs.68 patients(63.6%) weaned off successfully from ECMO.62 of them were discharged and 6 died of post-operative complications.45 patients could not weaned off from ECMO.Total survival discharge rate was 57.9%.The survival discharge rate is significantly higher in patients whose ECMO indication is failure to withdraw from cardiopulmonary bypass and pulmonary hypertension.Lactic acid concentration of artery blood before ECMO in survived patients was significantly lower than that of dead patients(P =0.005).MAP before ECMO in survived patients was significantly higher than that of dead patients(P=0.038).Weights and ECMO duration between the survival and the dead also had statistic difference(P=0.001 and 0.009 separately).Bleeding,renal failure,hemolysis,infection,lower limb ischemia,MSOF,DIC,Oxygenator plasma leakage are the complications significantly related to the dead.The follow up study that used telephone interviews found that 6 case missing and 7 patients died while other 49 patients alive after clischarged.ConclusionsECMO is an effective mechanical assistant therapy method for cardiac and pulmonary failure after cardiac surgery.Earlier usage of ECMO for heart lung failure patient and avoiding the main organs from un-recovery trauma are still the key point of success of ECMO. ObjectiveTo retrospectively summarize and analyze the files of consecutive 45 pediatric ECMO performed in Fuwai Hospital.MethodsWe reviewed the clinical protocols of 45 pediatric ECMO after cardiac surgery from Dec.2004 to Dec.2008 in our hospital.All patients applied veno-artery ECMO and active clotting time(ACT)maintained between 140～180sec and heparin usage dose was 5～20 U /(kg·h).Mean blood flow was 40～220 ml /(kg·min)during ECMO assistant period.ResultsThe shortest ECMO time was 16h and longest 504h and mean time 152h.ECMO were weaned off successfully in 22 patients and 20 of them were survival to discharged and 2 of them were died of persistent cardiopulmonary failure or post-operation complications.23 patients could not been weaned off ECMO.Total survival discharge rate was 44.4%(20/45)in this cohort study.Mean age and weight in survived patients was significantly higher than that of dead patients.ECMO duration and complications(renal failure、infection、oxygenator plasma leakage) between the survivors and the nonsurvivors also had statistic difference.The follow up study that used telephone interviews found that 2 case missing and 2 patients died while other 16 patients alive after discharged.ConclusionsECMO is an effective mechanical assistant therapy for cardiac and pulmonary failure patients after cardiac surgery with pediatric complicated congenital heart disease.Perfect correction of abnormality and earlier usage of ECMO for cardiac and respiratory failure patients and avoiding the main organs from irreversible injury are still the key of success of ECMO. ObjectiveTo summarize the clinical experience of extracorporeal membrane oxygenation(ECMO) support for end-stage cardiopathy(ESC) in our hospital.MethodsFrom Jul.2005 to Dec.2008,ECMO support for ESC was performed in 17 patients(13 with end-stage cardiomyopathy,2 with coronary heart disease, 2 with post valve replacement,male 13,female 4,15～67 years old,weight 42.5～100kg).All patients developed refractory cardiogenic shock and/or acute pulmonary dysfunction.The ECMO cannulation was performed through femoral vessels.The patients were sedatived or conscious during ECMO. Hemodynamic and respiratory parameters were made stably.ResultsMean duration of ECMO was 125.5 hours(20～416hours).16 patients were successfully weaned from ECMO,15 patients of which survived.1 patient could not wean form ECMO.The follow up study that used telephone interviews found that 2 patients died while other 13 patients alive after discharged.ConclusionECMO is an effective technique of treatment on ESC patients with refractory cardiogenic shock and acute pulmonary dysfunction.It can prolong some ESC Datients’ lives. ObjectiveThe complications associated with extracorporeal membrane oxygenation (ECMO)can be classified into mechanical and patient—medical complications.Mechanical complications include oxygenator failure,tubing clots,pump and heat exchanger malfunction.Patient—related medical problems are bleeding,neurological complications,organ failure and infection.The objective of this study was to retrospectively investigate and analyze the data of 107 consecutive ECMO cases performed in Fuwai Hospital.MethodsThe author reviewed clinical records of the ECMO patients in Fuwai Hospital from Dec.2004 to Dec.2008.A total of 107 patients with the ECMO supported in our hospital were studied for the incidence of complications.The inter-surface of the ECMO equipment system was completely coated by heparin-coating technique.All patients were applied veno-artery ECMO and activated clotting time(ACT) was maintained between 120～180 sec and heparin usage dose was 5～20U/(Kg·h).Mean blood flow was 40～220ml/(Kg·min) during ECMO assistant period.ResultsWe support 107 patients(age range 5days～76 years,median age 28.86±25.20 years;weight range 3.2～100 kg,median weight 43.49±29.04 kg) with extracorporeal membrane oxygenation.68 patients(63.6%) weaned off successfully from ECMO.62 of them were discharged and 6 died of post-operative complications.45 patients could not weaned off from ECMO. Total survival discharge rate was 57.9%.They suffered the complications, such as bleeding,infection,renal failure,neurological complications,MSOF, limb ischemia and oxygenator plasma leakage with the incidence of 32.7%, 11.2%,28.3%,7.48%,5.61%,8.41%and 30.8%respectively.Bleeding, renal failure,hemolysis,infection,limb ischemia,MSOF,DIC and oxygenator plasma leakage are significantly related to nonsurvival rate.ConclusionsGenerally,the risk of complications increases with the duration of time on ECMO support.Bleeding and oxygenator plasma leakage are the most important complications of ECMO.During the ECMO treatment,it is also important of prevent from the complications.Once they occur,active therapies must be carried out to save the patients lives.更多还原