体外膜肺氧合致下肢缺血损伤的危险因素分析

摘要

目的：总结体外膜肺氧合（ECMO）在成人心源性休克（CS）中的临床救治经验，探讨 ECMO 的临床应用价值及导致下肢缺血损伤的可能危险因素。方法：回顾性分析中山大学附属中山医院2009年7月至2014年7月因传统药物和（或）主动脉内球囊反搏（IABP）无效而行 ECMO 救治的成人 CS 患者的临床资料，将辅助前合并颅脑损伤及多器官功能衰竭的病例排除在外，根据患者是否合并下肢缺血将其分为缺血损伤组（n＝9）与无缺血损伤组（n＝49），通过组间单因素比较筛选出影响脱机的可能危险因素。结果：本研究入选的58例 ECMO 患者中，建立循环时间15－25 min，辅助时间132．5±89．2h，成功脱机35例（60．4％），康复出院26例（44．8％）。与无下肢缺血损伤组比较，患者平均年龄、糖尿病比例、心跳骤停比例、血乳酸水平以及 ECMO 辅助时间显著高于血运正常组（P＜0．05），但心脏左室射血分数显著低于血运正常组（P＜0．05）。组件插管口径、插管深度无统计学差异（P＞0．05）。结论：ECMO 是救治成人心源性休克的较有效手段，肢体远端缺血损伤可直接影响疗效，尽早识别发生并发症的高危因素，并采取有效措施积极防治，是降低肢体远端缺血发生率，提高 ECMO 辅助成功的关键。%Objective:To summarize the clinical experience of treatment for adult cardiogenic shock (CS) with extracorporeal membrane oxygenation (ECMO) and analyze on risk factors of limb ischemia injury after ECMO. Methods:Patients with cardiogenic shock required veno-arterial ECMO after failure of conventional therapy and intra-aortic balloon pump counterpulsation therapy from July 2009 to July 2014 were retrospectively studied. Patients with traumatic brain injury and multiple organ failure were excluded. All patients were divided into limb ischemia injury group(n=9) and not limb ischemia injury group(n=49) according to the ECMO weaning. The risk factors were found by using one-way ANOVA to determine the possible risk factors associated with ECMO weaning. Results: Fifty-eight patients were required veno-arterial ECMO. The time to establish access to the circulation was 15-25 minutes. The duration of ECMO was 132.5±89.2 hours. There were thirty-five patients could be successfully weaned from ECMO. Twenty-six patients survived to discharge. Compared with patients of not limb ischemia injury group, the average age of patients, the ratio of diabetes and cardiac arrest, levels of blood lactate and duration of ECMO were higher in limb ischemia injury (P<0.05). But ejection fraction of heart was lower (P<0.05). There was no significant difference in the size and the depth of intubation. Conclusion: ECMO is an effective mechanical assistant therapy for adult cardiogenic shock. Limb ischemia injury affected the curative effect. Early recognizing the risk factors and adopting effective measure can reduce the ratio of limb ischemia. It is the key to ECMO supporting successfully.