特发性肺动脉高压患者肺移植围手术期应用体外膜肺氧合的临床效果

Perioperative clinical effect of extracorporeal membrane oxygenation for lung transplantation in idiopathic pulmonary hypertension patients

目的 总结体外膜肺氧合（ECMO）技术在特发性肺动脉高压（IPAH）患者双肺移植中的应用效果.方法 18例因IPAH接受双肺移植的受者,术前肺动脉压达（98.56±14.86） mmHg,WHO心功能评级分别为Ⅲ级11例、Ⅳ级7例.所有受者均在麻醉诱导后给予ECMO转流辅助,术中根据氧合及心功能情况,调整ECMO转速和流量.手术结束后,ECMO流量降至1L·min^-1·m^-2,血流动力学平稳,氧合指数＞300即可撤除ECMO.分别在入手术室时（术前）、麻醉后双肺通气30min、ECMO转流后15 min、建立单肺通气时、肺动脉阻断30 min,肺动脉开放30min、手术结束时共7个时间点采集数据.术后观察受者的转归情况.结果 所有受者均在ECMO支持下顺利完成手术.与术前相比,麻醉后双肺通气30 min时PaO2、PaCO均明显升高（P＜0.05）;与麻醉后双肺通气30min时相比,ECMO转流后15 min时PaO2明显升高（P＜0.05）,PaCO2和肺动脉压均显著下降（P＜0.05）;与ECMO转流后15 min时相比,肺动脉阻断30 min时肺动脉压明显升高（P＜0.05）;与肺动脉阻断30 min时相比,肺动脉开放30 min时肺动脉压明显降低（P＜0.05）.术毕3例受者即刻撤除ECMO,15例带入ICU后继续应用（3.3±2.5）d.有10例（包括术毕即刻撤除ECMO的3例受者）在撤除ECMO后出现不同程度的左心功能不全,其中3例再次给予ECMO转流,其余7例给予强心、利尿及扩血管对症处理后心功能改善.术后ECMO致伤口脂肪液化和感染2例及股动脉血栓形成（中度）2例,经对症治疗后均好转.1例于术后5d出现肾功能衰竭,经ECMO管道行连续性血液滤过治疗,术后2周死于多器官功能衰竭,其余17例受者均顺利出院.术后2个月时,受者肺动脉压为（30.79±6.18） mmHg,心功能评级较术前明显改善（P＜0.01）.结论 ECMO作为一种控制肺动脉高压的有效手段应用于IPAH患者的肺移植手术,可提高手术的安全性,并对受者围手术期心功能的维护效果良好.

Objective To summarize the perioperative clinical effect of extracorporeal membrane oxygenation （ECMO） technique in bilateral lung transplantation of patients with idiopathic pulmonary arterial hypertension.Methods Of 18 recipients with idiopathic pulmonary arterial hypertension receiving double lung transplantation,there were 11 cases of 11 grade Ⅲ （WHO cardiac function ratings） and 7 cases of grade Ⅳ.All patients were given ECMO technique after anesthetic induction,and the speed and volume of ECMO were adjusted according to oxygenation and cardiac function.At the end of the operation,the ECMO flow rate was decreased to 1 L·min^-1·m^-2.If the hemodynamics was stable and the oxygenation index was above 300,the ECMO could be removed.All data were Collected at 7 time points （preoperation,30 min after two lung ventilation,15 min after ECMO,the establishment of one lung ventilation,30 min after pulmonary artery occlusion,30 min after pulmonary artery open and at the end of the operation）.The prognosis of the recipients was observed postoperatively.Results All patients successfully completed operation under the support of ECMO technique.As compared with preoperation,PaO2 and PaCO2 were significantly increased at 30 min after two lung ventilation （P〈0.05）.As compared with 30 min after two lung ventilation,PaO2 was significantly elevated （P〈0.05）,PaCO2 and PAP were reduced at 15 min after ECMO （P〈0.05）.As compared with 15 min after ECMO,PAP was significantly increased at 30 min after pulmonary artery occlusion （P〈0.05）.As compared with 30 min after pulmonary artery occlusion,PAP was significantly reduced at 30 min after pulmonary artery open （P 〈 0.05）.ECMO of 3 patients was removed after operation at once and of 15 patients were not removed until 3.3 ± 2.5 days in ICU.Tencases suffered from left cardiac insufficiency to varying degrees after removing ECMO （including 3cases whose ECMO was removed at once after operation）,3 of them received ECMO bypass again and 7 of them were relieved after administration of cardiotonic,diuretics and vasodilators.Two cases sufferred from wound fat liquefaction and infection and 2 cases had moderate femoral artery thrombosis after postoperative ECMO.One case had renal failure 5 days after operation and thereafter died of multiple organ failure 2 weeks later after treatment with the continuous ECMO pipelines of hemofiltration,then 17 cases were cured.The pulmonary arterial pressure of all recipients was （30.79 ± 6.18） mmHg 2 months after operation and the cardiac function rating was significantly increased （P 〈0.01）.Conclusion The application of ECMO technique in the lung transplantation patients with idiopathic pulmonary hypertension can reduce the pulmonary arterial pressure,improve the safety of operation and has obvious auxiliary effect on the perioperative cardiac function.