顽固性感染性休克的ECMO治疗课件

难治性感染性休克的ECMO治疗

重症医学科

顽固性感染性休克的ECMO治疗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？？？顽固性感染性休克的ECMO治疗definedasevidenceoforganhypoperfusion(extensiveskinmottling,progressivelacticacidosis,oliguriaoralteredmentalstatus)，despiteadequateintravascularvolumeandtheinabilitytomaintainmeanarterialpressure>65mmHgdespiteinfusionofveryhigh-dosecatecholamines(norepinephrine>1μg/kg/min,dopamine>20μg/kg/minorepinephrine>1μg/kg/minwithdobutamine>20μg/kg/min)顽固性感染性休克的ECMO治疗感染性休克流行病学themortalityat28daysinPatientswithsepticshockthatwasvariousfrom49.2%-57.5%Theeffectofearlygoal-directedtherapyontreatmentofcriticalpatientswithseveresepsis/septicshock:amulti-center,prospective,randomized,controlledstudy].EarlyGoal-DirectedTherapyintheTreatmentofSevereSepsisandSepticShock顽固性感染性休克的ECMO治疗需在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顽固性感染性休克的ECMO治疗严重脓毒症/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顽固性感染性休克的ECMO治疗顽固性感染性休克的ECMO治疗最初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%)顽固性感染性休克的ECMO治疗Theeffectofvasopressinongastricperfusionincatecholamine-dependentpatientsinsepticshock.

Chest.

2003;124:

2256–2260Patientswithvasodilatorysepticshockthatremainsunresponsivetoaggressivefluidreplacementandincreasesincatecholaminetherapycontinuetohaveanextremelyhighmortalityrate(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？？顽固性感染性休克的ECMO治疗

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？顽固性感染性休克的ECMO治疗相关指南顽固性感染性休克的ECMO治疗相关指南顽固性感染性休克的ECMO治疗顽固性感染性休克的ECMO治疗新生儿和小儿中的应用顽固性感染性休克的ECMO治疗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顽固性感染性休克的ECMO治疗Extracorporealtherapiesinpediatricseveresepsis:findingsfromthepediatrichealth-careinformationsystemRuthetal.CriticalCare(2015)19:397顽固性感染性休克的ECMO治疗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顽固性感染性休克的ECMO治疗DISCUSSIONThebenefitsincludemaintainingasubstantiallyhighercircuitbloodflowAvoidingthepotentiallydetrimentaleffectsofleftventricularbloodenteringtheaortainpatientswithseverelungExtracorporealmembraneoxygenationforrefractorysepticshockinchildren:Oneinstitution’sexperiencePediatrCritCareMed2007Vol.8,No.5顽固性感染性休克的ECMO治疗PediatrCritCareMed2011Vol.12Patients:Twenty-threechildrenwithrefractorysepticshockwhoreceivedcentralECMOprimarilyascirculatorysupport顽固性感染性休克的ECMO治疗RESULTSEight(35%)patientssufferedcardiacarrestandrequiredexternalcardiacmassagebeforeECMO.Eighteen(78%)patientssurvivedtobedecannulatedoffECMO,and17(74%)childrensurvivedtohospitaldischarge.Higherpre-ECMOarteriallactatelevelswereassociatedwithincreasedmortality(11.7mmol/Linnonsurvivorsvs.6.0mmol/Linsurvivors,p<0.007).DISCUSSIONThetheoreticalbenefitsofcentralcannulationincludesafelyachievinghigherECMOflowrates,potentiallyreversingshockandmultiorgandysfunctionsyndromemorequicklythanmightbeaccomplishedbyothercannulationstrategiesTheremayalsohavebeenotherfactorsunrelatedtoECMOcannulationthatcontributedtotheimprovementinsurvivalovertime,suchasbettercircuittechnologyandgeneralimprovementsincriticalcare顽固性感染性休克的ECMO治疗小结11、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顽固性感染性休克的ECMO治疗近年来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，如感染中毒性休克顽固性感染性休克的ECMO治疗Forsepticshockunresponsivetoallothermeasures,theAmericanCollegeofCriticalCareMedicinehassuggestedthatextracorporealmembraneoxygenation(ECMO)isaviabletherapyinneonatesandchildren.However,althoughsuccessfuluseofECMOinadultswithrefractorysepticshockhasbeenreportedinafewcases,theexperiencewithECMOinadultswithsepticshockremainslimited.顽固性感染性休克的ECMO治疗对比之间差异并分析原因TheChestandCardiovascularSurgerycVolume146,Number5顽固性感染性休克的ECMO治疗顽固性感染性休克的ECMO治疗结果Thesurvivors(age,43.8years)weresignificantlyyoungerthanthenonsurvivors(age,59.3years),andall20patients(38%)aged60yearsorolderdied顽固性感染性休克的ECMO治疗顽固性感染性休克的ECMO治疗顽固性感染性休克的ECMO治疗RESULTSsurvivalofadultpatientswithrefractorysepticshockwas22%(7/32)inspiteofECMOsupportCPRwasanindependentpredictorofin-hospitalmortalityafterECMOinpatientswithrefractorysepticshock

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