体外膜肺氧合对感染甲型H1N1流感病毒危重症患者的辅助治疗初探

Assistance of extracorporeal membrane oxygenation in a patient with severe novel H1N1 influenza

目的探索体外膜肺氧合(ECMO)支持在感染甲型H1N1流感病毒危重症患者中的辅助治疗作用。方法2009年11月29日兰州大学第一医院收治一位咳嗽、咳痰2d、发热1d的25岁临产孕妇。入院经皮氧饱和度(SpO2)64%,吸氧后升至70%,急诊行剖宫产手术,术后SpO2降至55%,术毕直接转入ICU病房,呼吸机BILEVE模式辅助呼吸,持续呼吸支持5d后,氧合通气无改善,胸片提示肺部阴影增加,低氧血症进行性加重,在北京阜外医院的帮助指导下行静脉-动脉(V-A)ECMO支持,连续辅助9d。结果ECMO支持期间,患者上下半身氧饱和度有差异,呼吸机辅助呼吸条件无法减低,肺部病变反复加重,因双肺部实变氧供无法维持终止ECMO辅助,终因多器官功能衰竭死亡。结论股动、静脉插管的V-AECMO可以迅速改善机体缺氧及二氧化碳蓄积,但是上半身氧供依靠自身肺脏的氧合;自身肺脏的充分休息和肺部病变的进展与否是决定患者预后的重要因素。

OBJECTIVE To explore the role of extracorporeal membrane oxygenation （ECMO） in a pregnant patient who suffered from severe novel HIN1 influenza virus pneumonia. METHODS A pregnant woman who had cold and dry cough two days and companied with one day＇s fever hospitalized in the first hospital of Lanzhou University. Pulse saturation of oxygen （ SpO2 ） was 64% when the patient registered and increased to 70% after inhaling oxygen. Patient delivered a healthy baby girl by emergency caesarean section. SpO2 of the woman decreased to 55% after the procedure and she was transferred directly to the intensive care unit（ICU） of the hospital. Mechanical assistant ventilation was initiated using BILEVE model with 13 cmH2O PEEP and 100% FiO2 in ICU. Patient＇s oxygenation deteriorated after 5 days mechanical ventilation and chest X - ray showed bilateral lung consolidation and hypoxemia gradually worsen. Then patient was initiated ECMO support with helping from Fuwai Hospital through right femoral venous and artery catheterization and supported for nearly nine days. RESULTS Saturation of oxygen between superior part and inferior part of the body was different during ECMO, so mechanical ventilation setting could not been set down and bilateral lung consolidation deteriorated repeatedly. At the end, ECMO had to be weaned off because of lung fibrosis and oxygenation failure, the patient died of multi - organs dysfunction. CONCLUSION Femoral venoartcrial ECMO could rapidly ameliorate hypoxemia and hyper carbon dioxide accumulation, however, the oxygen delivery to the superior part of the body still depended on this patient＇s lung. Complete rest of patient＇s lung and whether the lung illness improved or not were two most important parts determining the prognosis of the patient with novel H1N1 influenza virus pneumonia.