体外膜肺氧合联合主动脉内球囊反搏治疗难治性心源性休克的疗效观察

Observation of extra-corporeal membrane oxygenation combined with intra-aortic balloon pump in the treatment of refractory cardiogenic shock

目的观察体外膜肺氧合（ECMO）联合主动脉内球囊反搏（IABP）治疗难治性心源性休克（RCS）的疗效及安全性。方法 96例RCS患者被分为3组：IABP组（n=34）、ECMO组（n=32）及联合（IABP＋ECMO）组（n=30）。在常规抗休克用药基础上分别应用IABP、ECMO及IABP＋ECMO支持治疗。比较3组患者治疗前、治疗后6h、1天、2天、3天的心率、平均动脉压（MAP）、中心静脉压（CVP）、血氧饱和度（SO2）、动脉血乳酸、心肌钙蛋白I（cTnⅠ）、脑利钠肽（BNP）、左心室舒张末内径（LVED）、左心室射血分数（LVEF）及血管活性药物（多巴酚丁胺、去甲肾上腺素）用量的变化、并发症及临床转归（撤机成功率及住院期间死亡率）。结果治疗3天后,3组患者上述指标均有逐步改善,而联合组上述指标的改善较IABP组及ECMO组更显著（P〈0.05或P〈0.01）;ECMO组的心率、MAP、CVP、SO_2、动脉血乳酸、cTnⅠ、LVEF及多巴酚丁胺、去甲肾上腺素用量等指标的改善优于IABP组（均P〈0.01）;IABP组BNP、LVED的改善优于ECMO组（P〈0.05,P〈0.01）;联合组并发症发生率高于IABP组和ECMO组（χ^2=15.875,P〈0.001;χ^2=4.504,P=0.034）;ECMO组并发症发生率高于IABP组（χ^2=3.957,P=0.047）;联合组撤机成功率高于IABP组和ECMO组（χ^2=16.063,P〈0.001;χ^2=5.792,P=0.016）;3组患者住院期间死亡率比较,差异无统计学意义（P〉0.05）。结论 IABP＋ECMO联合治疗在改善RCS患者血液动力学方面优于IABP和ECMO,但联合治疗增加了并发症发生率,影响了临床预后的改善;降低并发症成为提高联合治疗疗效的关键。

Aim To study the efficacy and safety of extra-corporeal membrane oxygenation （ECMO） combined with intra-aortic balloon pump （IABP） in the treatment of refractory cardiogenic shock （RCS）. Methods 96 patients with RCS were divided into 3 groups： IABP group （n= 34）, ECMO group （n = 32） and IABP＋ECMO combination group （n= 30）. On the basis of conventional antishock drugs, IABP, ECMO and IABP＋ECMO were used respectively to sup- port the treatment. Changes of heart rate, mean arterial pressure （ MAP）, central venous pressure （ CVP）, oxygen satu- ration （SO2 ）, arterial lactate, cardiac troponin I （cTnl）, brain natriuretic peptide （BNP）, left ventricular end-diastolic diameter （LVED）, left ventricular ejection fraction （LVEF）, and vasoactive drugs （dobutamine, norepinephrine ） dosage, complications and clinical outcomes （weaning success rate and in-hospital mortality） were compared among three groups before treatment and 6 hours, 1 day, 2 days, 3 days after treatment. Results After 3 days of treatment, the a- bove indexes were improved gradually in all the three groups, and the above indexes in the combination group were signifi- cantly better than those in the IABP group and the ECMO group （P〈0.05 or P〈0.01 ）. The improvements of heart rate,MAP, CVP, SO2, arterial lactate, cTnI, LVEF, dobutamine and norepinephrine dosage in ECMO group were better than those in IABP group （ all P〈0.01 ）. The improvements of BNP and LVED in IABP group were better than those in ECMO group （ P〈0.05, P〈0.01 ）. The incidence of complications in combination group was higher than that in IABP group and ECMO group （X^2= 15.875, P〈0.001 ; X^2=4.504, P= 0.034） ; The incidence of complications in ECMO group was higher than that in IABP group （X^2=3.957, P=0.047）. The weaning success rate in combination group was higher than that in IABP group and ECMO group （X^2 = 16.063, P〈0.001 ;X^2 = 5.792, P= 0.016）. There was no significant difference in the in-hospital mortality among the three groups （P〉0.05 ）. Conclusion IABP ＋ECMO combined therapy is superior to IABP and ECMO in improving hemodynamics in patients with RCS, but combined therapy increases the incidence of com- plications, decreases the improvement of clinical prognosis; Reducing complications is the key to improve the efficacy of combined therapy.