顽固性感染性休克的ECMO治疗课件

顽固性感染性休克的ECMO治疗难治性感染性休克的难治性感染性休克的ECMOECMO治疗治疗 重症医学科重症医学科 顽固性感染性休克的ECMO治疗全身炎症反应综合症（全身炎症反应综合症（SIRSSIRS）脓毒症：脓毒症：(可能或已有的可能或已有的)感染引起的全身炎症反应。感染引起的全身炎症反应。严重脓毒症：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。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。Surviving Sepsis Campaign:International Guidelines for Management of Severe Sepsis and Septic Shock:2012何为难治性脓毒症休克？何为难治性脓毒症休克？顽固性感染性休克的ECMO治疗 defined as evidence of organ hypoperfusion(extensive skin mottling,progressive lactic acidosis,oliguria or altered mental status)，despite adequate intravascular volume and the inability to maintain meanarterial pressure 65 mmHg despite infusion of very high-dosecatecholamines(norepinephrine 1 g/kg/min,dopamine 20g/kg/min or epinephrine 1 g/kg/min with dobutamine 20g/kg/min)顽固性感染性休克的ECMO治疗感染性休克流行病学感染性休克流行病学the mortality at 28 days in Patients with septic shock that was various from 49.2%-57.5%The effect of early goal-directed therapy on treatment of critical patients with severe sepsis/septic shock:a multi-center,prospective,randomized,controlled study.Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock顽固性感染性休克的ECMO治疗需在需在 3 3 小时内完成的项目小时内完成的项目 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 30 mL/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)65 mm Hg 6)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 4 mmol/L(36 mg/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严重脓毒症/脓毒症休克早期治疗脓毒症休克早期治疗Surviving Sepsis Campaign:International Guidelines for Management of Severe Sepsis and Septic Shock:2012顽固性感染性休克的ECMO治疗严重脓毒症严重脓毒症/脓毒症休克早期治疗目标脓毒症休克早期治疗目标最初6小时复苏目标：a)CVP：812 mm Hg。b)MAP 65 mm Hg。c)尿量 0.5 mL/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。Surviving Sepsis Campaign:International Guidelines for Management of Severe Sepsis and Septic Shock: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%VS 33.3%)。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%VS 24.8%)顽固性感染性休克的ECMO治疗The effect of vasopressin on gastric perfusion in catecholamine-dependent patients in septic shock.Chest.2003;124:22562260Patients with vasodilatory septic shock that remains unresponsive to aggressive fluid replacement and increases in catecholamine therapy continue to have an extremely high mortality rate(close to 100%).24.8-33.3%24.8-33.3%的患者液体复苏的患者液体复苏差的感染性休克能否再进一差的感染性休克能否再进一步提高患者的治愈率？步提高患者的治愈率？顽固性感染性休克的ECMO治疗ECMOECMO的应用的应用 各种急性心力衰竭的心脏支持 V-A ECMO 各种急性呼吸衰竭的肺通气支持 V-V ECMO E-CPR 脓毒症休克的患者在积极脓毒症休克的患者在积极EGDTEGDT后循环呼吸仍未见明显改善的难治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性感染性休克患者是否也可以行ECMOECMO支持来改善氧供？支持来改善氧供？顽固性感染性休克的ECMO治疗相关指南相关指南顽固性感染性休克的ECMO治疗相关指南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）Extracorporeal therapies in pediatric severe sepsis:findings from the pediatric health-care information system Ruth et al.Critical Care(2015)19:397 顽固性感染性休克的ECMO治疗Extracorporeal therapies in pediatric severe sepsis:findings from the pediatric health-care information system Ruth et al.Critical Care(2015)19:397 顽固性感染性休克的ECMO治疗Pediatr Crit Care Med 2007 Vol.8,No.5 441例ECMO患者中有45例脓毒症休克患者行V-A ECMO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DISCUSSIONDISCUSSIONThe benefits include maintaining a substantially higher circuit blood flow Avoiding the potentially detrimental effects of left ventricular blood entering the aorta in patients with severe lungExtracorporeal membrane oxygenation for refractory septic shock in children:One institutions experience Pediatr Crit Care Med 2007 Vol.8,No.5顽固性感染性休克的ECMO治疗Pediatr Crit Care Med 2011 Vol.12Patients:Patients:Twenty-three children with refractory septic shockwho received central ECMO primarily as circulatory support顽固性感染性休克的ECMO治疗RESULTSRESULTSEight(35%)patients suffered cardiac arrest and required external cardiacmassage before ECMO.Eighteen(78%)patients survived to be decannulated off ECMO,and 17(74%)children survived to hospital discharge.Higher pre-ECMO arterial lactate levels were associated with increased mortality(11.7 mmol/L in nonsurvivors vs.6.0 mmol/L in survivors,p 0.007).DISCUSSIONDISCUSSIONThe theoretical benefits of central cannulation include safely achieving higher ECMO flow rates,potentially reversing shock and multiorgan dysfunctionsyndrome more quickly than might be accomplished by other cannulation strategies There may also have been other factors unrelated to ECMO cannulation that contributed to the improvement in survival over time,such as better circuit technology and general improvements in critical care顽固性感染性休克的ECMO治疗小结小结1 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治疗近年来近年来 ECMO ECMO 的临床适应证不断扩展包括：的临床适应证不断扩展包括：1.1.