成人体外膜肺氧合联合连续性肾脏替代治疗研究进展

Research progresses in extracorporeal membrane oxygenation(ECMO)combined with continuous renal replacement therapy(CRRT)for adult patients

体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)临床上主要用于心脏功能不全和/或呼吸功能不全的支持,是治疗难以控制的严重心力衰竭和呼吸衰竭的关键技术。在ECMO期间,液体超载(fluid overload,FO)是最常见的肾脏替代治疗(renal replacement therapy,RRT)适应证,而连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)是最常用的方式。在ECMO患者中,CRRT可以通过不同的血管通路与ECMO并联运行,也可以通过连接管路串联运行。ECMO的抗凝通常采用全身性肝素,但CRRT回路可以采用几种方法,从不抗凝到添加滤内肝素或局部柠檬酸盐抗凝。CRRT联合ECMO可以被认为是一种多器官支持治疗的形式,但这种方法仍然需要在时机、设置、抗凝、处方和递送方面进行优化。本文对目前成人ECMO联合CRRT的意义,CRRT的启动时机、CRRT处方、管路连接和预后进行总结,以期为临床医生在面对此类患者时的治疗上提供一些参考。

Extracorporeal membrane oxygenation(ECMO)is mainly used in clinical practice to support cardiac insufficiency and/or respiratory insufficiency,and is a key technology for the treatment of severe and intractable heart failure and respiratory failure.During ECMO,fluid overload is frequently an indication for renal replacement therapy,and continuous renal replacement therapy(CRRT)is the commonly used modality.In patients on ECMO treatment,CRRT can be run in parallel with ECMO through different vascular access,or series connection in ECMO circuit.Anticoagulation for ECMO is usually with systemic heparin,but for CRRT circuit several methods can be used,such as no anticoagulation,addition of filtered heparin or local citrate anticoagulation.CRRT in combination with ECMO can be considered as a form of multi-organ supportive therapy,but this approach needs to be optimized in terms of timing,settings,anticoagulation,prescribing,and delivery.This review summarizes the implications of ECMO plus CRRT in adults,the timing of CRRT initiation,CRRT prescribing,circuit connection and prognosis in order to provide references for clinicians to treat the patients with appropriate indications.