体外心肺复苏救治心脏骤停患者的病例系列报道
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摘要
目的描述性总结体外心肺复苏(extracorporeal cardiopulmonary resuscitation,ECPR)救治心脏骤停患者的预后及实践经验。方法观察2012年1月至2017年12月陆军军医大学第一附属医院体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)团队救治的全院(胸心外科、急救部、心内科、麻醉科、重症医学科)ECPR患者的临床资料,对ECPR组成、团队配合、患者生存率及并发症等进行回顾性分析。结果 13例ECPR患者,年龄16～69岁,中位年龄44岁,其中男性8例。原发疾病包括急性心肌梗死、暴发性心肌炎、外科术后等。均采用股动静脉插管的V-A ECMO模式,从心脏骤停到ECMO建立运转时间26～83 min,中位时间46 min;ECMO支持时间为27～189 h,中位时间为111 h;ECMO撤机后到出院时间0～21 d,中位时间7 d。7例成功撤机,4例存活出院。13例患者中插管部位渗血3例(23. 08%),5例(38. 46%)急性肾功能衰竭,脑死亡1例(7. 69%),2例(15. 38%)肺部感染,1例(7. 69%)心包填塞,插管侧下肢出院轻度跛行1例(7. 69%),多器官功能衰竭3例(23. 08%)。无截肢、肢体缺血坏死并发症发生。结论熟练有效的ECMO和常规心肺复苏团队配合,尽量缩短从心脏骤停到ECMO转流的时间,是保证ECPR救治成功率的重要因素。
Objective To analyze and summarize the practical experience and prognosis of extracorporeal cardiopulmonary resuscitation(ECPR) in the resuscitation of cardiac arrest patients. Methods The clinical data of ECPR patients rescued by our extracorporeal membrane oxygenation(ECMO) team(including departments of cardiothoracic surgery,emergency,cardiology,anesthesiology and intensive care medicine) from January 2012 to December 2017 were collected and retrospectively analyzed. The components of our ECPR team,team cooperation,survival rate and complications were analyzed. Results The 13 ECPR patients were 8 males and 5 females,at an age of 16 ～ 69(median age 44) years. Their primary diseases include acute myocardial infarction,fulminant myocarditis,postoperative surgery,and so on. All the 13 patients underwent V-A ECMO model of femoral arteriovenous intubation. The operation time from cardiac arrest to ECMO establishment was only 26 to 83(median time 46) min,and the time of ECMO support was 27 to 189(median time 111) h. The time from ECMO weaning to discharge was 0 ～ 21(median time 7) d.Seven patients were successfully weaned, and 4 were discharged alive. Incision bleeding occurred in3(23. 08%) patients. Five(38. 46%) patients had acute renal failure,1 patient(7. 69%) brain death,2(15. 38%) patients with pulmonary infection,1(7. 69%) patient with cardiac tamponade,1(7. 69%)patient with slight limp,and 3(23. 08%) patients suffered from multiple organ failure. No complication of amputation or limb ischemia necrosis occurred. Conclusion Skilled and effective teamwork of ECMO and CPR teams,and prompt and rapid initiation of ECPR after cardiac arrest are important factors to ensure the success rate of ECPR treatment.
Objective To analyze and summarize the practical experience and prognosis of extracorporeal cardiopulmonary resuscitation(ECPR) in the resuscitation of cardiac arrest patients. Methods The clinical data of ECPR patients rescued by our extracorporeal membrane oxygenation(ECMO) team(including departments of cardiothoracic surgery,emergency,cardiology,anesthesiology and intensive care medicine) from January 2012 to December 2017 were collected and retrospectively analyzed. The components of our ECPR team,team cooperation,survival rate and complications were analyzed. Results The 13 ECPR patients were 8 males and 5 females,at an age of 16 ～ 69(median age 44) years. Their primary diseases include acute myocardial infarction,fulminant myocarditis,postoperative surgery,and so on. All the 13 patients underwent V-A ECMO model of femoral arteriovenous intubation. The operation time from cardiac arrest to ECMO establishment was only 26 to 83(median time 46) min,and the time of ECMO support was 27 to 189(median time 111) h. The time from ECMO weaning to discharge was 0 ～ 21(median time 7) d.Seven patients were successfully weaned, and 4 were discharged alive. Incision bleeding occurred in3(23. 08%) patients. Five(38. 46%) patients had acute renal failure,1 patient(7. 69%) brain death,2(15. 38%) patients with pulmonary infection,1(7. 69%) patient with cardiac tamponade,1(7. 69%)patient with slight limp,and 3(23. 08%) patients suffered from multiple organ failure. No complication of amputation or limb ischemia necrosis occurred. Conclusion Skilled and effective teamwork of ECMO and CPR teams,and prompt and rapid initiation of ECPR after cardiac arrest are important factors to ensure the success rate of ECPR treatment.
引文
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[4] STUB D,BYRNE M,PELLEGRINO V,et al. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in a sheep model of refractory ischaemic cardiac arrest[J]. Heart Lung Circ,2013,22(6):421-427. DOI:10.1016/j. hlc. 2012. 11. 020.
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[6] FAGNOU D,COMBES A,DE BACKER D. Extracorporeal cardiopulmonary resuscitation[J]. Curr Opin Crit Care,2014,20(3):259-265. DOI:10. 1097/MCC. 0000000000000098.
[7] KASHIURA M,SUGIYAMA K,TANABE T,et al. Effect of ultrasonography and fluoroscopic guidance on the incidence of complications of cannulation in extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest:a retrospective observational study[J]. BMC Anesthesiol,2017,17(1):4. DOI:10. 1186/s12871-016-0293-z.
