顽固性感染性休克的ECMO治疗.ppt

难治性感染性休克的ECMO治疗 宁波市第一医院重症医学科范震 全身炎症反应综合症 SIRS 脓毒症 可能或已有的 感染引起的全身炎症反应 严重脓毒症 脓毒症所致的组织低灌注或器官功能障碍 脓毒性休克 脓毒症所致低血压 虽经液体复苏后仍无法逆转 SurvivingSepsisCampaign InternationalGuidelinesforManagementofSevereSepsisandSepticShock 2012 何为难治性脓毒症休克 de nedasevidenceoforganhypoperfusion extensiveskinmottling progressivelacticacidosis oliguriaoralteredmentalstatus despiteadequateintravascularvolumeandtheinabilitytomaintainmeanarterialpressure 65mmHgdespiteinfusionofveryhigh dosecatecholamines norepinephrine 1 g kg min dopamine 20 g kg minorepinephrine 1 g kg minwithdobutamine 20 g kg min 感染性休克流行病学 themortalityat28daysinPatientswithsepticshockthatwasvariousfrom49 2 57 5 Theeffectofearlygoal directedtherapyontreatmentofcriticalpatientswithseveresepsis septicshock amulti center prospective randomized controlledstudy EarlyGoal DirectedTherapyintheTreatmentofSevereSepsisandSepticShock 需在3小时内完成的项目1 检测血乳酸水平2 应用抗生素前获取血液培养标本3 使用广谱抗生素4 低血压或血乳酸 4mmol L时 按30mL kg给予晶体液需在6小时内完成的项目5 应用血管升压药 对早期液体复苏无效的低血压 维持平均动脉压 MAP 65mmHg6 当经过容量复苏后仍持续性低血压 即脓毒性休克 或早期血乳酸 4mmol L 36mg dL 时 测量中心静脉压 CVP 测量中心静脉血氧饱和度 Scvo2 7 如果早期血乳酸水平升高 应重复进行测量 严重脓毒症 脓毒症休克早期治疗 SurvivingSepsisCampaign InternationalGuidelinesforManagementofSevereSepsisandSepticShock 2012 严重脓毒症 脓毒症休克早期治疗目标 最初6小时复苏目标 a CVP 8 12mmHg b MAP 65mmHg c 尿量 0 5mL kg hr d 上腔静脉血氧饱和度 ScvO2 或混合静脉血氧饱和度 SvO2 分别为70 或65 e 动态监测乳酸水平 SurvivingSepsisCampaign InternationalGuidelinesforManagementofSevereSepsisandSepticShock 2012 最初6小时应达到的生理标准作为复苏目标 可使患者28天死亡率降低15 9 此治疗策略称为早期目标指导性输液治疗 49 2 VS33 3 一项涉及314名严重脓毒症患者的8个多中心的研究显示在按照早期目标治疗后患者的28天死亡率降低了17 7 42 5 VS24 8 Theeffectofvasopressinongastricperfusionincatecholamine dependentpatientsinsepticshock Chest 2003 124 2256 2260 Patientswithvasodilatorysepticshockthatremainsunresponsivetoaggressivefluidreplacementandincreasesincatecholaminetherapycontinuetohaveanextremelyhighmortalityrate closeto100 24 8 33 3 的患者液体复苏差的感染性休克能否再进一步提高患者的治愈率 ECMO的应用 各种急性心力衰竭的心脏支持V AECMO各种急性呼吸衰竭的肺通气支持V VECMOE CPR脓毒症休克的患者在积极EGDT后循环呼吸仍未见明显改善的难治性感染性休克患者是否也可以行ECMO支持来改善氧供 相关指南 相关指南 新生儿和小儿中的应用 636842例患者 总体死亡率39 小儿严重脓毒症及脓毒症休克 PSS 49153例入选 ECMO治疗死亡率47 8 RRT死亡率32 3 ECMO RRT死亡率58 4795接受了体外支持治疗 ECMO RRT ECMO RRT Extracorporealtherapiesinpediatricseveresepsis findingsfromthepediatrichealth careinformationsystemRuthetal CriticalCare 2015 19 397 Extracorporealtherapiesinpediatricseveresepsis findingsfromthepediatrichealth careinformationsystemRuthetal CriticalCare 2015 19 397 PediatrCritCareMed2007Vol 8 No 5 441例ECMO患者中有45例脓毒症休克患者行V AECMO支持 8例患者在插管前发生心跳骤停并行胸外按压 平均支持时间84小时 32 135h ECMO管路机械问题有17人发生 如 氧合器和泵头 管路血栓 插管移位 47 患者脱机并最终出院 经胸插管灌注的ECMO支持者生存并出院率为73 高于外周插管的44 对于首选股 颈内静脉 颈动脉插管 如流量过低或无法达到目标流量 改正中胸骨切开右心房插管 主动脉灌注 体重小于10kg患儿流量不小于150ml kg min 体重大于10kg患儿流量2 