体外膜肺氧合联合吸入性一氧化氮治疗重度急性呼吸窘迫综合征病态肥胖患者的护理体会  

Nursing experience of extracorporeal membrane oxygenation combined with inhaled nitric oxide in the treatment of morbid obesity with severe acute respiratory distress syndrome

作　　者：沈玉英 申叶林 黎春常 李海艳 付霞 孙诚 陈丽芳 Shen Yuying;Shen Yelin;Li Chunchang;Li Haiyan;Fu Xia;Sun Cheng;Chen Lifang(Department of Critical Care Medicine,Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences),Southern Medical University,Guangzhou 510080,Guangdong,China)

机构地区：[1]南方医科大学附属广东省人民医院(广东省医学科学院)重症医学科,广东广州510080

出　　处：《中国中西医结合急救杂志》2024年第5期616-620,共5页Chinese Journal of Integrated Traditional and Western Medicine in Intensive and Critical Care

基　　金：广东省医学科研基金(B2021188)。

摘　　要：目的总结1例病态肥胖患者脓胸手术后并发重度急性呼吸窘迫综合征(ARDS)采用体外膜肺氧合(ECMO)联合吸入性一氧化氮(iNO)治疗成功的经验,并探讨其护理要点。方法2023年7月3日南方医科大学附属广东省人民医院(广东省医学科学院)重症监护病房(ICU)收治1例外院考虑脓血胸行胸腔闭式引流置管失败后患者,入院后通过快速整合微信组群,搭建多学科协作诊疗(MDT)模式,专业及规范的整合临床资料及实施治疗经过,缩短快速响应时间及优化整体护理流程。观察临床疗效,分享护理经验。结果病态肥胖患者男性,27岁,因“呼吸困难,胸痛7d余”入院。①治疗经过:患者7月4日在全麻下行电视辅助胸腔镜手术(VATS)右胸探查+胸膜黏连松解+脓胸引流术,留置胸腔引流管2条并接水封瓶,引流液为脓性液体,术后患者气促,病情加重转入ICU。入院时患者床旁胸部X线提示:双肺可闻及较多湿啰音,以右侧明显。7月10日18:30脉搏血氧饱和度(Sp0,)0.75~0.80,立即行纤维支气管镜(纤支镜)治疗,上调呼吸机参数、改变体位、呋塞米注射液20mg静脉注射等,效果不佳。尝试行俯卧位通气,SpO,未见好转。21:30SpO_(2)逐渐下降至0.60,立即给予体外循环。7月11日2:30行静脉-静脉ECMO(VV-ECMO)后SpO,0.90,多次复查血气尚平稳。7月12日期间仍有气促,氧合指数欠佳,根据MDT会诊意见,紧急联合iNO治疗,1h、2h后氧合指数快速改善为172mmHg(1mmHg~0.133kPa)和190mmHg;6d后氧合指数稳定在222~285mmHg。7月17日逐渐降低iNO支持力度并顺利撤除。7月21日,胸部X线显示患者肺部病变较前明显好转,ECMO支持参数逐步减小,直至成功停用ECMO治疗。8月3日,患者意识恢复清醒,各项指标基本恢复正常,给予停机拔管高流量氧疗观察。8月8日转出ICU,8月15日康复出院。②护理要点:注重个性化镇痛镇静,分阶段调整镇静药物种类和剂量,以降低氧耗并减少并发�Objective To summarize the successful experience of extracorporeal membrane oxygenation(ECMO)combined with inhaled nitric oxide(iNO)in the treatment of severe acute respiratory distress syndrome(ARDS)after empyema surgery in a morbid obesity patient,and to explore the nursing points.Methods On July 3.2023,a patient was admitted to the department of intensive care unit(ICU)of Guangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences),Southern Mediceal University following the failure of closed thoracic drainage and catheterization at another hospital.Using the rapid integration of the WeChat group,a multidisciplinary team(MDT)model was built.This approach enabled the professional and standardized integration of clinical data and the implementation of targeted treatments,significantly reducing response times and optimizing the overall nursing process.Results A 27-year-old male patient with morbid obesity was admitted to the hospital due to dyspnea and chest pain for more than 7 days.Treatment process:on July 4,the patient underwent video-assisted thoracic surgery(VATS),including right chest exploration,pleural adhesion release,and empyema,performed under general anesthesia.Two thoracic drainage tubes were retained and water-sealed bottles were connected.The drainage fluid was purulent.After the operation,the patient was short of breath and the condition was aggravated and transferred to ICU.On admission,the patient's bedside chest X-ray showed that more moist rales were heard in both lungs,especially on the right side.At 18:30 on July 10,the pluse oxygen saturation(SpO_(2))was 0.75-0.80,and fiberoptic bronchoscopy was performed immediately.The ventilator parameters were up-regulated,the position was changed,and 20 mg of furosemide injection was injected intravenously,the effect was not good.Attempted to perform prone position ventilation,SpO_(2) did not improve.At 21:30 the SpO_(2)gradually decreased to 0.60,and the extracorporeal circulation was immediately decided.After veno-venous ECMO(VV-ECMO

关 键 词：病态肥胖 急性呼吸窘迫综合征 体外膜肺氧合 吸入性一氧化氮 个案护理 

分 类 号：R47[医药卫生—护理学]