体外膜肺氧合治疗暴发性心肌炎的临床疗效及其影响因素  

The effect and factors associated with outcome of extracorporeal membrane oxygenation in acute fulminant myocarditis patients

作　　者：周柱江 刘长智 朱瑞秋 卢剑海 左六二 Zhou Zhu-jiang;Liu Chang-zhi;Zhu Rui-qiu;Lu Jian-hai;Zuo Liu-er(Department of Critical Care Medicine,Shunde Hospital,Southern Medical University,Foshan 528300,China)

机构地区：[1]南方医科大学顺德医院(佛山市顺德区第一人民医院)重症医学科,广东佛山528300

出　　处：《中国急救医学》2019年第7期649-654,共6页Chinese Journal of Critical Care Medicine

基　　金：广东省医学科研基金项目(A2016575).

摘　　要：目的观察体外膜肺氧合(ECMO)治疗暴发性心肌炎的效果,探讨影响因素。方法回顾性分析南方医科大学顺德医院自2013年5月至2017年12月经ECMO救治的暴发性心肌炎患者。记录入选患者ECMO前状态、ECMO并发症及疗效,收集入选患者ECMO支持前2 h及使用ECMO支持后2、6、24和48 h的血流动力学数据。结果共纳入14例患者,其中女性8例,男性6例,年龄15.0 (12.8,32.2)岁,APACHEⅡ评分17.0 (14.5,21.8)分。ECMO支持前,血乳酸水平(9.0±4.4)mmol/L,肌酸激酶同工酶(187.1±142.3)U/L,肌钙蛋白I 12.1(9.7,31.8) ng/mL,左室射血分数(26.8±6.8)%;ECMO前需要大剂量血管活性药物支持,正性肌力药物指数为159.8±151.4。启动ECMO指征:12例为难治性心源性休克,2例为难治性心脏骤停。与ECMO支持前2 h比较,ECMO支持2 h后心率下降(次:122.7±41.8 vs. 94.2±31.9,F=3.468,P=0.012),平均动脉压上升(mm Hg:64.9±14.1 vs. 74.9±9.5,F=2.609,P=0.043)、中心静脉压下降(cm H2O:15.2±3.5 vs. 13.0±3.2,F=2.910,P=0.028)、中心静脉血氧饱和度上升[(54.8±10.0)% vs.(70.9±9.1)%,F=12.270,P<0.001]、正性肌力药物指数下降(159.8±151.4 vs. 50.9±59.6,F=8.037,P<0.001),差异有统计学意义。ECMO支持6 h后,乳酸开始下降(mmol/L:9.5±4.8 vs. 5.7±4.4,F=5.996,P<0.001),差异有统计学意义。脉压差在ECMO支持前后无明显变化(P均>0.05)。ECMO支持24、48 h后,血流动力学保持稳定,休克得到明显改善。并发症:6例患者合并急性肾功能衰竭;肢体并发症2例,包括 1例股动脉破裂、下肢脓肿并缺血,1例下肢缺血并感染;感染性休克2例。转归:ECMO辅助时间(143.8±100.8)h,ECMO撤机成功率12/14,生存出院率11/14。死亡原因:1例为脑脓肿,2例为感染性休克。结论 ECMO能迅速改善暴发性心肌炎患者血流动力学稳定性,而准确把握应用ECMO时机,减少并发症有助于提高疗效。Objective To observe the clinical efficacy and factors associated with outcome of extracorporeal membrane oxygenation ( ECMO) in acute fulminant myocarditis ( AFM ) patients. Methods Patients with AFM received ECMO treatment in the Shunde Hospital of Southern Medical University from May 2013 to December 2017 were retrospectively analyzed. The clinical status before EC MO support, supported timing of ECMO, complications and outcome of ECMO were observed and collected. The hemodynamic data 2 hours before ECMO support and after ECMO support (2 , 6, 24 and 48 hours) were collected. Results Fourteen patients were enrolled in the age range of 15. 0 ( 12. 8 , 32. 2) that contained 8 female. Median score of APACHE U was 17.0( 14. 5 , 21.8). Mean lactate was (9.0 ±4.4) years, mean CK - MB was (187. 1 ± 142. 3) U/L. Meanwhile median troponin I was 12. 1 (9.7, 31. 8 ) ng/mL, mean LVEF was ( 26. 8 ± 6. 8 )%. Before ECMO support, large dose of vasoactive medications were used, and mean inotropic equivalents was (159. 8 ± 151.4). The indication for ECMO included refractory cardiogenic shock ( n = 12 ) and long - term conventional cardiopulmonary resuscitation without return of spontaneous circulation ( n =2). After ECMO was supported for 2 hours, HR decreased (122. 7 ±41.8 vs. 94. 2 ±31.9, F = 3. 468 , P = 0. 012), MAP increased (64. 9 ± 14. 1 vs. 74.9 ±9.5, F=2.609, P=0.043), CVP decreased (15.2±3.5 vs. 13. 0 ± 3. 2 ,F = 2. 910, P = 0. 028), ScvO2 increased (54. 8 ± 10. 0 vs. 70. 9 ± 9. 1 , F = 12. 270, P<0. 001 ), dose of inotropic drugs decreased ( 159. 8 ± 151.4 vs. 50. 9 ± 59. 6 , F = 8.037 , P <0. 001). After ECMO was supported for six hours, lactate level decreased. There was no significant increase in pulse pressure after ECMO support. When ECMO was supported for 24 or 48 hours, hemodynamics kept stable and shock was significantly controlled. Major limb complications were observed in two patients, which contained limb ischemia ( n = 1 ) rupture of femoral artery with limb ischemia and abscess ( n = 1). Ac

关 键 词：体外膜肺氧合 暴发性心肌炎 疗效 影响因素 

分 类 号：R542.21[医药卫生—心血管疾病]