经皮穿刺置管建立体外膜氧合87例操作经验总结

Percutaneous catheterization for extracorporeal membrane oxygenation： a retrospective case series

目的 探讨经皮穿刺置管建立体外膜氧合（ECMO）过程中的技术要点、风险评估及其并发症.方法 回顾性调查2009年11月至2017年1月北京朝阳医院呼吸与危重症医学科87例经皮穿刺置管建立ECMO成人患者的流行病学资料、支持类型、置管部位、血管内置管型号、位置确定及相关并发症.结果 87例患者中男61例,女26例;年龄15 ～ 82岁,平均（47±16）岁;原发病为ARDS 56例（65％）,肺移植过渡16例（18％）,其他病因15例（17％）.81例患者给予VV-ECMO支持,6例给予VA-ECMO支持.最常用置管型号为动脉端15 ～ 17 F、静脉端21 ～ 23 F.其中62例患者（71％）在穿刺置管前进行床边血管超声定位,11例患者（13％）在置管成功后通过床边X线胸片协助调整插管末端位置,33例（38％）患者置管后经床边超声确认股静脉导管末端位置保证血流量.经皮穿刺置管成功85例（97％）,2例女性患者因皮下脂肪层过厚,经皮穿刺过程中置管困难请血管外科医师行切开股静脉置管.6例VA-ECMO患者自主完成经皮穿刺股动脉侧支循环建立5例,另1例股动脉因未建立侧支循环出现肢体坏疽.9例出现置管部位出血,4例导管相关性血流感染和1例撤离时肺栓塞.结论 经皮穿刺置管建立ECMO成功率较高且并发症较低.

Objective To review the experience of percutaneous catheterization for extracorporeal membrane oxygenation （ECMO） by respiratory intensivists at a single institution.Methods A retrospective review of 87 patients undergoing percutaneous catheterization for ECMO in Department of Respiratory and Critical Care Medicine of Beijing Chaoyang Hospital from November 2009 to January 2017.Subject demographics,type of support,cannulation configuration,types of cannulas,use of imaging modalities,and complications were recorded and summarized.Results The 87 patients consisted of 61 males and 26 females.The average age was （47 ± 16）years （range 15-82 years）.Fifty-six patients were given ECMO therapy because of acute respiratory distress syndrome（ARDS）,and 16 were treated as a bridge for lung transplantation and 15 for other causes.Eighty-one cases were given VV-ECMO support,and 6 cases were given VA-ECMO support.The most commonly used cannulas were 15-17 F arterial cannulas and 21-23 F venous cannulas.Preinsertion ultrasound was performed in 62 patients （71%）.Bedside chest radiography was used to help adjust the position of the end of the cannula in 11 patients （13%）.Percutaneous catheterization was successful in 85 cases （97%）,while it failed in 2 female patients due to thick subcutaneous fat layer,and open surgical approach was used.Percutaneous femoral artery collateral circulation was established by ourselves in 5 cases.One patient with femoral artery catheterization without collateral circulation had gangrene of limbs.The complications included 9 cases of catheter site hemorrhage,4 catheter-related bloodstream infection and 1 pulmonary embolism during ECMO weaning.Conclusion Percutaneous catheterization for ECMO can be performed with a high rate of success and a low rate of complications.