頑固性感染性休克的ECMO治療課件

難治性感染性休克的ECMO治療

重癥醫(yī)學科

頑固性感染性休克的ECMO治療全身炎癥反應綜合癥（SIRS）膿毒癥：(可能或已有的)感染引起的全身炎癥反應。嚴重膿毒癥：

膿毒癥所致的組織低灌注或器官功能障礙。膿毒性休克：膿毒癥所致低血壓，雖經(jīng)液體復蘇后仍無法逆轉。SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012何為難治性膿毒癥休克？？？頑固性感染性休克的ECMO治療de?nedasevidenceoforganhypoperfusion(extensiveskinmottling,progressivelacticacidosis,oliguriaoralteredmentalstatus)，despiteadequateintravascularvolumeandtheinabilitytomaintainmeanarterialpressure>65mmHgdespiteinfusionofveryhigh-dosecatecholamines(norepinephrine>1μg/kg/min,dopamine>20μg/kg/minorepinephrine>1μg/kg/minwithdobutamine>20μg/kg/min)頑固性感染性休克的ECMO治療感染性休克流行病學themortalityat28daysinPatientswithsepticshockthatwasvariousfrom49.2%-57.5%Theeffectofearlygoal-directedtherapyontreatmentofcriticalpatientswithseveresepsis/septicshock:amulti-center,prospective,randomized,controlledstudy].EarlyGoal-DirectedTherapyintheTreatmentofSevereSepsisandSepticShock頑固性感染性休克的ECMO治療需在3小時內完成的項目1)檢測血乳酸水平2)應用抗生素前獲取血液培養(yǎng)標本3)使用廣譜抗生素4)低血壓或血乳酸≥4mmol/L時，按30mL/kg給予晶體液需在6小時內完成的項目5)應用血管升壓藥(對早期液體復蘇無效的低血壓)維持平均動脈壓(MAP)≥65mmHg6)當經(jīng)過容量復蘇后仍持續(xù)性低血壓(即膿毒性休克)或早期血乳酸≥4mmol/L(36mg/dL)時：測量中心靜脈壓(CVP)測量中心靜脈血氧飽和度(Scvo2)7)如果早期血乳酸水平升高，應重復進行測量嚴重膿毒癥/膿毒癥休克早期治療SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012頑固性感染性休克的ECMO治療嚴重膿毒癥/膿毒癥休克早期治療目標最初6小時復蘇目標：a)CVP：8–12mmHg。b)MAP≥65mmHg。c)尿量≥0.5mL/kg/hr。d)上腔靜脈血氧飽和度(ScvO2)或混合靜脈血氧飽和度(SvO2)分別為70%或65%。e)動態(tài)監(jiān)測乳酸水平。SurvivingSepsisCampaign:InternationalGuidelinesforManagementofSevereSepsisandSepticShock:2012頑固性感染性休克的ECMO治療頑固性感染性休克的ECMO治療最初6小時應達到的生理標準作為復蘇目標，可使患者28天死亡率降低15.9%。此治療策略稱為早期目標指導性輸液治療(49.2%VS33.3%)。一項涉及314名嚴重膿毒癥患者的8個多中心的研究顯示在按照早期目標治療后患者的28天死亡率降低了17.7%(42.5%VS24.8%)頑固性感染性休克的ECMO治療Theeffectofvasopressinongastricperfusionincatecholamine-dependentpatientsinsepticshock.

Chest.

2003;124:

2256–2260Patientswithvasodilatorysepticshockthatremainsunresponsivetoaggressivefluidreplacementandincreasesincatecholaminetherapycontinuetohaveanextremelyhighmortalityrate(closeto100%).24.8-33.3%的患者液體復蘇差的感染性休克能否再進一步提高患者的治愈率？？頑固性感染性休克的ECMO治療

ECMO的應用各種急性心力衰竭的心臟支持V-AECMO各種急性呼吸衰竭的肺通氣支持V-VECMOE-CPR膿毒癥休克的患者在積極EGDT后循環(huán)呼吸仍未見明顯改善的難治性感染性休克患者是否也可以行ECMO支持來改善氧供？頑固性感染性休克的ECMO治療相關指南頑固性感染性休克的ECMO治療相關指南頑固性感染性休克的ECMO治療頑固性感染性休克的ECMO治療新生兒和小兒中的應用頑固性感染性休克的ECMO治療636842例患者總體死亡率39%小兒嚴重膿毒癥及膿毒癥休克（PSS）49153例入選ECMO治療死亡率47.8%RRT死亡率32.3%ECMO+RRT死亡率58.%4795接受了體外支持治療（ECMO/RRT/ECMO+RRT）Extracorporealtherapiesinpediatricseveresepsis:findingsfromthepediatrichealth-careinformationsystemRuthetal.CriticalCare(2015)19:397頑固性感染性休克的ECMO治療Extracorporealtherapiesinpediatricseveresepsis:findingsfromthepediatrichealth-careinformationsystemRuthetal.CriticalCare(2015)19:397頑固性感染性休克的ECMO治療PediatrCritCareMed2007Vol.8,No.5

441例ECMO患者中有45例膿毒癥休克患者行V-AECMO支持，8例患者在插管前發(fā)生心跳驟停并行胸外按壓。平均支持時間84小時（32-135h）。ECMO管路機械問題有17人發(fā)生，如：氧合器和泵頭，管路血栓、插管移位。47%患者脫機并最終出院。經(jīng)胸插管灌注的ECMO支持者生存并出院率為73%，高于外周插管的44%。

