静脉-静脉体外膜肺氧合在体外循环手术后难治性低氧血症治疗中的应用价值

Therapeutic effect of veno-venous extracorporeal membrane oxygenation on refractory hypoxemia after cardiopulmonary bypass surgery

目的观察体外循环手术后难治性低氧血症患者应用静脉-静脉体外膜肺氧合(V-VECMO)支持治疗的效果,探讨其预后。方法2018年1月—2022年7月新疆医科大学第一附属医院诊治体外循环手术后难治性低氧血症患者65例,经改善心功能、优化呼吸机设置、肺复张、预防感染、液体管理维持液体负平衡等常规治疗后均符合V-VECMO上机指征,其中30例行V-VECMO支持治疗者为ECMO支持组,35例继续采用常规治疗者为常规治疗组。比较2组性别比例、年龄、体质量指数、吸烟史、欧洲心脏手术风险评估系统评分(EuroScore)、心脏手术类型、体外循环时间及入ICU时急性生理和慢性健康状况评估Ⅱ(APACHEⅡ)评分、肺损伤Murray评分、序贯器官衰竭(SOFA)评分等临床资料;记录ECMO支持组ECMO支持前及ECMO支持24h时,2组ECMO支持48h时pa(O_(2))、呼吸机吸入氧浓度、氧合指数、呼气末正压、平台压、驱动压、血乳酸、血管活性药物指数等;记录ECMO支持组ECMO支持治疗时间及撤机情况;记录2组主动脉内球囊反搏支持时间、机械通气时间、ICU治疗时间及住院期间心律失常、血栓形成、出血并发症和院内死亡发生情况。结果(1)2组年龄,体质量指数,EuroScore,体外循环时间,入ICU时APACHEⅡ评分、SOFA评分、左室射血分数、Murray评分、血管活性药物指数、呼气末正压、驱动压、平台压、动脉血pH、氧合指数、血乳酸,男性、有吸烟史、主动脉内球囊反搏比率及手术类型比较差异均无统计学意义(P>0.05)。(2)ECMO支持组ECMO支持24h时呼吸机吸入氧浓度[(60.51±7.02)%]、呼气末正压[(7.73±1.42)cmH_(2)O]、驱动压[(11.70±1.21)cmH_(2)O]、平台压[(19.33±2.32)cmH_(2)O]、血乳酸[(2.22±1.20)mmol/L]、心率[(93.58±10.31)次/min]、血管活性药物指数(24.20±9.13)均低于ECMO支持治疗前[100.00%、(10.27±1.87)cmH_(2)O、(13.67±1.32)cmH_(2)O、(23.93±2.08)cmH_(2)O、(5.02±3.19)mmol/L、(114.73±21.72)次/min、31.57±11.23](P<0.05),pa(O_(2))[(123.93±22.33)mmHg]、氧合指数[(215.02±33.23)mmHg]、平均动脉压[(83.67±6.61)mmHg]均高于ECMO支持治疗前[(66.03±8.58)、(66.03±8.58)、(74.12±9.91)mmHg](P<0.05)。(3)ECMO支持组ECMO支持治疗48h时呼吸机吸入氧浓度[(56.50±9.57)%]、血乳酸[(1.74±1.14)mmol/L]均低于常规治疗组[(96.86±4.71)%、(4.50±3.15)mmol/L](P<0.05),pa(O_(2))[(125.33±30.41)mmHg]、氧合指数[(222.97±44.65)mmHg]均高于常规治疗组[(97.10±15.67)、(100.89±19.42)mmHg](P<0.05),血管活性药物指数、呼气末正压、驱动压、平台压、动脉血pH值与常规治疗组比较差异均无统计学意义(P>0.05)。(4)ECMO支持组V-VECMO支持时间为71~351(164.12±83.52)h,成功撤机27例(90%)。ECMO支持组主动脉内球囊反搏支持时间[(8.61±2.75)d]、机械通气时间[(14.33±4.99)d]、ICU治疗时间[(17.57±6.96)d]均短于常规治疗组[(15.08±5.70)、(18.57±8.02)、(22.57±10.20)d](P<0.05),住院期间心律失常发生率(43.3%)、院内死亡率(23.3%)均低于常规治疗组(68.6%、60.0%)(P<0.05),出血发生率(33.3%)高于常规治疗组(8.6%)(P<0.05),血栓形成发生率与常规治疗组比较差异无统计学意义(P>0.05)。结论体外循环手术后难治性低氧血症患者应用V-VECMO支持可迅速改善氧合,利于保护性肺通气的实施,维持血流动力学稳定,促进脱机,减少术后心律失常,降低病死率,改善患者预后。

