CAJ | 학술논문

目的总结体外膜肺氧合(ECMO)在成人心原性休克(CS)中的临床救治经验,探讨ECMO的临床应用价值及影响脱机的可能危险因素.方法回顾性分析中山大学附属中山医院2003年1月至2011年1月因药物和(或)主动脉内球囊反搏(IABP)无效而行ECMO救治的成人CS患者的临床资料,排除辅助前合并重型颅脑损伤、难以控制的大出血及多器官功能衰竭的病例,根据患者是否脱机将其分为成功脱机组(n=31)与脱机失败组(n=23),通过组间单因素比较筛选出影响脱机的可能危险因素.结果 54例ECMO患者的辅助时间为24.16(14.12,56.75)h,成功脱机31例,其中康复出院22例,脱机后死亡9例(5例死于多器官功能衰竭).与脱机失败组比较,辅助前心脏射血分数、平均动脉压高于脱机失败组,组间差异有统计学意义(P＜0.01).血乳酸水平低于脱机失败组[(8.64 ±3.17) mmol/L比(14.44±2.52) mmol/L,t=-7.235,P＜0.01]；脱机成功组心脏骤停患者(n=10)的自主循环恢复时间[(16.70±5.29) min比(35.64 ±5.89) min,t=-7.721,P＜0.01]、胸外按压到辅助开始时间[(29.40 ±5.19) min比(38.64 ±4.20)min,t=-4.502,P＜0.01]均小于脱机失败组心脏骤停者(n=11),ECMO辅助时间大于脱机失败组,多器官功能衰竭发生率低于脱机失败者[0比17.4％ (4/23),x2=5.643,P＜0.05].结论 ECMO是目前救治成人CS的较有效手段,选择恰当的病例并尽早行ECMO是提高总体救治率的决定性因素,而患者的心功能及其心肌的可逆性是影响脱机的可能危险因素,尽早识别影响脱机的危险因素有助于提高脱机成功率.
목적 총결체외막폐양합(ECMO)재성인심원성휴극(CS)중적림상구치경험,탐토ECMO적림상응용개치급영향탈궤적가능위험인소.방법 회고성분석중산대학부속중산의원2003년1월지2011년1월인약물화(혹)주동맥내구낭반박(IABP)무효이행ECMO구치적성인CS환자적림상자료,배제보조전합병중형로뇌손상、난이공제적대출혈급다기관공능쇠갈적병례,근거환자시부탈궤장기분위성공탈궤조(n=31)여탈궤실패조(n=23),통과조간단인소비교사선출영향탈궤적가능위험인소.결과 54례ECMO환자적보조시간위24.16(14.12,56.75)h,성공탈궤31례,기중강복출원22례,탈궤후사망9례(5례사우다기관공능쇠갈).여탈궤실패조비교,보조전심장사혈분수、평균동맥압고우탈궤실패조,조간차이유통계학의의(P＜0.01).혈유산수평저우탈궤실패조[(8.64 ±3.17) mmol/L비(14.44±2.52) mmol/L,t=-7.235,P＜0.01]；탈궤성공조심장취정환자(n=10)적자주순배회복시간[(16.70±5.29) min비(35.64 ±5.89) min,t=-7.721,P＜0.01]、흉외안압도보조개시시간[(29.40 ±5.19) min비(38.64 ±4.20)min,t=-4.502,P＜0.01]균소우탈궤실패조심장취정자(n=11),ECMO보조시간대우탈궤실패조,다기관공능쇠갈발생솔저우탈궤실패자[0비17.4％ (4/23),x2=5.643,P＜0.05].결론 ECMO시목전구치성인CS적교유효수단,선택흡당적병례병진조행ECMO시제고총체구치솔적결정성인소,이환자적심공능급기심기적가역성시영향탈궤적가능위험인소,진조식별영향탈궤적위험인소유조우제고탈궤성공솔.
Objective To summarize the clinical experience of extracorporeal membrane oxygenation (ECMO) treatment for adult refractory cardiogenic shock.Methods From January 2003 to January 2011,patients with refractory cardiogenic shock required veno-arterial ECMO by failure of conventional therapy and intra-aortic balloon pump counterpulsation therapy were retrospectively studied.Patients with severe traumatic brain injury,advanced malignancies and multiple organ failure were excluded.Patients were divided into weaned group(n =31) and not weaned group(n =23) according to the ECMO weaning.Results The duration of ECMO was 24.16(14.12,56.75) hours.Twenty-two out of 31 patients in the weaned group survived and were discharged,9 patients died after successfully weaned from ECMO (5 due to multisystem organ failure,2 due to reoccurred cardiogenic shock,1 due to infectious shock and 1 due to disseminated or diffuse intravascular coagulation).Pre-ECMO mean arterial pressure,ejection fraction,the duration of ECMO were significantly higher while pre-ECMO blood lactate [(8.64 ± 3.17) vs.(14.44 ± 2.52),P ＜0.01],the duration of ROSC [(16.70 ± 5.29) vs.(35.64 ± 5.89),P ＜0.01] and multisystem organ failure [0 vs.17.4％ (4/23),P ＜0.05] were lower in weaned group than in not wean group.Conclusions ECMO is an effective mechanical assistant therapy strategy for adult refractory cardiogenic shock patients.Timely applying this strategy on suitable patients is crucial for the success of ECMO.Cardiac function and reversibility of heart failure are key factors determine the fate of weaned or not weaned ECMO in adult refractory cardiogenic shock patients.