体外膜肺氧合用于成人心脏外科术后26例临床分析

Clinical analysis of extracorporeal membrane oxygenation for 26 adult patients after cardiac surgical procedures

目的总结我院心脏术后患者体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)使用经验,综合分析影响患者预后的危险因素,讨论ECMO治疗过程中的并发症及预防管理经验。方法回顾性分析2012年1月至2017年9月在复旦大学附属中山医院接受心脏手术后因心肺功能不全等原因行ECMO支持且辅助时间>8h的26例患者的临床资料,其中男19例、女7例,年龄24~80(58.0±13.9)岁。结果26例中成功脱机12例,6例存活出院。其中行VAECMO(veno-arterialECMO)总共24例,包括心脏移植术后5例,心脏瓣膜术后9例,成功脱机3例。7例瓣膜术后患者因难治性低心排血量综合征(low cardiac output syndrome,LCOS),术后48h内ECMO插管;主动脉手术后8例,其中3例脱机;冠状动脉旁路移植术及其他心脏术后4例。VAECMO除2例大血管术后患者行股静脉-腋动脉置管外,其余均行经股静脉-股动脉插管。VVECMO患者均行股静脉-颈静脉插管。ECMO支持后出血10例,成功脱机5例。所有患者在辅助期间均有不同程度的输血治疗,ECMO支持后出现感染7例;所有患者中发生远端肢体严重缺血4例。存活与死亡患者中乳酸等在ECMO支持前后差异均无统计学意义,但存活病例中血清乳酸的下降速度始终比死亡患者快,术后前6h下降趋势最显著。结论ECMO是治疗心脏术后LCOS和顽固性低氧血症的重要支持手段之一,患者所接受手术类型、置管时机的选择是ECMO成功的关键因素。ECMO插管方式的不同、ECMO期间对出血的预防与控制、乳酸等代谢产物水平的监测及管理、抗感染措施的使用都是ECMO成功的重要因素。

Objective To summarize the clinical experience of extracorporeal membrane oxygenation (ECMO) in adult patients with cardiac surgery, analyze the risk factors associated with the mortality and other severe complications and to discuss prevention methods of complications during ECMO treatment. Methods The clinical data of 26 patients with cardiac surgery, who underwent ECMO because of cardiopulmonary insufficiency ect in Zhongshan Hospital, Fudan University from January 2012 to September 2017, were retrospectively analyzed. There were 19 males and 7 females aged 24–80 (58.0±13.9) years. Results Twelve (42.3%) patients successfully weaned from ECMO and six (23.1%) were discharged from hospital. Among 26 patients, 24 received VA ECMO (veno-arterial ECMO), including 5 after heart transplantation, 9 after heart valve surgery, and 3 were successfully weaned from ECMO. Seven patients with valvular surgery underwent ECMO within 48 hours due to refractory low cardiac output syndrome (LCOS). Eight patients underwent major angioplasty, 3 of whom were successfully weaned from ECMO. Four patients underwent coronary artery bypass grafting and other cardiac surgeries. Patients with VA ECMO were treated with femoral vein-femoral artery cannulation except for 2 patients undergoing femoral vein-radial artery cannulation after major angioplasty. Patients with VV ECMO (veno-venous ECMO) underwent femoral vein-jugular vein cannulation. After ECMO support, 10 patients with bleeding occurred, and 5 patients were successfully weaned from ECMO. All patients had transfusion therapy during the assist period, 7 patients had infection after ECMO support, 4 patients suffered severe distal limb ischemia. There was no significant difference in the lactic acid between the survival and the dead patients before and after ECMO support. However, the decline of serum lactic acid in the survivors was faster than that of the dead patients. The trend was the most significant within 6 h after the operation. Conclusion ECMO is one of the significant treatments for LCOS and refractory hypoxemia after cardiac surgery. The type of cardiac surgery and the timing of catheter placement are key factors for the success of ECMO. The different ways of ECMO intubation, prevention and control of bleeding during ECMO, monitoring and management of internal environment and the strategies of anti-infection are all important for success of ECMO.