难治性感染性休克的难治性感染性休克的ECMOECMO治疗治疗宁波市第一医院宁波市第一医院 重症医学科重症医学科 范范 震震1顽固性感染性休克的ECMO治疗全身炎症反应综合症（全身炎症反应综合症（SIRS）脓毒症：脓毒症： (可能或已有的可能或已有的)感染引起的全身炎症反应。感染引起的全身炎症反应。严重脓毒症：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。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何何为难治性治性脓毒症休克？毒症休克？2顽固性感染性休克的ECMO治疗definedasevidenceoforganhypoperfusion(extensiveskinmottling,progressivelacticacidosis,oliguriaoralteredmentalstatus)，despiteadequateintravascularvolumeandtheinabilitytomaintainmeanarterialpressure65mmHgdespiteinfusionofveryhigh-dosecatecholamines(norepinephrine1g/kg/min,dopamine20g/kg/minorepinephrine1g/kg/minwithdobutamine20g/kg/min)3顽固性感染性休克的ECMO治疗感染性休克流行病学感染性休克流行病学themortalityat28daysinPatientswithsepticshockthatwasvariousfrom49.2%-57.5%Theeffectofearlygoal-directedtherapyontreatmentofcriticalpatientswithseveresepsis/septicshock:amulti-center,prospective,randomized,controlledstudy.EarlyGoal-DirectedTherapyintheTreatmentofSevereSepsisandSepticShock4顽固性感染性休克的ECMO治疗需在需在 3小时内完成的项目小时内完成的项目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 30mL/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)65mmHg6)当经过容量复苏后仍持续性低血压 (即脓毒性休克)或早期血乳酸 4mmol/L(36mg/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重脓毒症毒症/ /脓毒症休克早期治毒症休克早期治疗Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 20125顽固性感染性休克的ECMO治疗严重脓毒症严重脓毒症/ /脓毒症休克早期治疗目标脓毒症休克早期治疗目标最初6小时复苏目标：a)CVP：812mmHg。b)MAP65mmHg。c)尿量 0.5mL/kg/hr。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: 20126顽固性感染性休克的ECMO治疗7顽固性感染性休克的ECMO治疗最初 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%VS33.3%)。一项涉及 314名严重脓毒症患者的8个多中心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%VS24.8%)8顽固性感染性休克的ECMO治疗Theeffectofvasopressinongastricperfusionincatecholamine-dependentpatientsinsepticshock.Chest.2003;124:22562260Patients with vasodilatory septic shock that remains unresponsive to aggressive fluid replacement and increases in catecholamine therapy continue to have an extremely high mortality rate (close to 100%).24.8-33.3%24.8-33.3%的患者液体复的患者液体复苏差的感染性休克能否再差的感染性休克能否再进一一步提高患者的治愈率？步提高患者的治愈率？9顽固性感染性休克的ECMO治疗ECMOECMO的应用的应用各种急性心力衰竭的心脏支持 V-AECMO各种急性呼吸衰竭的肺通气支持 V-VECMOE-CPR脓毒症休克的患者在积极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治性感染性休克患者是否也可以行ECMO支持来改善氧供？支持来改善氧供？10顽固性感染性休克的ECMO治疗相关指南相关指南11顽固性感染性休克的ECMO治疗相关指南相关指南12顽固性感染性休克的ECMO治疗13顽固性感染性休克的ECMO治疗新生儿和小儿中的应用新生儿和小儿中的应用14顽固性感染性休克的ECMO治疗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 (2015) 19:397 15顽固性感染性休克的ECMO治疗Extracorporeal therapies in pediatric severe sepsis: findings from the pediatric health-care information system Ruth et al. Critical Care (2015) 19:397 16顽固性感染性休克的ECMO治疗Pediatr Crit Care Med 2007 Vol. 8, No. 5441例ECMO患者中有45例脓毒症休克患者行V-AECMO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（32-135h）。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/m217顽固性感染性休克的ECMO治疗DISCUSSIONThebenefitsincludemaintainingasubstantiallyhighercircuitbloodflowAvoidingthepotentiallydetrimentaleffectsofleftventricularbloodenteringtheaortainpatientswithseverelungExtracorporeal membrane oxygenation for refractory septic shock in children: One institutions experience Pediatr Crit Care Med 2007 Vol. 8, No. 518顽固性感染性休克的ECMO治疗Pediatr Crit Care Med 2011 Vol. 12Patients:Patients:Twenty-threechildrenwithrefractorysepticshockwhoreceivedcentralECMOprimarilyascirculatorysupport19顽固性感染性休克的ECMO治疗RESULTSRESULTSEight(35%)patientssufferedcardiacarrestandrequiredexternalcardiacmassagebeforeECMO.Eighteen(78%)patientssurvivedtobedecannulatedoffECMO,and17(74%)childrensurvivedtohospitaldischarge.Higherpre-ECMOarteriallactatelevelswereassociatedwithincreasedmortality(11.7mmol/Linnonsurvivorsvs.6.0mmol/Linsurvivors,p0.007).DISCUSSIONDISCUSSIONThetheoreticalbenefitsofcentralcannulationincludesafelyachievinghigherECMOflowrates,potentiallyreversingshockandmultiorgandysfunctionsyndromemorequicklythanmightbeaccomplishedbyothercannulationstrategiesTheremayalsohavebeenotherfactorsunrelatedtoECMOcannulationthatcontributedtotheimprovementinsurvivalovertime,suchasbettercircuittechnologyandgeneralimprovementsincriticalcare20顽固性感染性休克的ECMO治疗小结小结1 11、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顽固性感染性休克的ECMO治疗近年来近年来 ECMOECMO的的临床适床适应证不断不断扩展包括：展包括：1. 