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、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。心肌炎、心搏骤停、心脏移植术后等。2.2.各种原因引起的严重急性呼吸衰竭，如严重各种原因引起的严重急性呼吸衰竭，如严重 ARDSARDS、哮喘持续状态、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。压危象、肺栓塞、严重支气管胸膜瘘等。3.3.各种原因引起的严重循环衰竭，如感染中毒性休克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 For septic shock unresponsive to all other measures,the American College of Critical Care Medicine has suggested that extracorporeal membrane oxygenation(ECMO)is a viable therapy in neonates and children.However,although successful use of ECMO in adults with refractory septic shock has been reported in a few cases,the experience with ECMO in adults with septic shock remains limited.顽固性感染性休克的ECMO治疗对比之间差异并分析原因对比之间差异并分析原因The Chest and Cardiovascular Surgery c Volume 146,The Chest and Cardiovascular Surgery c Volume 146,Number 5 Number 5 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The survivors(age,43.8 years)were significantly younger than the nonsurvivors(age,59.3 years),and all 20 patients(38%)aged 60 years or older died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RESULTSRESULTSsurvival of adult patients with refractory septic shock was 22%(7/32)in spite of ECMO supportCPR was an independent predictor of in-hospital mortality after ECMO in patients with refractory septic shock myocardial injury as evaluatedby peak troponin I was associated with the lower risk of in-hospitalmortalitysurvivors showed lower SOFA score at Day 3 compared with the non-survivors(15 vs 18,P=0.01)顽固性感染性休克的ECMO治疗DISCUSSIONDISCUSSIONwhile 14 patients(43.8%)received CPR in our study,7 of whom did not achieve the return of spontaneous circulation before initiation of ECMO.Only two of these patients survived,and they recovered spontaneous circulation within 5 min after cardiac arrest。These findings suggest that the use of ECMO might be contraindicated in patients whodeveloped cardiac arrest associated with refractory septic shockThere are two haemodynamic patterns of early death in septic shock:distributive shock(low systemic vascular resistance and refractory hypotension despite preserved cardiac index)or a cardiogenic form of septic shock(decreased cardiac index)Distributive shock may be related to a maldistribution of blood flow at the organ level or microvascular leveland ECMO might be of little value in patients ECMO might be of little value in patients with distributive shock who present with lower normal or supranormal cardiac with distributive shock who present with lower normal or supranormal cardiac functionfunction.However,ECMO may support decreased cardiac output in patients with the cardio顽固性感染性休克的ECMO治疗Critical Care MedicineCritical Care MedicineV-A-ECMO was indicated in case of acute refractory cardiovascular failure defined as evidence of tissue hypoxia(such as extensive skin mottling or elevated blood lactate)concomitant with adequate intravascular volume;severely altered left ventricular ejection fraction(LVEF)(25%);low cardiac index(1 g/kg/min or dobutamine 20 g/kg/min with norepinephrine 1 g/kg/min)Nonsurvivors procalcitonin concentrations were higher than survivors levels(respectively,164 ng/mL 78605 vs 41 ng/mL 11187;p=0.008顽固性感染性休克的ECMO治疗Conclusions:Conclusions:VA-ECMO rescued more than 70%of the patients who developed refractory cardiovascular dysfunction during severe bacterial septic shock.Survivors reported good long-term quality of life.Venoarterial extracorporeal membrane oxygenation might represent a valuable therapeutic option for adults in severe septic shock with refractory cardiac and hemodynamic failure顽固性感染性休克的ECMO治疗小结小结2 2对于各种积极治疗后仍持续恶化的难治性感染性休克，可尝试应用ECMO支持治疗难治性感染性休克患者中因心功能衰竭导致的休克应用ECMO治疗效果较好；因感染导致外周血管阻力下降的休克ECMO治疗效果欠佳顽固性感染性休克的ECMO治疗Thanks for your attion!