顽固性感染性休克的ECMO治疗PPT参考课件

1、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,1,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。,Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012,何为难治性脓毒症休克？,2,2020/9/3,dened as evidence of organ hypoper

2、fusion (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 epi

3、nephrine 1 g/kg/min with dobutamine 20g/kg/min),3,2020/9/3,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, rand

4、omized, controlled study. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock,4,2020/9/3,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 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)

5、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/脓毒症休克早期治疗,Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012,5,2020/9/3,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：812 mm Hg。 b) MAP 65 mm Hg。 c) 尿量 0.5 mL/kg/hr

6、。 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: 2012,6,2020/9/3,7,2020/9/3,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

7、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%),8,2020/9/3,The effect of vasopressin on gastric perfusion in catecholamine-dependent patients in septic shock.Chest.2003;124:22562260,Patients with vasodilatory septic shock that remains unresponsive to aggressive fluid replacement and increases in

8、 catecholamine therapy continue to have an extremely high mortality rate (close to 100%).,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？,9,2020/9/3,ECMO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？,10,2020/9/3,相关指南,11,2020/9/3,相关指南,12,2020

9、/9/3,13,2020/9/3,新生儿和小儿中的应用,14,2020/9/3,636842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

10、(2015) 19:397,15,2020/9/3,Extracorporeal therapies in pediatric severe sepsis: findings from the pediatric health-care information system Ruth et al. Critical Care (2015) 19:397,16,2020/9/3,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-

11、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/m2,17,2020/9/3,DISCUSSION The benets include maintaining a substantially higher circuit blood ow Avoiding t

12、he potentially detrimental effects of left ventricular blood entering the aorta in patients with severe lung,Extracorporeal membrane oxygenation for refractory septic shock in children: One institutions experience Pediatr Crit Care Med 2007 Vol. 8, No. 5,18,2020/9/3,Pediatr Crit Care Med 2011 Vol. 1

13、2,Patients: Twenty-three children with refractory septic shock who received central ECMO primarily as circulatory support,19,2020/9/3,RESULTS Eight (35%) patients suffered cardiac arrest and required external cardiacmassage before ECMO. Eighteen (78%) patients survived to be decannulated off ECMO, a

14、nd 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).,DISCUSSION The theoretical benets of central cannulation include safely achieving higher ECMO ow

15、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 technol

16、ogy and general improvements in critical care,20,2020/9/3,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,21,2020/9/3,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、

17、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,22,2020/9/3,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

18、adults with refractory septic shock has been reported in a few cases,the experience with ECMO in adults with septic shock remains limited.,23,2020/9/3,对比之间差异并分析原因,The Chest and Cardiovascular Surgery c Volume 146, Number 5,24,2020/9/3,25,2020/9/3,结果 The survivors (age,43.8 years) were signicantly yo

19、unger than the nonsurvivors(age, 59.3 years), and all 20 patients (38%) aged 60 years or older died,26,2020/9/3,27,2020/9/3,28,2020/9/3,RESULTS survival of adult patients with refractory septic shock was 22% (7/32) in spite of ECMO support CPR was an independent predictor of in-hospital mortality af

20、ter ECMO in patients with refractory septic shock myocardial injury as evaluatedby peak troponin I was associated with the lower risk of in-hospitalmortality survivors showed lower SOFA score at Day 3 compared with the non-survivors (15 vs 18, P = 0.01),29,2020/9/3,DISCUSSION while 14 patients (43.8

21、%) 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 ndings suggest that the use of ECMO might be contraindicat

22、ed in patients whodeveloped cardiac arrest associated with refractory septic shock There 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

23、 (decreased cardiac index) Distributive shock may be related to a maldistribution of blood ow at the organ level or microvascular leveland ECMO might be of little value in patients with distributive shock who present with lower normal or supranormal cardiac function. However, ECMO may support decrea

24、sed cardiac output in patients with the cardio,30,2020/9/3,Critical Care Medicine,V-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