對于首選股、頸內靜脈-頸動脈插管，如流量過低或無法達到目標流量，改正中胸骨切開右心房插管-主動脈灌注。體重小于10kg患兒流量不小于150ml/kg/min，體重大于10kg患兒流量2.4l/min/m2頑固性感染性休克的ECMO治療DISCUSSIONThebene?tsincludemaintainingasubstantiallyhighercircuitblood?owAvoidingthepotentiallydetrimentaleffectsofleftventricularbloodenteringtheaortainpatientswithseverelungExtracorporealmembraneoxygenationforrefractorysepticshockinchildren:Oneinstitution’sexperiencePediatrCritCareMed2007Vol.8,No.5頑固性感染性休克的ECMO治療PediatrCritCareMed2011Vol.12Patients:Twenty-threechildrenwithrefractorysepticshockwhoreceivedcentralECMOprimarilyascirculatorysupport頑固性感染性休克的ECMO治療RESULTSEight(35%)patientssufferedcardiacarrestandrequiredexternalcardiacmassagebeforeECMO.Eighteen(78%)patientssurvivedtobedecannulatedoffECMO,and17(74%)childrensurvivedtohospitaldischarge.Higherpre-ECMOarteriallactatelevelswereassociatedwithincreasedmortality(11.7mmol/Linnonsurvivorsvs.6.0mmol/Linsurvivors,p<0.007).DISCUSSIONThetheoreticalbene?tsofcentralcannulationincludesafelyachievinghigherECMO?owrates,potentiallyreversingshockandmultiorgandysfunctionsyndromemorequicklythanmightbeaccomplishedbyothercannulationstrategiesTheremayalsohavebeenotherfactorsunrelatedtoECMOcannulationthatcontributedtotheimprovementinsurvivalovertime,suchasbettercircuittechnologyandgeneralimprovementsincriticalcare頑固性感染性休克的ECMO治療小結11、新生兒及兒童發(fā)生難治性感染性休克應用ECMO具有良好的支持作用2、在新生兒及兒童發(fā)生難治性感染性休克需要ECMO支持時，經(jīng)胸中心插管的生存率和出院率較高頑固性感染性休克的ECMO治療近年來ECMO的臨床適應證不斷擴展包括：1.各種原因引起的嚴重心源性休克，如心臟術后、心肌梗死、心肌病、心肌炎、心搏驟停、心臟移植術后等。2.各種原因引起的嚴重急性呼吸衰竭，如嚴重ARDS、哮喘持續(xù)狀態(tài)、過渡到肺移植肺移植后原發(fā)移植物衰竭、彌漫性肺泡出血、肺動脈高壓危象、肺栓塞、嚴重支氣管胸膜瘺等。3.各種原因引起的嚴重循環(huán)衰竭，如感染中毒性休克頑固性感染性休克的ECMO治療Forsepticshockunresponsivetoallothermeasures,theAmericanCollegeofCriticalCareMedicinehassuggestedthatextracorporealmembraneoxygenation(ECMO)isaviabletherapyinneonatesandchildren.However,althoughsuccessfuluseofECMOinadultswithrefractorysepticshockhasbeenreportedinafewcases,theexperiencewithECMOinadultswithsepticshockremainslimited.頑固性感染性休克的ECMO治療對比之間差異并分析原因TheChestandCardiovascularSurgerycVolume146,Number5頑固性感染性休克的ECMO治療頑固性感染性休克的ECMO治療結果Thesurvivors(age,43.8years)weresigni?cantlyyoungerthanthenonsurvivors(age,59.3years),andall20patients(38%)aged60yearsorolderdied頑固性感染性休克的ECMO治療頑固性感染性休克的ECMO治療頑固性感染性休克的ECMO治療RESULTSsurvivalofadultpatientswithrefractorysepticshockwas22%(7/32)inspiteofECMOsupportCPRwasanindependentpredictorofin-hospitalmortalityafterECMOinpatientswithrefractorysepticshock

myocardialinjuryasevaluatedbypeaktroponinIwasassociatedwiththelowerriskofin-hospitalmortalitysurvivorsshowedlowerSOFAscoreatDay3comparedwiththenon-survivors(15vs18,P=0.01)頑固性感染性休克的ECMO治療DISCUSSIONwhile14patients(43.8%)receivedCPRinourstudy,7ofwhomdidnotachievethereturnofspontaneouscirculationbeforeinitiationofECMO.Onlytwoofthesepatientssurvived,andtheyrecoveredspontaneouscirculationwithin5minaftercardiacarrest。These?ndingssuggestthattheuseofECMOmightbecontraindicatedinpatientswhodevelopedcardiacarrestassociatedwithrefractorysepticshockTherearetwohaemodynamicpatternsofearlydeathinsepticshock:distributiveshock(lowsystemicvascularresistanceandrefractoryhypotensiondespitepreservedcardiacindex)oracardiogenicformofsepticshock(decreasedcardiacindex)Distributiveshockmayberelatedtoamaldistributionofblood?owattheorganlevelormicrovascularlevelandECMOmightbeoflittlevalueinpatientswithdistributiveshockwhopresentwithlowernormalorsupranormalcardiacfunction.However,ECMOmaysupportdecreasedcardiacoutputinpatientswiththecardio頑固性感染性休克的ECMO治療CriticalCareMedicineV-A-ECMOwasindicatedincaseofacuterefractorycardiovascularfailuredefinedasevidenceoftissuehypoxia(suchasextensiveskinmottlingorelevatedbloodlactate)concomitantwithadequateintravascularvolume;severelyalteredleftventricularejectionfraction(LVEF)(<25%);lowcardiacindex(<2.2L/min/m2);andsustainedhypotensiondespiteinfusionofveryhigh-