泵控逆流试验在成人静脉-动脉体外膜氧合撤机过程中的应用

Application of pump-controlled retrograde trial off in weaning from veno-arterial extracorporeal membrane oxygenation in adult patients

目的:总结泵控逆流试验(PCRTO)在成人静脉-动脉体外膜氧合(VA-ECMO)撤机中应用的经验及作用。方法:回顾性研究。纳入2019年3至7月北京安贞医院心外科重症监护病房(ICU)接受体外膜氧合(ECMO)辅助后符合脱机试验标准的成人患者。根据我中心撤机流程开始PCRTO,记录过程中血流动力学指标变化,试验通过者撤机,并追踪患者撤机后48 h存活率、ECMO再辅助率及血栓并发症、撤机后ICU停留时间及住院时间。结果:成人VA-ECMO辅助46例,符合脱机试验标准21例,男10例(47.6%),年龄65(55,68)岁,共进行PCRTO 26次,18例试验通过后撤机。撤机后复查下肢动静脉彩超未发现新发血栓,床旁胸片未发现肺栓塞影像。PCRTO成功率69.23%(18/26)。18次PCRTO成功组撤机次日D-二聚体下降[584(348,2107)μg/L比1440(631,2916)μg/L,P=0.014],左室射血分数(LVEF)升高(51.4%±8.5%比46.9%±10.6%,P=0.013),差异均有统计学意义。8次PCRTO失败组试验后心率、中心静脉压(CVP)、乳酸均升高,氧合指数下降(均P<0.05)。成功组与失败组比较,年龄,逆流血流速,试验前CVP,试验后心率、脉搏血氧饱和度(SpO 2)、CVP、乳酸及氧合指数,试验前后SpO 2及CVP、乳酸变化值差异均有统计学意义(均P<0.05)。结论:PCRTO简单可逆、安全有效,可以在成人VA-ECMO撤机过程中使用。

Objective To Summarize the experience of pump-controlled retrograde trial off(PCRTO)in the process of veno-arterial extracorporeal membrane oxygenation(VA-ECMO)withdrawal in adult patients.Methods Adult patients who received ECMO assistance in Intensive Care Unit for Cardiac Surgery from March to July 2019 were collected.According to our strategies,PCRTO was used if the patients can wean from VA-ECMO and hemodynamic indexes were recorded during the process.The statistics data was collected,including the 48 hours survival rate,ECMO re-assistance rate,thrombus complications,Intensive Care Unit(ICU)stay time and hospital stay time after weaning from VA-ECMO.The patients who failed in the test were continued to be assisted by ECMO.Results There were 46 patients assisted by VA-ECMO in our center.In total,21 adults who met the offline test standard underwent 26 PCRTOs,including 10 male adults(47.6%),with an age of 65(55,68)years old.Eighteen adults passed the withdrawal test.No new thrombus was found in the arteriovenous ultrasound of the lower extremity after weaning from ECMO,and no pulmonary embolism was found in the chest X-ray.The success rate of weaning from ECMO was 69.23%(18/26).The D-dimer decreased[584(348,2107)μg/L vs 1440(631,2916)μg/L,P=0.014]and the left ventricular ejection fraction(LVEF)increased(51.4%±8.5%vs 46.9%±10.6%,P=0.013)on the next day after weaning.There were significant differences in heart rate(HR),central venous pressure(CVP),oxygenation index and lactate(Lac)during the PCRTO in the group which involved the cases of the 8 failed experiments(all P<0.05).Compared with the failure group,there were significant differences in age,blood flow rate,CVP before the test,HR,pulse oxygen saturation(SpO2),CVP,Lac and oxygenation index after the test,and the variations of SpO2,CVP and Lac.Conclusion PCRTO is a simple,reversible,safe and effective weaning method.It can be used in the process of VA-ECMO withdrawal in adult patients.