Objective To observe the therapeutic effect of veno-venous extracorporeal membrane oxygenation(V-V ECMO)support in patients with refractory hypoxemia after cardiopulmonary bypass surgery,and to investigate the prognosis.Methods From January 2018 to July 2022,65 patients with refractory hypoxemia after cardiopulmonary bypass surgery in the First Affiliated Hospital of Xinjiang Medical University met the indications of V-V ECMO after conventional treatment such as improving cardiac function,optimizing ventilator settings,lung recruitment maneuvers,infection prevention,and fluid management to maintain negative fluid balance,among whom 30 patients received V-V ECMO support(ECMO support group)and 35 received conventional treatment(conventional treatment group).The gender ratio,age,body mass index,smoking history,European system for cardiac operative risk evaluation score(EuroScore),type of cardiac surgery,cardiopulmonary bypass time,and scores of acute physiology and chronic health evaluationⅡ(APACHEⅡ),Murray lung injury and sequential organ failure assessment(SOFA)on ICU admission were compared between two groups.The pa(O_(2)),fraction of inspiration oxygen,oxygenation index,positive end-expiratory pressure,plateau pressure,driving pressure,blood lactate and vasoactive drug index were compared in ECMO support group before and 24 h after ECMO support,and between two groups 48 h after ECMO support.The duration of V-V ECMO support and successful weaning were recorded in ECMO support group.The intra-aortic balloon pump support time,mechanical ventilation time,length of ICU stay,and incidences of arrhythmia,thrombosis and bleeding complications as well as in-hospital mortality were recorded in two groups.Results(1)There were no significant differences in the age,body mass index,EuroScore,cardiopulmonary bypass time,APACHEⅡscore,SOFA score,left ventricular ejection fraction,Murray score,vasoactive drug index,positive end-expiratory pressure,driving pressure,plateau pressure,arterial blood pH,oxygenation index and blood lactate on admission to ICU,male ratio,percentages of patients with smoking history and intra-aortic balloon pump,and type of surgery between two groups(P>0.05).(2)The fraction of inspiration oxygen,positive end-expiratory pressure,driving pressure,plateau pressure,blood lactate,heart rate and vasoactive drug index in ECMO support group were lower 24 h after ECMO support[(60.51±7.02)%,(7.73±1.42)cmH_(2)O,(11.70±1.21)cmH_(2)O,(19.33±2.32)cmH_(2)O,(2.22±1.20)mmol/L,(93.58±10.31)beats/min,24.20±9.13]than those before ECMO support[100.00%,(10.27±1.87)cmH_(2)O,(13.67±1.32)cmH_(2)O,(23.93±2.08)cmH_(2)O,(5.02±3.19)mmol/L,(114.73±21.72)beats/min,31.57±11.23](P<0.05),pa(O_(2)),oxygenation index and mean arterial pressure were higher 24 h after ECMO support[(123.93±22.33),(215.02±33.23),(83.67±6.61)mmHg]than those before ECMO support[(66.03±8.58),(66.03±8.58),(74.12±9.91)mmHg](P<0.05).(3)The fraction of inspiration oxygen and blood lactate 48 h after ECMO support were lower in ECMO support group[(56.50±9.57)%,(1.74±1.14)mmol/L]than those in conventional treatment group[(96.86±4.71)%,(4.50±3.15)mmol/L](P<0.05),pa(O_(2))and oxygenation index were higher in ECMO support group[(125.33±30.41),(222.97±44.65)mmHg]than those in conventional treatment group[(97.10±15.67),(100.89±19.42)mmHg](P<0.05),and there were no significant difference in vasoactive drug index,positive end-expiratory pressure,driving pressure,plateau pressure and arterial blood pH value between two groups(P>0.05).(4)The V-V ECMO support lasted for 71 to 351(164.12±83.52)h,and ECMO was successfully weaned in 27 patients(90%).The intra-aortic balloon pump support time,mechanical ventilation time and length of ICU stay were shorter in ECMO support group[(8.61±2.75),(14.33±4.99),(17.57±6.96)d]than those in conventional treatment group[(15.08±5.70),(18.57±8.02),(22.57±10.20)d](P<0.05),the incidence of arrhythmia and in-hospital mortality were lower in ECMO support group(43.3%,23.3%)than those in conventional treatment group(68.6%,60.0%)(P<0.05),the incidence of bleeding was higher in ECMO support group(33.3%)than that in conventional treatment group(8.6%)(P<0.05),and there was no significant difference in the incidence of thrombosis between two groups(P>0.05).Conclusion The application of V-V ECMO support after cardiopulmonary bypass surgery can rapidly improve oxygenation,facilitate the implementation of lung protective ventilation,maintain hemodynamic stability,promote weaning,reduce the incidence of postoperative arrhythmia,reduce mortality,and improve the prognosis of patients with refractory hypoxemia.