4l min m2 DISCUSSIONThebene tsincludemaintainingasubstantiallyhighercircuitblood owAvoidingthepotentiallydetrimentaleffectsofleftventricularbloodenteringtheaortainpatientswithseverelung Extracorporealmembraneoxygenationforrefractorysepticshockinchildren Oneinstitution sexperiencePediatrCritCareMed2007Vol 8 No 5 PediatrCritCareMed2011Vol 12 Patients Twenty threechildrenwithrefractorysepticshockwhoreceivedcentralECMOprimarilyascirculatorysupport 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 小结1 1 新生儿及儿童发生难治性感染性休克应用ECMO具有良好的支持作用2 在新生儿及儿童发生难治性感染性休克需要ECMO支持时 经胸中心插管的生存率和出院率较高 近年来ECMO的临床适应证不断扩展包括 1 各种原因引起的严重心源性休克 如心脏术后 心肌梗死 心肌病 心肌炎 心搏骤停 心脏移植术后等 2 各种原因引起的严重急性呼吸衰竭 如严重ARDS 哮喘持续状态 过渡到肺移植肺移植后原发移植物衰竭 弥漫性肺泡出血 肺动脉高压危象 肺栓塞 严重支气管胸膜瘘等 3 各种原因引起的严重循环衰竭 如感染中毒性休克 Forsepticshockunresponsivetoallothermeasures theAmericanCollegeofCriticalCareMedicinehassuggestedthatextracorporealmembraneoxygenation ECMO isaviabletherapyinneonatesandchildren However althoughsuccessfuluseofECMOinadultswithrefractorysepticshockhasbeenreportedinafewcases theexperiencewithECMOinadultswithsepticshockremainslimited 对比之间差异并分析原因 TheChestandCardiovascularSurgerycVolume146 Number5 结果Thesurvivors age 43 8years weresigni cantlyyoungerthanthenonsurvivors age 59 3years andall20patients 38 aged60yearsorolderdied RESULTSsurvivalofadultpatientswithrefractorysepticshockwas22 7 32 inspiteofECMOsupportCPRwasanindependentpredictorofin hospitalmortalityafterECMOinpatientswithrefractorysepticshockmyocardialinjuryasevaluatedbypeaktroponinIwasassociatedwiththelowerriskofin hospitalmortalitysurvivorsshowedlowerSOFAscoreatDay3comparedwiththenon survivors 15vs18 P 0 01 DISCUSSIONwhile14patients 43 8 receivedCPRinourstudy 7ofwhomdidnotachievethereturnofspontaneouscirculationbeforeinitiationofECMO Onlytwoofthesepatientssurvived andtheyrecoveredspontaneouscirculationwithin5minaftercardiacarrest These ndingssuggestthattheuseofECMOmightbecontraindicatedinpatientswhodevelopedcardiacarrestassociatedwithrefractorysepticshockTherearetwohaemodynamicpatternsofearlydeathinsepticshock distributiveshock lowsystemicvascularresistanceandrefractoryhypotensiondespitepreservedcardiacindex oracardiogenicformofsepticshock decreasedcardiacindex Distributiveshockmayberelatedtoamaldistributionofblood owattheorganlevelormicrovascularlevelandECMOmightbeoflittlevalueinpatientswithdistributiveshockwhopresentwithlowernormalorsupranormalcardiacfunction However ECMOmaysupportdecreasedcardiacoutputinpatientswiththecardio CriticalCareMedicine V A ECMOwasindicatedincaseofacuterefractorycardiovascularfailuredefinedasevidenceoftissuehypoxia suchasextensiveskinmottlingorelevatedbloodlactate concomitantwithadequateintravascularvolume severelyalteredleftvent