静脉-静脉体外膜肺氧合支持治疗对体外循环心脏手术后难治性低氧血症患者预后的影响  

Effect of veno-venous extracorporeal membrane oxygenation support on prognosis of patients with refractory hypoxemia after cardiopulmonary bypass cardiac surgery

作　　者：通耀威 王于强 周旺涛 叶斯力·哈力木别克 居来提·肉扎洪 郭驹[1] 李颖[1] 王正凯[1] 宋云林[1] TONG Yao-wei;WANG Yu-qiang;ZHOU Wang-tao;Yesili HALIMUBIEKE;Julaiti ROUZHAHONG;GUO Ju;LI Ying;WANG Zheng-kai;SONG Yun-Iin(Department of Intensive Care Unit,the First Affiliated Hospital of Xinjiang Medical University,Urumqi,Xinjiang Uygur Autonomous Region 830054,China)

机构地区：[1]新疆医科大学第一附属医院重症医学中心,新疆维吾尔自治区乌鲁木齐830054

出　　处：《中华实用诊断与治疗杂志》2022年第4期380-384,共5页Journal of Chinese Practical Diagnosis and Therapy

摘　　要：目的 观察体外循环心脏手术后发生难治性低氧血症患者行静脉-静脉体外膜肺氧合(veno-venous extracorporeal membrane oxygenation, VV-ECMO)支持的疗效,探讨其发生院内死亡的影响因素。方法 体外循环心脏手术后发生难治性低氧血症患者12例,均行VV-ECMO支持治疗,治疗时间均≥24 h,观察患者VV-ECMO治疗期间发生插管处出血、术区出血、鼻出血、泵功能障碍、肺部感染等并发症发生情况及VV-ECMO撤机成功情况;比较VV-ECMO治疗前与治疗24 h后氧合指数、血浆乳酸水平、心率、平均动脉压、血管活性药物指数。根据患者存活出院情况分为死亡组4例和生存组8例,比较2组年龄、VV-ECMO治疗前急性生理学与慢性健康评估(Acute Physiology and Chronic Health EvaluationⅡ, APACHEⅡ)评分、VV-ECMO治疗24 h氧合指数等临床资料;采用多因素logistic回归分析体外循环心脏手术后难治性低氧血症患者行VV-ECMO治疗后发生院内死亡的影响因素。结果 12例患者VV-ECMO治疗时间为(191.0±85.3)h;撤机成功10例,存活出院8例,院内死亡4例;VV-ECMO治疗期间发生插管处出血6例,术区出血5例,鼻出血1例,口腔出血1例,氧合器血栓1例,泵功能障碍1例,肺部感染10例。12例患者VV-ECMO治疗24 h后氧合指数[(215.70±61.30)mm Hg]、平均动脉压[(83.60±7.30) mm Hg]均高于治疗前[(61.50±10.40)、(77.90±9.20)mm Hg](t=-8.315,P<0.001;t=-2.679,P=0.021),血浆乳酸水平[(1.60(1.33,2.00)mmol/L]、心率[(93.40±9.60)次/min]、血管活性药物指数(24.30±14.30)均低于治疗前[5.30(3.30,9.58)mmol/L、(121.50±23.40)次/min、33.80±20.90](P<0.05)。生存组年龄[(51.30±7.00)岁]、VV-ECMO治疗前APACHEⅡ评分[(18.25±2.70)分]、红细胞输注量[(8.40±6.70)u]、连续肾脏替代治疗比率(25.0%)、VV-ECMO治疗期间发生严重出血并发症比率(12.5%)均低于死亡组[(58.80±0.50)岁、(23.50±1.90)分、(20.10±9.70)u、100.0%、75.0%](P<0.05),体质量指数[(31.00±3.10Objective To observe the efficacy of veno-venous extracorporeal membrane oxygenation(VV-ECMO) in patients with refractory hypoxemia after cardiac surgery with cardiopulmonary bypass(CPB), and to explore the influencing factors of nosocomial death. Methods Twelve patients with refractory hypoxemia after cardiac surgery with CPB received VV-ECMO for 24 h or over. The complications during VV-ECMO such as intubation site bleeding, surgical site bleeding, epistaxis, pump dysfunction and pulmonary infection as well as successful weaning from VV-ECMO were observed. The oxygenation index(OI), lactic acid level, heart rate, mean arterial pressure and vasoactive-inotropic score were compared before and after 24-h VV-ECMO. According to survival at discharge, 12 patients were divided into death group(n=4) and survival group(n=8). The clinical data including age, pre-VV-ECMO Acute Physiology and Chronic Health Evaluation Ⅱ(APACHEⅡ) score and OI after 24-h VV-ECMO were compared between two groups.Multivariate logistic regression analysis was done to assess the influencing factors of nosocomial death after VV-ECMO in patients with refractory hypoxemia after cardiac surgery with CPB.Results All patients received VV-ECMO for(191.0±85.3)h,among which 10patients were weaned successfully from VV-ECMO,8patients survived and were discharged,and 4patients died in hospital.During VV-ECMO,there were 6cases of intubation site bleeding,5cases of surgical site bleeding,1case of epistaxis,1case of oral bleeding,1case of oxygenator thrombosis,1case of pump dysfunction,and 10cases of pulmonary infection.The OI and mean arterial pressure were higher after 24-h VV-ECMO[(215.70±61.30),(83.60±7.30)mm Hg]than those before treatment[(61.50±10.40),(77.90±9.20)mm Hg]in12patients(t=-8.315,P<0.001;t=-2.679,P =0.021),and the lactic acid level,heart rate and vasoactive-inotropic score were lower after 24-h VV-ECMO [1.60(1.33,2.00)mmol/L,(93.40±9.60)beats/min,24.30±14.30]than those before VV-ECMO [5.30(3.30,9.58)mmol/L,(121.50±23.40)beats/min,3

关 键 词：静脉-静脉体外膜肺氧合 难治性低氧血症 体外循环 心脏手术 

分 类 号：R654.2[医药卫生—外科学]