静脉-动脉-静脉体外膜氧合在危重症呼吸衰竭合并难治性休克患者中的应用

Application of veno-arterio-venous extracorporeal membrane oxygenation in patients with critical respiratory failure combined with refractory shock

目的汇总分析静脉-动脉-静脉体外膜氧合(VAV-ECMO)的临床应用经验。方法分析首都医科大学附属北京朝阳医院呼吸重症监护病房自2016年2月至2022年2月所有因危重症呼吸衰竭,同时合并或继发难治性休克而给予VAV-ECMO支持患者的临床和预后特征。结果共15例患者纳入研究,年龄53(40,65)岁,男性11例。12例患者因呼吸衰竭建立静脉-静脉体外膜氧合(VV-ECMO),后改为VAV-ECMO的主要原因为心源性休克(7/12)和脓毒症休克(4/12);2例因肺移植手术直接建立VAV-ECMO;1例因肺炎并发脓毒症休克入科即建立静脉-动脉体外膜氧合(VA-ECMO),后因氧合状态难以维持改为VAV-ECMO。从建立VV-ECMO或VA-ECMO到更改为VAV-ECMO的时间为3(1,5)d,VAV-ECMO支持时间为5(2,8)d。15例患者的主要并发症为出血,多为消化道和气道出血(4例),未发生颅内出血,2例出现下肢动脉灌注不良。15例患者中,8例病死于ICU,其中因合并脓毒症休克和心源性休克给予VAV-ECMO支持的患者分别为4、3例,因肺移植过渡建立VAV-ECMO支持的2例患者均存活。结论对于经过慎重选择的危重症呼吸衰竭合并心源性休克或者终末期肺病肺移植过渡患者,VAV-ECMO可能是一种安全、有效的救治手段,但对于脓毒症休克的患者可能获益较小。

Objective To preliminarily analyze the application experience of veno-arterio-venous extracorporeal membrane oxygenation(VAV-ECMO).The VAV-ECMO is a rescue strategy for patients with extremely critical respiratory failure combined with refractory shock.Methods From February 2016 to February 2022,the characteristics and outcomes of patients who were started on either veno-venous or veno-arterial ECMO due to respiratory or hemodynamic failure,and then converted to VAV-ECMO in respiratory intensive care unit(ICU)of Beijing Chaoyang Hospital were analyzed.Results A total of 15 patients underwent VAV-ECMO,aged 53(40,65)years,and 11 of whom were male.Within the group,VV-ECMO was initially used in 12 patients due to respiratory failure,but then VAV-ECMO was used due to cardiogenic shock(7/12)and septic shock(4/12),while VAV-ECMO was established in two patients due to lung transplantation.One patient was diagnosed with pneumonia complicated by septic shock,which was initially determined to be VA-ECMO,but then switched to VAV-ECMO because it was difficult to maintain oxygenation.The time from the establishment of VV or VA-ECMO to the switch to VAV-ECMO was 3(1,5)days and the VAV-ECMO support time was 5(2,8)days.ECMO-related complications were bleeding,mostly in the digestive tract(n=4)and airway hemorrhage(n=4),without intracranial hemorrhage,and poor arterial perfusion of the lower limbs(n=2).Among these 15 patients,the overall ICU mortality was 53.3%.The mortality of patients who received VAV-ECMO due to septic shock and cardiogenic shock was 100%(4/4)and 42.8%(3/7),respectively.Two patients who received VAV-ECMO due to lung transplantation all survived.Conclusion VAV-ECMO may be a safe and effective treatment for carefully selected patients with critical respiratory failure associated with cardiogenic shock or end-stage lung disease lung transplantation transition,however,patients with septic shock may benefit the least.