Ambulatory veno-venous extracorporeal membrane oxygenation: Innovation and pitfalls
Ambulatory veno-venous extracorporeal membrane oxygenation: Innovation and pitfalls
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DOI：
10.1016/j.jtcvs.2011.07.029
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发表时间：
2011-10-01
影响因子：
6
通讯作者：
Griffith, Bartley P.
中科院分区：
文献类型：
--
作者：
Garcia, Jose P.;Kon, Zachary N.;Griffith, Bartley P.
目的：终末期肺疾病和严重急性肺损伤是复杂的实体，仍然是管理的挑战。治疗方法包括早期机械通气、呼气末正压通气、允许性高碳酸血症、肺血管扩张剂和复杂的液体方案。静脉-静脉体外膜氧合是这些患者的一种可用治疗选择，但在其传统形式下，可能与严重并发症相关。我们提出了我们的早期经验，试图优化体外膜肺氧合，强调减少连续性机械通气支持和积极的康复，目的是amphibia。这一战略已启用通过引入双腔绘制和返回插管放置通过颈内静脉。方法：第一个10例（平均年龄45.3岁，8名男性）与此策略之间的治疗，2009年1月1日，2009年10月1日，进行了回顾性分析。启动了非卧床体外膜肺氧合策略，目的是最小限度的机械通气和积极的康复。这些患者将脱离所有呼吸支持或过渡到移植。体外膜肺氧合的平均持续时间为20（9-59）天，平均血流量为3.5（1.6-4.9）L/min，CO2去除率为228（54-570）mL/min，O-2传递率为127（36-529）mL/min。10例患者中有6例脱离呼吸支持（N = 4）或接受移植（N = 2），并存活至出院。其余4例患者死于脓毒症（N = 3）和肾衰竭后停药（N = 1）。6例存活患者中有4例拔管并可走动，但仍接受体外膜肺氧合。在此期间，4例患者中有3例在床边锻炼，其余患者能够接受完整的心肺康复，包括跑步机walking.Conclusions：膜式血液氧合器和泵的耐用性的改善，促使人们重新考虑严重肺部疾病患者的体外膜肺氧合。本报告描述了一种尝试，以增加体外膜肺氧合的目标，通过最大限度地减少机械呼吸支持和使用积极的床内外康复。（《胸血管外科杂志》2011; 142：755-61）
Objective: End-stage lung disease and severe acute lung injury are complex entities that remain challenges to manage. Therapies include early institution of mechanical ventilation with positive end-expiratory pressure, permissive hypercapnia, pulmonary vasodilators, and complex fluid regimens. Veno-venous extracorporeal membrane oxygenation is an available treatment option for these patients but, in its conventional form, can be associated with significant complications. We present our early experience with an attempt to optimize extracorporeal membrane oxygenation, emphasizing reduced adjunctive mechanical ventilatory support and aggressive rehabilitation, with a goal of ambulation. This strategy has been enabled by the introduction of a dual-lumen draw and return cannula placed via the internal jugular vein.Methods: The first 10 patients (mean age of 45.3 years, 8 male) treated with this strategy between January 1, 2009, and October 1, 2009, were retrospectively reviewed. The ambulatory extracorporeal membrane oxygenation strategy was initiated with an aim of minimal mechanical ventilation and aggressive rehabilitation. The patients were intended to be weaned from all respiratory support or bridged to transplantation.Results: The mean duration of extracorporeal membrane oxygenation was 20 (9-59) days, with average mean blood flows of 3.5 (1.6-4.9) L/min, and levels of CO2 removal and O-2 transfer of 228 (54-570) mL/min and 127 (36-529) mL/min, respectively. Six of 10 patients were weaned from respiratory support (N = 4) or underwent transplantation (N = 2) and survived to discharge from the hospital. The remaining 4 patients died of sepsis (N = 3) and withdrawal of care after renal failure (N = 1). Four of the 6 surviving patients were extubated and ambulatory while still on extracorporeal membrane oxygenation. During that time, 3 of the 4 patients exercised at the bedside, with the remaining patient able to undergo full cardiopulmonary rehabilitation, including treadmill walking.Conclusions: Improvements in the durability of membrane blood oxygenators and pumps have prompted renewed consideration of extracorporeal membrane oxygenation in patients with severe lung disease. This report describes an attempt to augment extracorporeal membrane oxygenation with the goal of ambulation by minimizing mechanical ventilatory support and using aggressive in-and-out-of-bed rehabilitation. (J Thorac Cardiovasc Surg 2011; 142: 755-61)