摘要
目的探讨体外膜肺氧合(ECMO)用于肺移植患者术前过渡的有效性。方法回顾性分析南京医科大学附属无锡市人民医院心肺诊疗中心2015年1月至2017年12月收治的18例接受ECMO过渡的肺移植手术患者的临床资料,包括性别、年龄、原发病、围手术期乳酸、术前白细胞、手术方式(单肺或双肺)、ECMO支持方式、ECMO过渡时间、术后ECMO使用时间、ECMO总使用时间、ECMO并发症、术后原发性移植物失功(PGD)、撤除ECMO以及生存情况。根据ECMO支持方式、ECMO是否成功撤除或原发病将患者进行分组,比较两组临床资料,并绘制患者180dKaplan-Meier生存曲线。结果①整体情况显示:18例接受ECMO过渡至肺移植手术的患者中,男性14例,女性4例;年龄23~78岁;特发性肺纤维化(IPF)6例,特发性肺动脉高压(IPAH)3例,间质性肺炎8例,矽肺1例;静脉-静脉(V-V)ECMO方式9例,静脉-动脉(V-A)ECMO方式9例;ECMO成功过渡至手术15例,过渡失败3例;ECMO过渡时间中位数为57.5(14.5,116.5)h;ECMO相关并发症中出血6例,肾功能不全12例,血栓2例,氧合器渗漏2例,下肢缺血1例;手术方式中单肺移植7例(右肺5例、左肺2例),双肺移植8例;术前死亡3例,死亡原因均为感染性休克;术后死亡9例,死亡原因为感染性休克4例,多器官功能衰竭4例,心源性猝死1例;长期生存6例。②分组比较显示:V-VECMO组(7例)与V-AECMO组(8例)通过ECMO成功过渡至肺移植手术的患者在性别、年龄、术前ECMO过渡时间、术后ECMO使用时间、ECMO总使用时间、术后PGD发生率、ECMO撤机成功率和术后180d累积生存率方面差异均无统计学意义。ECMO成功撤除组(11例)与撤除失败组(7例)患者性别、年龄、原发病、ECMO支持方式、手术方式、术前白细胞差异均无统计学意义,但成功撤除组较撤除失败组围手术期乳酸水平低(mmol/L:3.01±1.51比8.27±3.49,t=-3.770,P=0.006),ECMO总使用时间短(h:72.82±40.53比210.71±107.10,t=-3.907,P=0.001),术后180d累积生存率高(54.5%比0,P=0.038)。③Kaplan-Meier生存曲线分析显示:18例使用ECMO过渡至肺移植患者术后7、30、60、180d累积生存率分别为72.2%、38.9%、33.3%、33.3%,其中成功撤除组(11例)术后7、30、60、180d累积生存率高于撤除失败组(7例;分别为81.8%比57.1%、63.6%比0、54.5%比0、54.5%比0;log-rank检验:χ2=8.009,P=0.005)。IPF组(6例)术后7、30、60、180d累积生存率低于非IPF组(12例;分别为33.3%比83.3%、16.7%比50.0%、16.7%比41.7%、16.7%比41.7%;log-rank检验:χ2=4.161,P=0.041)。结论ECMO是肺移植患者术前过渡的有效手段,排除严重心室功能衰竭的前提下,V-VECMO和V-AECMO同样能为患者提供有效的生命支持;围手术期乳酸水平和ECMO使用时间是影响患者ECMO能否成功撤除的重要因素;原发病可影响患者预后。
Objective To evaluate the effect of extracorporeal membrane oxygenation(ECMO)as a bridge to lung transplantation(LTx).Methods The clinical data of 18 patients with end-stage lung diseases was retrospectively reviewed,using ECMO as a bridge to LTx in intensive care unit of Affiliated Wuxi People's Hospital from January 2015 to December 2017.Clinical parameters were obtained from these patients,including gender,age,primary disease,preoperative lactate level,preoperative leukocyte,operation modality(unilateral or bilateral),type of ECMO,ECMO support time as a bridge to LTx,ECMO support time after operation,total usage time of ECMO,ECMO associated complications,primary graft dysfunction(PGD),successful ECMO weaning,and survival.Patients were divided according to type of ECMO,whether successfully weaned from ECMO or not,and primary disease.Clinical data was compared,and the Kaplan-Meier survival of 180-day was studied.Results ① The overall situation showed:A total of 18 patients were enrolled,with 14 males and 4 females,age ranged from 23 to 78 years old.Primary disease included 6 cases of idiopathic pulmonary fibrosis(IPF),3 cases of idiopathic pulmonary hypertension(IPAH),8 cases of interstitial pneumonia and 1 case of silicosis.Nine patients received venous-venous(V-V)ECMO and 9 venous-artery(V-A)ECMO as a bridge to LTx;15 patients received LTx successfully,and failed in 3 cases.The average bridge