体外膜肺氧合在成人急性呼吸窘迫综合征中的临床应用

Clinical application of extracorporeal membrane oxygenation for treatment of adult acute respiratory distress syndrome

目的总结体外膜肺氧合（ECMO）在成人因肺部感染引起急性呼吸窘迫综合征（ARDS）中的救治经验，探讨ECMO的临床疗效及应用价值。方法收集2003年1月至2015年1月中山大学附属中山医院因机械通气效果欠佳的重症ARDS患者。使用ECMO救治的ARDS患者为研究组（7例），使用传统方法救治的为对照组（7例）。选择经皮切开颈内静脉-股静脉（V—V）进行ECMO插管置管，采用V—V ECMO模式进行辅助转流。通过比较两组血流动力学、血气分析及氧代谢指标综合评估ECMO的辅助疗效。结果本研究共有7例因肺部感染引起ARDS的患者行ECMO支持，其中细菌性肺炎4例，H7N9感染2例，H1N1感染1例。ECMO辅助时间（21．00±10．06）d，成功脱机2例，康复出院1例。对照组为7例重症细菌性肺炎引起的ARDS患者，所有患者均未康复出院。研究组治疗后心率（HR）、肺动脉楔压（PCWP）、静脉血二氧化碳分压（PvCO2）、动脉血乳酸（Lac）均较对照组明显降低[HR（次／min）为100±12比120±19，PCWP（mmHg,1mmHg=0．133kPa）：8．8±2．6比11．6±3．8，PvCO2（mmHg）：40．8±13．1比48．9±16．2，Lac（mmol／L）：2．1±0．8比5．2±0．6，均P〈0．05]；平均动脉压（MAP）、心排血指数（CI）、动静脉血pH值、动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）、动脉血氧饱和度（SaO2）、氧输送（DO2）、氧耗指量（VO2）及氧摄取率（ERO2）均较对照组明显升高[MAP（mmHg）为83．6±8．2比72．2±94，CI（mL·s^-1·m^-2）：93．35±3．33比81．68±8．33，动脉血pH值：7．4±0．1比7．1±0．3，PaO2（mmHg）：98．5±20．4比49．3±12．6，PaCO2（mmHg）：38．9±16．2比26．1±17．4，SaO2：0．95±0．02比0．58±0．04，静脉血pH值：7．1±0．2比6．4±0．3，PvO2（mmHg）：88．9±9．6比33．4±8．9，SvO2：0．75±0．07比0．49±0．08，DO2（mL·min^-1·m^-2）：651±36比400±81，VO2（mL·min^-1·m^-2）：245．0±11．2比103．0±14．8，ERO2：（35．6±3．9）％比（21．3±5．2）％，均P〈0．05]。结论ECMO能够纠正低氧血症，从而改善氧代谢及维持血流动力学稳定，可为肺部原发病的诊治赢得时间，选择合适的病例及加强并发症的防治是ECMO救治成功的关键。

Objective To summarize the clinical experience of extracorporeal membrane oxygenation （ECMO） treatment for adult acute respiratory, distress syndrome （ARDS） caused by lung infections, so as to explore the clinical efficacy and application value of ECMO. Methods The patients with 7 ARDS who were responded poorly to mechanical ventilation in Zhongshan Affiliated Hospital of Sun Yat-sen University from January 2003 to January 2015 were collected. All patients were divided into a study group （7 cases） treated by ECMO and a control group （7 cases） treated by traditional methods. The percutaneous incision on femoral vein-internal jugular vein （V-V） was selected to carry out ECMO intubation, and the V-V ECMO model was used for auxiliary bypass of flow. The comparisons between the two groups for the results of hemodynamics, blood-gas analysis and oxygen metabolism were performed to evaluate synthetically the adjuvant effects of ECMO. Results Seven ARDS patients caused by lung infections were treated by ECMO, including 4 cases with bacterial pneumonia, 2 cases with H7N9 and 1 case with H1N1. The duration of ECMO was （21.00 ± 10.06） days; 2 cases were weaned from ECMO successfully, and 1 case recovered and discharged. Seven cases with ARDS caused by severe lung bacterial infections in control group were all not recovered on discharge. After treatment, the heart rate （HR）, pulmonary arterial wedge pressure （PCWP）, venous partial pressure of oxygen （PRO2）, arterial blood lactic acid （Lac） in study group were significantly lower than those in the control group [HR （bpm） was 100± 12 vs. 120± 19, PCWP （mmHg, 1 mmHg = 0.133 kPa） was 8.8±2.6 vs. 11.6±3.8, PvCO2 （mmHg） was 40.8 ± 13.1 vs. 48.9 ± 16.2, Lac （mmol/L） was 2.1 ± 0.8 vs. 5.2 ± 0.6, all P 〈 0.05], the mean arterial pressure （MAP）, cardiac output index （CI）, arterial and venous blood pH values, arterial partial pressure of oxygen （PaO2）, arterial partial pressure carbon dioxide （PaCO2）, arterial oxygen saturation （SaO2）, oxygen delivery （DO2）, oxygen consumption （VO2）, oxygen extraction （ERO2） were obviously higher in study group than those control group [MAP （mmHg） was 83.6 ± 8.2 vs. 72.2 ± 94, CI （mL· s^-1 · m^-2） was 93.35 ± 3.33 vs. 81.68 ± 8.33, pH of arterial blood was 7.4 ± 0.1 vs. 7.1 ± 0.3, PaO2 （mmHg）： 98.5 ± 20.4 vs. 49.3 ± 12.6, PaCO2 （mmHg）： 38.9 ± 16.2 vs. 26.1 ± 17.4, SaO2：0.95 ± 0.02 vs. 0.58 ± 0.04, pH of venous blood was 7.1 ± 0.2 vs. 6.4 ± 0.3, PvCO2 （mmHg） was 40.8 ± 13.1 vs. 48.9 ± 16.2, SvO2 was 0.75 ± 0.07 vs. 0.49 ± 0.08, DO2 （mL· min^-1 ·m^-2） was 651 ± 36 vs. 400 ± 81, VO2 （mL· min^-1· m^-2） was 245.0 ± 11.2 vs. 103.0 ± 14.8, ERO2 was （35.6 ± 3.9）% vs. （21.3 ± 5.2）%, all P 〈 0.05]. Conclusions ECMO can improve hypoxemia. So it can improve the metabolism and maintain hemodynamic stability, in the mean time the patients may gain more time for diagnosis and treatment of their primary lung diseases. The key points of a successful ECMO are suitable selection of patients and forceful prevention of complications.