ECM技术ICU王培栋

0,ECMO 技术,历史和现状,1,原理和结果,2,未来的展望,3,中国何处去,4,内容,0,历史和现状,0,原理和结果,用钱向上帝买时间用心向死神要生命,等待,MO,Pump,CPB,体外循环的改善,肝素涂抹技术经皮插管技术泵膜肺的优化,肝素涂抹技术,经皮插管技术,泵和膜肺优化,氧中毒,机械损伤,作用有限,常规急性呼衰治疗的缺陷,全身炎性反应,支持:,休息:,有效气体交换,高氧损伤机械损伤,ECMO 对呼吸的作用,降低后负荷降低前负荷增加心收缩,血供难保证速度较慢效果有限,使用大量活性药,的弊病,弊病,全身炎性反应,支持:,休息:,维持有效循环, 减少心脏做功 减少药物应用,ECMO对心脏的作用,心脏移植,供心动脉粥样硬化,取自体血管行CABG术,渗血严重，大量输血输液导致心肺功能恶化。少尿,IABP及ECMO,缺血时间长,心肌收缩仍差,CPB下二次心脏移植，暂停ECMO,术后呼吸功能未恢复,再次进行ECMO辅助,心肺功能改善,PLT低，手臂有出血点,停止ECMO,心脏移植和ECMO过程图,肺,心,脑,功能恢复,经济能力,建立ECMO前必须慎重考虑,经费预算,首次运行 2.5 3.0 万每天维持 0.4 0.6 万每例估计 4.5 6.0 万,瞳孔意识乳酸尿量活性药,时机的判断,He is life or death ?,what is next step ?,停机,放弃,继续转流,心肺移植,ECMO转归,适应症,团队,时机,ECMO 成功关键,0,未来展望,供体（心、肺）,原发性肺高压受体（心、肺）供体（心）,复杂先心ECMO无效受体（心）,天外有天,ECMO pECMO,经皮静脉插管房间隔打孔,AALA bridge to XP: Hoopes, 2009,清醒 ECMO,Rudich SM, et al, Transplantation, 2002,ECS assisted DCD,成人双腔引流灌注管,ADP,tPA,heparin,thrombomodulin,NO,ADP,PGI2,tissue plasminogen activator,Endothelial Cell,Non-thrombogenic Endothelium,thrombin,CollagenTissue FactorFibronectin,PAF,cytokines,Quiescent Platelet,prostaglandin I2,nitric oxide,thrombin,plateletactivatingfactor,platelet activating inhibitor,PAI-1,protein S,PS,TFPI,Effect of Nitric Oxide on Platelets,Direct Effects:directly binds to guanylate cyclase to increase cGMP:inhibits Ca 2+ influx into plateletsinhibits phosphorylation of myosin light chainsinhibits GpIIb/IIIa expressioninhibits phosphorylation by protein kinase Cmodulates phospholipase A2 and C mediated responsesdecreases local plasma Ca 2+Indirect Effects:NO reacts with S-thiols in the blood to create nitrosothiols,NO Releasing and Generating Materials as Thromboresistant Materials,NO flux from the endothelial cell (EC) surfaceVaughn, M. W.; et al. Am. J. Physiol. 274 (Heart Circ. Physiol. 43) 1998, H2163.4.1 10-10 molecm-2min-1Estimated based on Radomskis experimental data (Biochem. Biophy. Res. Comm. 1987, 148, 1482.)1.6 10-10 molecm-2min-1(Bradykinin stimulated EC)0.5 10-10 molecm-2min-1(unstimulated EC)Materials with equal or higher NO flux from their surfaces might be able to help prevent platelet adhesion/activation/aggregation on such materials.,Neonatal Respiratory Cases,Jan 2009,HFOVSurfactant,iNO,Cardiac Cases By YearUnder 16 years 1/09,ECMO 和 H1N1,EMERGENCY MEDICINE,0,中国何处去,ECMO,团结协作 争取成功,恢复室,体外循环,不断学习,加强宣传建立网络正规培训数据库医疗保险,几点建议,避免畸形发展 脚踏实地工作