[8] TONNA J E,JOHNSON N J,GREENWOOD J,et al. Practice characterristics of Emergency Department extracorporeal cardiopulmonary resuscitation(e CPR)programs in the United States:The current state of the art of Emergency Department extracorporeal membrane oxygenation(ED ECMO)[J].Resuscitation,2016,107:38-46. DOI:10. 1016/j. resuscitation. 2016. 07. 237.
[9] TRUMMER G,BENK C,KLEMM R,et al. Short-term heart and lung support:extracorporeal membrane oxygenation and extracorporeal life support[J]. Multimed Man Cardiothorac Surg,2013,2013:1-9. DOI:10. 1093/mmcts/mmt008.
[10] CONRAD S A,RYCUS P T. Extracorporeal membrane oxygenation for refractory cardiac arrest[J]. Ann Card Anaesth,2017,20(Suppl 1):S4-S10. DOI:10. 4103/0971-9784. 197790.
[11] RICHARDSON A S,SCHMIDT M,BAILEY M,et al. ECMO Cardio-Pulmonary Resuscitation(ECPR),trends in survival from an internationalmulticentre cohort study over 12-years[J]. Resuscitation,2017,112:34-40. DOI:10. 1016/j.resuscitation. 2016. 12. 009.
[12] JOFFE A R,LEQUIER L,ROBERTSON C M. Pediatric outcomes after extracorporeal membrane oxygenation for cardiac disease and for cardiac arrest:a review[J]. ASAIO J,2012,58(4):297-310. DOI:10. 1097/MAT. 0b013e31825a21ff.
[13]江春景,杨峰,郝星.体外膜肺氧合辅助院内难治性心脏骤停患者转归的预测指标[J].心肺血管病杂志,2015,34(12):899-903. DOI:10. 3969/j. issn. 1007-5062. 2015.12. 006.JIANG C J,YANG F,HAO X. Outcome predictors in extracorporeal membrane oxygenation for in-hospital refractory cardiac arrest:a retrospective study[J]. J Cardiovasc Pulmonary Dis,2015,34(12):899-903. DOI:10. 3969/j. issn. 1007-5062. 2015. 12. 006.
[2] KERN K B,HILWIG R W,BERG R A,et al. Postresuscitation left ventricular systolic and diastolic dysfunction. Treatment with dobutamine[J]. Circulation,1997,95(12):2610-2613.
[3] SIAO F Y,CHIU C C,CHIU C W,et al. Managing cardiac arrest with refractory ventricular fibrillation in the emergency department:Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation[J].Resuscitation,2015,92:70-76. DOI:10. 1016/j. resuscitation. 2015. 04. 016.
[4] STUB D,BYRNE M,PELLEGRINO V,et al. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in a sheep model of refractory ischaemic cardiac arrest[J]. Heart Lung Circ,2013,22(6):421-427. DOI:10.1016/j. hlc. 2012. 11. 020.
[5] RYU J A,CHUNG C R,CHO Y H,et al. The association of findings on brain computed tomography with neurologic outcomes following extracorporeal cardiopulmonary resuscitation[J]. Crit Care,2017,21(1):15. DOI:10. 1186/s13054-017-1604-6.
[6] FAGNOU D,COMBES A,DE BACKER D. Extracorporeal cardiopulmonary resuscitation[J]. Curr Opin Crit Care,2014,20(3):259-265. DOI:10. 1097/MCC. 0000000000000098.
[7] KASHIURA M,SUGIYAMA K,TANABE T,et al. Effect of ultrasonography and fluoroscopic guidance on the incidence of complications of cannulation in extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest:a retrospective observational study[J]. BMC Anesthesiol,2017,17(1):4. DOI:10. 1186/s12871-016-0293-z.
[8] TONNA J E,JOHNSON N J,GREENWOOD J,et al. Practice characterristics of Emergency Department extracorporeal cardiopulmonary resuscitation(e CPR)programs in the United States:The current state of the art of Emergency Department extracorporeal membrane oxygenation(ED ECMO)[J].Resuscitation,2016,107:38-46. DOI:10. 1016/j. resuscitation. 2016. 07. 237.
[9] TRUMMER G,BENK C,KLEMM R,et al. Short-term heart and lung support:extracorporeal membrane oxygenation and extracorporeal life support[J]. Multimed Man Cardiothorac Surg,2013,2013:1-9. DOI:10. 1093/mmcts/mmt008.
[10] CONRAD S A,RYCUS P T. Extracorporeal membrane oxygenation for refractory cardiac arrest[J]. Ann Card Anaesth,2017,20(Suppl 1):S4-S10. DOI:10. 4103/0971-9784. 197790.
[11] RICHARDSON A S,SCHMIDT M,BAILEY M,et al. ECMO Cardio-Pulmonary Resuscitation(ECPR),trends in survival from an internationalmulticentre cohort study over 12-years[J]. Resuscitation,2017,112:34-40. DOI:10. 1016/j.resuscitation. 2016. 12. 009.
[12] JOFFE A R,LEQUIER L,ROBERTSON C M. Pediatric outcomes after extracorporeal membrane oxygenation for cardiac disease and for cardiac arrest:a review[J]. ASAIO J,2012,58(4):297-310. DOI:10. 1097/MAT. 0b013e31825a21ff.
[13]江春景,杨峰,郝星.体外膜肺氧合辅助院内难治性心脏骤停患者转归的预测指标[J].心肺血管病杂志,2015,34(12):899-903. DOI:10. 3969/j. issn. 1007-5062. 2015.12. 006.JIANG C J,YANG F,HAO X. Outcome predictors in extracorporeal membrane oxygenation for in-hospital refractory cardiac arrest:a retrospective study[J]. J Cardiovasc Pulmonary Dis,2015,34(12):899-903. DOI:10. 3969/j. issn. 1007-5062. 2015. 12. 006.