危重症心脏外科患者的ECMO辅助技术与IABP、CRRT、呼吸机的相互配合治疗策略

Therapy strategy of extracorporeai membrane oxygenation （ECMO） combine with intra aortic balloon pump （ IABP）, continuous renal replacement therapy （CRRT） and respiratory machine in serious condition cardiac surgery cases

目的探讨危重症心脏外科术后患者联合体外膜肺氧合技术（ECMO）、主动脉球囊反搏（IABP）、持续血液滤过（CRRT）和呼吸机辅助治疗的效果。方法对北京安贞医院2004至2009年心脏外科术后重症病例进行ECMO、IABP、CRRT和呼吸机辅助治疗进行回顾性总结。结果2004年10月至2009年4月，北京安贞医院心外科患者术后心力衰竭（心衰）行ECMO辅助治疗180例，总ECMO辅助脱机比例68．9％，生存比例72．8％。69例ECMO代常规体外循环手术病例。111例常规ECMO辅助循环中死亡49例，生存比例55．9％。180例中，ECMO联合使用IABP40例，死亡23例，生存比例42．5％。先使用IABP后血流动力学不稳定而再使用ECMO者28例，死亡9例，生存比例54％。重症瓣膜病、心脏移植等心衰血流动力学不稳定，或紧急心肺复苏而先使用ECMO后，因脉压差小，心脏左心室收缩减弱而再使用IABP者12例，死亡10例，存活比例16．7％。ECMO联合使用CRRT48例，总生存比例40％。先使用CRRT后使用ECMO6例，死亡4例，生存比例33．3％。先使用ECMO后使用CRRT42例，死亡25例，生存比例47．9％。180例中，ECMO＋IABP＋CRRT＋呼吸机联合治疗共19例，死亡12例（生存比例36．1％）。结论ECMO辅助技术治疗心脏外科术后心衰，效果切实有效，患者应用越早心脏功能恢复越早。危重症患者出现心脏、肺脏、肾脏多器官衰竭时使用ECMO＋IABP＋CRRT＋呼吸机的联合治疗，要注意各机器间的协调作用和撤除顺序。

Objective To investigate clinic results of the extracorporeal membrane oxygenation （ECMO） technique combine with Intro aortic balloon pump （ IABP）, Continuous renal replacement therapy （ CRRT）, respiratory machine therapy in the serious condition cardiac surgery cases. Methods From 2004 to 2009 all data of the cases received the ECMO therapy were analyzed retrospectively. Results Totally 180 cases were treated with extracorporeal membrane oxygenation （ECMO） technique in this period of time with weaning rate of 68.9% and survival rate of 72.8%. Besides of the of replacing rountine CPB 69 cases, 49 cases died in the 111 cases of routine used ECMO cases （ survival rate 55.9% ）. There were 40 cases treated with ECMO combined with IABP in which 23 cases died （ survival rate 42.5% ）. After the first use of IABP 28 cases were trea- ted with ECMO because of hemodynamic instability and 9 died （ survival rate 54% ）. After the first use of ECMO because of se- vere valve disease or hemodynamic instability after heart transplantation, or emergency cardiopulmonary resuscitation and the IABP was admitted in 12 cases for the small pulse pressure, decreased left ventricular contraction （ 10 died, survival rate 36. 1% ）. 48 cases were treated with ECMO combined with CRRT （total survival rate 40% ）. In these cases 6 cases were trea- ted with CRRT first and 4 cases died （ survival rate 33.3% ）. And 42 cases received the ECMO first and 25 cases died （ sur- vival rate 47.9% ）. In the total series 19 cases were treated with ECMO combined with IABP, CRRT, respiratory machine and 12 cases died （ survival rate 36.1% ）. Conclusion ECMO is an effective technique for the heart failure after cardiac surgery, the earlier use may bring earlier recovery of the heart function. Combine administration of ECMO, CRRT, IABP and respiratory machine may be adopted for the multiple organs failure cases with attention of the coordinate and weaning orders among the machines.