頑固性感染性休克的ecmo治療

1、難治性感染性休克的ECMO治療,寧波市第一醫(yī)院 重癥醫(yī)學(xué)科 范 震,全身炎癥反應(yīng)綜合癥（SIRS）膿毒癥： ( 可能或已有的) 感染引起的全身炎癥反應(yīng)。嚴(yán)重膿毒癥： 膿毒癥所致的組織低灌注或器官功能障礙。 膿毒性休克：膿毒癥所致低血壓，雖經(jīng)液體復(fù)蘇后仍無法逆轉(zhuǎn)。,Surviving Sepsis Campaign: International Guidelines for M

2、anagement of Severe Sepsis and Septic Shock: 2012,何為難治性膿毒癥休克？？？,de?ned as evidence of organ hypoperfusion (extensive skin mottling, progressive lactic acidosis, oliguria or altered mental status) ，despite adequate intr

3、avascular volume and the inability to maintain meanarterial pressure >65 mmHg despite infusion of very high-dosecatecholamines (norepinephrine > 1 μg/kg/min, dopamine > 20μg/kg/min or epinephrine > 1 μg/kg/m

4、in with dobutamine > 20μg/kg/min),感染性休克流行病學(xué),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 sev

5、ere sepsis/septic shock: a multi-center, prospective, randomized, controlled study].Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock,需在 3 小時(shí)內(nèi)完成的項(xiàng)目 1) 檢測血乳酸水平

6、 2) 應(yīng)用抗生素前獲取血液培養(yǎng)標(biāo)本 3) 使用廣譜抗生素 4) 低血壓或血乳酸 ≥ 4mmol/L 時(shí)，按 30 mL/kg 給予晶體液需在 6 小時(shí)內(nèi)完成的項(xiàng)目 5) 應(yīng)用血管升壓藥 ( 對(duì)早期液體復(fù)蘇無效的低血壓) 維持平均動(dòng)脈壓 (MAP) ≥ 65 mm Hg 6) 當(dāng)經(jīng)過容量復(fù)蘇后仍持續(xù)性低血壓 (

7、即膿毒性休克) 或早期血乳酸 ≥ 4 mmol/L (36 mg/dL) 時(shí)：測量中心靜脈壓 (CVP)測量中心靜脈血氧飽和度(Scvo2) 7) 如果早期血乳酸水平升高，應(yīng)重復(fù)進(jìn)行測量,嚴(yán)重膿毒癥/膿毒癥休克早期治療,Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic

8、Shock: 2012,嚴(yán)重膿毒癥/膿毒癥休克早期治療目標(biāo),最初6小時(shí)復(fù)蘇目標(biāo)： a) CVP：8–12 mm Hg。 b) MAP ≥ 65 mm Hg。 c) 尿量 ≥ 0.5 mL/kg/hr。 d) 上腔靜脈血氧飽和度 (ScvO2) 或混合靜脈血氧飽和度 (SvO2) 分別為 70% 或 65%。 e)動(dòng)態(tài)監(jiān)測乳酸水平。,Surviving Sepsis Campaign: Internatio

9、nal Guidelines for Management of Severe Sepsis and Septic Shock: 2012,,,最初 6 小時(shí)應(yīng)達(dá)到的生理標(biāo)準(zhǔn)作為復(fù)蘇目標(biāo)，可使患者 28 天死亡率降低 15.9%。此治療策略稱為早期目標(biāo)指導(dǎo)性輸液治療(49.2% VS 33.3%)。一項(xiàng)涉及 314 名嚴(yán)重膿毒癥患者的8個(gè)多中心的研究顯示在按照早期目標(biāo)治療后患者的 28 天死亡率降低了 17.7%(42.5

10、% VS 24.8%),The effect of vasopressin on gastric perfusion in catecholamine-dependent patients in septic shock. Chest. 2003;124: 2256–2260,Patients with vasodilatory septic shock that remains unrespons

11、ive to aggressive fluid replacement and increases in catecholamine therapy continue to have an extremely high mortality rate (close to 100%).,24.8-33.3%的患者液體復(fù)蘇差的感染性休克能否再進(jìn)一步提高患者的治愈率？？,ECMO的應(yīng)用,各種急性心力衰竭的心臟支持 V-A ECMO各種急性

12、呼吸衰竭的肺通氣支持 V-V ECMOE-CPR膿毒癥休克的患者在積極EGDT后循環(huán)呼吸仍未見明顯改善的難治性感染性休克患者是否也可以行ECMO支持來改善氧供？,相關(guān)指南,,相關(guān)指南,新生兒和小兒中的應(yīng)用,636842例患者,總體死亡率39%,小兒嚴(yán)重膿毒癥及膿毒癥休克（PSS）49153例入選,ECMO治療死亡率47.8%,RRT死亡率32.3%,ECMO+RRT死亡率58.%,4795接受了體外支持治療（ECMO/RRT/