time was 57.5(14.5,116.5)hours.ECMO associated complications included 6 cases with bleeding,12 cases with renal failure,2 cases with thrombosis,2 cases with oxygenator leak,and 1 case with leg ischemia.There were 7 unilateral(5 right lungs and 2 left lungs)and 8 bilateral LTx.Three patients died before LTx due to septic shock.Nine patients died after LTx,4 for septic shock,4 for multiple organ failure,and 1 for sudden cardiac death.Six patients survived after LTx.② Group comparison showed:There was no significant difference in gender,age,ECMO support time as a bridge to LTx,ECMO support time after operation,total ECMO usage time,incidence of PGD,successful weaning from ECMO,and 180-day survival rate between V-V ECMO group(n=7)and V-A ECMO group(n=8).There was no significant difference in gender,age,primary disease,type of ECMO,operation modality,preoperative leukocyte count between groups of successfully weaned from ECMO(n=11)and the failed(n=7).Lower level of preoperative lactate acid(mmol/L:3.01±1.51 vs.8.27±3.49,t=-3.770,P=0.006),shorter total ECMO usage time(hours:72.82±40.53 vs.210.71±107.10,t=-3.907,P=0.001),and higher 180-day survival rate(54.5% vs.0,P=0.038)were found in the group of successfully weaned from ECMO,when compared with the failed group.③ Kaplan-Meier survival analysis showed that postoperative survival rates of 7,30,60,and 180 days of 18 patients was 72.2%,38.9%,33.3%,and 33.3%,respectively.Among them,the postoperative survival rates of 7,30,60,and 180 days in the group of successfully weaned from ECMO(n=11)were higher than those in group of failed(n=7;81.8% vs.57.1%,63.6 % vs.0,54.5% vs.0,54.5% vs.0,respectively;log-rank test:χ2=8.009,P=0.005).The postoperative survival rates of 7,30,60,and 180 days in IPF group(n=6)were lower than those in non-IPF group(n=12;33.3% vs.83.3%,16.7% vs.50.0%,16.7% vs.41.7%,16.7% vs.41.7%;log-rank test:χ2=4.161,P=0.041).Conclusions The use of ECMO as a bridge to LTx may provide survival benefit for LTx recipients.V-V ECMO provides effective life support for patients without severe heart failure,and V-A ECMO for patients with unstable hemodynamics.Preoperative lactate level and total ECMO duration time were closely related to ECMO weaning rate.Primary diagnosis may affect prognosis.
作者
夏维
许红阳
毛文君
陈静瑜
Xia Wei;Xu Hongyang;Mao Wenjun;Chen Jingyu(Department of lntensive Care Unit,Affiliated Wuxi People's Hospital,Nanjing Medical University,Wuxi 214023,Jiangsu, China;Department of Thoracic Surgery,Affiliated Wuxi People's Hospital,Nanjing Medical University, Wuxi 214023,Jiangsu,China)
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2018年第12期1167-1172,共6页
Chinese Critical Care Medicine
基金
江苏省科教强卫工程青年医学重点人才项目(QNRC2016193).
关键词
肺移植
体外膜肺氧合
术前过渡
Lung transplantation
Extracorporeal membrane oxygenation
Preoperative bridge
