新型冠状病毒肺炎疫情期间ECMO院际转运流程探讨:基于6例重症甲型H1N1流感病毒性肺炎ECMO转运经验的提示

Study on the extracorporeal membrane oxygenation inter-hospital transport during coronavirus disease 2019 epidemic:based on the transport experience of 6 cases of severe H1N1 influenza virus pneumonia on extracorporeal membrane oxygenation

目的基于6例重症甲型H1N1流感病毒性肺炎患者使用体外膜肺氧合(ECMO)的转运经验,为新型冠状病毒肺炎(新冠肺炎)疫情中使用ECMO院际转运提供参考。方法回顾性分析2018年10月至2019年12月皖南医学院第一附属医院实施ECMO转运重症甲型H1N1流感病毒性肺炎患者的临床资料,包括患者的一般资料,ECMO转运距离、时间,ECMO上机前后患者氧合指数(PaO2/FiO2)、呼吸频率(RR)、脉搏血氧饱和度(SpO2)、动脉血二氧化碳分压(PaCO2)、pH值,转运过程中发生的各种并发症,机械通气时间,患者最终预后等指标,从个人防护、转运流程、转运设备、团队配合、转运途中监测、质量控制等方面总结经验,对重型新冠肺炎患者使用ECMO院际转运流程及防护给出参考建议。结果共实施ECMO转运重症甲型H1N1流感病毒性肺炎患者6例,所有患者均由本科室ECMO转运团队在当地医院建立ECMO后使用救护车安全转运至皖南医学院第一附属医院重症监护病房(ICU),转运距离11~197 km,平均(93.8±58.6)km;转运时间30~150 min,平均(79.2±40.6)min;其中有2例患者在搬运、转运过程中出现ECMO流量和SpO2下降,主要原因为血容量不足,经过补液和调整体位后好转;所有患者SpO2维持在0.93以上。6例患者均存活出院;ECMO辅助时间4~9 d,平均(6.5±1.5)d;机械通气时间7~24 d,中位时间10.0(8.0,14.5)d。无一例医务人员出现感染。取得良好的治疗效果,主要经验是:选择合适的ECMO启动时机和模式;转运车辆和设备完好,减少或避免出现机械性并发症;转运途中有效的呼吸、循环管理,避免出现呼吸机相关性肺损伤(VALI)和严重的低氧血症;转运团队队员车内合适的占位可迅速处理各种危急情况;个人防护需要贯穿始终,避免感染。结论在具有丰富经验的ECMO转运团队、良好的转运设备、全面的防护措施、合理的转运流程、完善的应急预案下,对于存在人与人传播的新冠肺炎患者使用ECMO转运是安全的。

Objective To provide a reference for extracorporeal membrane oxygenation(ECMO)inter-hospital transport during coronavirus disease 2019(COVID-19),based on the transport experience of 6 patients with severe H1N1 influenza virus pneumonia using ECMO.Methods Clinical data of patients with severe H1N1 influenza virus pneumonia implemented by ECMO in the First Affiliated Hospital of Wannan Medical College from October 2018 to December 2019 were retrospective analyzed,including general information,ECMO transport distance,time,clinical parameters before and after ECMO,including the patients'oxygenation index(PaO2/FiO2),respiratory rate(RR),pulse blood oxygen saturation(SpO2),arterial blood carbon dioxide partial pressure(PaCO2),and pH value,various complications during transport,mechanical ventilation time,patients'prognosis and other indicators.Experience from the aspects of personal protection,transport process and equipment,team cooperation,mid-transit monitoring,quality control,etc.,was summarized to provide suggestions for patients with severe COVID-19 using ECMO during inter-hospital transport and protection.Results A total of 6 patients with severe H1N1 influenza virus pneumonia were transported on ECMO.All patients were transported to the intensive care unit(ICU)of the First Affiliated Hospital of Wannan Medical College by the ECMO transport team after the establishment of ECMO in the local hospital.The transfer distance was 11 to 197 km,with an average of(93.8±58.6)km;the transfer time was 30 to 150 minutes,with an average of(79.2±40.6)minutes.Two patients experienced a drop in ECMO flow and SpO2 during the process,and the main reason was insufficient volume,which was improved after fluid resuscitation and posture adjustment.All patients maintained SpO2 above 0.93.Six patients survived and were discharged.ECMO assisted time was 4-9 days,with an average of(6.5±1.5)days;mechanical ventilation time was 7-24 days,and median time was 10.0(8.0,14.5)days.No H1N1 transmission occurred in medical personnel.To achieve good therapeutic effect,the main experience was to choose the proper timing and mode of ECMO;intact transportation vehicles and equipment to reduce or avoid mechanical complications;the effective management of respiration and circulation during the transportation to avoid ventilation-associated lung injury(VALI)and serious hypoxemia;the appropriate space for the transfer team to quickly handle various critical situations;and personal protection to avoid infection.Conclusion With an experienced ECMO transport team,good transport equipment,comprehensive protection measures,reasonable transport procedures,and a perfect emergency plan,it is safe to use ECMO transport for COVID-19 patients.