13、ECMO+RRT）,Extracorporeal therapies in pediatric severe sepsis: findings from the pediatric health-care information system Ruth et al. Critical Care (2015) 19:397,,,,,,,Extracorporeal therapies in pediatric severe sepsis

14、: findings from the pediatric health-care information system Ruth et al. Critical Care (2015) 19:397,Pediatr Crit Care Med 2007 Vol. 8, No. 5,441例ECMO患者中有45例膿毒癥休克患者行V-A ECMO支持，8例患者在插管前發(fā)生心跳驟停并行胸外按壓。平均支持時(shí)間84小時(shí)（32-135h）。EC

15、MO管路機(jī)械問題有17人發(fā)生，如：氧合器和泵頭，管路血栓、插管移位。 47%患者脫機(jī)并最終出院。經(jīng)胸插管灌注的ECMO支持者生存并出院率為73%，高于外周插管的44%。 對(duì)于首選股、頸內(nèi)靜脈-頸動(dòng)脈插管，如流量過低或無法達(dá)到目標(biāo)流量，改正中胸骨切開右心房插管-主動(dòng)脈灌注。體重小于10kg患兒流量不小于150ml/kg/min，體重大于10kg患兒流量2.4l/min/m2,DISCUSSIONThe

16、bene?ts include maintaining a substantially higher circuit blood ?ow Avoiding the potentially detrimental effects of left ventricular blood entering the aorta in patients with severe lung,Extracorporeal membrane oxygen

17、ation for refractory septic shock in children: One institution’s experience Pediatr Crit Care Med 2007 Vol. 8, No. 5,Pediatr Crit Care Med 2011 Vol. 12,Patients: Twenty-three children with refractory septic shockwho

18、received central ECMO primarily as circulatory support,,RESULTSEight (35%) patients suffered cardiac arrest and required external cardiacmassage before ECMO. Eighteen (78%) patients survived to be decannulated off ECMO

19、, 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).,DISCUSSIO

20、NThe theoretical bene?ts of central cannulation include safely achieving higher ECMO ?ow rates, potentially reversing shock and multiorgan dysfunctionsyndrome more quickly than might be accomplished by other cannulation

21、 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,小結(jié)

22、1,1、新生兒及兒童發(fā)生難治性感染性休克應(yīng)用ECMO具有良好的支持作用2、在新生兒及兒童發(fā)生難治性感染性休克需要ECMO支持時(shí)，經(jīng)胸中心插管的生存率和出院率較高,近年來 ECMO 的臨床適應(yīng)證不斷擴(kuò)展包括：1.各種原因引起的嚴(yán)重心源性休克，如心臟術(shù)后、心肌梗死、心肌病、心肌炎、心搏驟停、心臟移植術(shù)后等。2. 各種原因引起的嚴(yán)重急性呼吸衰竭，如嚴(yán)重 ARDS、哮喘持續(xù)狀態(tài)、過渡到肺移植肺移植后原發(fā)移植物衰竭、彌漫性肺泡出血、肺動(dòng)

23、脈高壓危象、肺栓塞、嚴(yán)重支氣管胸膜瘺等。3.各種原因引起的嚴(yán)重循環(huán)衰竭，如感染中毒性休克,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

24、 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.,對(duì)比

25、之間差異并分析原因,,The Chest and Cardiovascular Surgery c Volume 146, Number 5,,,結(jié)果The survivors (age,43.8 years) were signi?cantly younger than the nonsurvivors(age, 59.3 years), and all 20 patients (38%) aged 60 years or olde

26、r died,,RESULTSsurvival 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 sh

27、ock 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),DISCUSSIO

28、Nwhile 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 circu

29、lation within 5 min after cardiac arrest。 These ?ndings suggest that the use of ECMO might be contraindicated in patients whodeveloped cardiac arrest associated with refractory septic shockThere are two haemodynamic pa

30、tterns 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) Distr

31、ibutive 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 c

32、ardiac function. However, ECMO may support decreased cardiac output in patients with the cardio,Critical Care Medicine,V-A-ECMO was indicated in case of acute refractory cardiovascular failure defined as evidence of ti

33、ssue hypoxia (such as extensive skin mottling or elevated blood lactate) concomitant with adequate intravascular volume; severely altered left ventricular ejection fraction (LVEF) ( 1 µg/kg/min or dobutamine >

34、; 20 µg/kg/min with norepinephrine > 1 µg/kg/min),Nonsurvivors’ procalcitonin concentrations were higher than survivors’ levels (respectively, 164 ng/mL [78–605] vs 41 ng/mL [11–187]; p = 0.008,Conclusions:

35、 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 ex

36、tracorporeal membrane oxygenation might represent a valuable therapeutic option for adults in severe septic shock with refractory cardiac and hemodynamic failure,小結(jié)2,對(duì)于各種積極治療后仍持續(xù)惡化的難治性感染性休克，可嘗試應(yīng)用ECMO支持治療難治性感染性休克患者中因心功能