1.各种原因引起的各种原因引起的严重心源性休克，如心重心源性休克，如心脏术后、心肌梗死、心肌病、后、心肌梗死、心肌病、心肌炎、心搏心肌炎、心搏骤停、心停、心脏移植移植术后等。后等。2. 2. 各种原因引起的各种原因引起的严重急性呼吸衰竭，如重急性呼吸衰竭，如严重重 ARDSARDS、哮喘持、哮喘持续状状态、过渡到肺移植肺移植后原渡到肺移植肺移植后原发移植物衰竭、弥漫性肺泡出血、肺移植物衰竭、弥漫性肺泡出血、肺动脉高脉高压危象、肺栓塞、危象、肺栓塞、严重支气管胸膜瘘等。重支气管胸膜瘘等。3. 3.各种原因引起的各种原因引起的严重循重循环衰竭，如感染中毒性休克衰竭，如感染中毒性休克22顽固性感染性休克的ECMO治疗Forsepticshockunresponsivetoallothermeasures,theAmericanCollegeofCriticalCareMedicinehassuggestedthatextracorporealmembraneoxygenation(ECMO)isaviabletherapyinneonatesandchildren.However,althoughsuccessfuluseofECMOinadultswithrefractorysepticshockhasbeenreportedinafewcases,theexperiencewithECMOinadultswithsepticshockremainslimited.23顽固性感染性休克的ECMO治疗对比之比之间差异并分析原因差异并分析原因TheChestandCardiovascularSurgerycVolume146,TheChestandCardiovascularSurgerycVolume146,Number5Number524顽固性感染性休克的ECMO治疗25顽固性感染性休克的ECMO治疗结果Thesurvivors(age,43.8years)weresignificantlyyoungerthanthenonsurvivors(age,59.3years),andall20patients(38%)aged60yearsorolderdied26顽固性感染性休克的ECMO治疗27顽固性感染性休克的ECMO治疗28顽固性感染性休克的ECMO治疗RESULTSsurvivalofadultpatientswithrefractorysepticshockwas22%(7/32)inspiteofECMOsupportCPRwasanindependentpredictorofin-hospitalmortalityafterECMOinpatientswithrefractorysepticshockmyocardialinjuryasevaluatedbypeaktroponinIwasassociatedwiththelowerriskofin-hospitalmortalitysurvivorsshowedlowerSOFAscoreatDay3comparedwiththenon-survivors(15vs18,P=0.01)29顽固性感染性休克的ECMO治疗DISCUSSIONwhile14patients(43.8%)receivedCPRinourstudy,7ofwhomdidnotachievethereturnofspontaneouscirculationbeforeinitiationofECMO.Onlytwoofthesepatientssurvived,andtheyrecoveredspontaneouscirculationwithin5minaftercardiacarrest。ThesefindingssuggestthattheuseofECMOmightbecontraindicatedinpatientswhodevelopedcardiacarrestassociatedwithrefractorysepticshockTherearetwohaemodynamicpatternsofearlydeathinsepticshock:distributiveshock(lowsystemicvascularresistanceandrefractoryhypotensiondespitepreservedcardiacindex)oracardiogenicformofsepticshock(decreasedcardiacindex)DistributiveshockmayberelatedtoamaldistributionofbloodflowattheorganlevelormicrovascularlevelandECMOmightbeoflittlevalueinpatientswithdistributiveshockwhopresentwithlowernormalorsupranormalcardiacfunction.However,ECMOmaysupportdecreasedcardiacoutputinpatientswiththecardio30顽固性感染性休克的ECMO治疗CriticalCareMedicineCriticalCareMedicineV-A-ECMOwasindicatedincaseofacuterefractorycardiovascularfailuredefinedasevidenceoftissuehypoxia(suchasextensiveskinmottlingorelevatedbloodlactate)concomitantwithadequateintravascularvolume;severelyalteredleftventricularejectionfraction(LVEF)(25%);lowcardiacindex(1g/kg/minordobutamine20g/kg/minwithnorepinephrine1g/kg/min) Nonsurvivors procalcitonin concentrations were higher than survivors levels (respectively, 164 ng/mL 78605 vs 41 ng/mL 11187; p = 0.00831顽固性感染性休克的ECMO治疗Conclusions:VA-ECMOrescuedmorethan70%ofthepatientswhodevelopedrefractorycardiovasculardysfunctionduringseverebacterialsepticshock.Survivorsreportedgoodlong-termqualityoflife.Venoarterialextracorporealmembraneoxygenationmightrepresentavaluabletherapeuticoptionforadultsinseveresepticshockwithrefractorycardiacandhemodynamicfailure32顽固性感染性休克的ECMO治疗小结小结2 2对于各种积极治疗后仍持续恶化的难治性感染性休克，可尝试应用ECMO支持治疗难治性感染性休克患者中因心功能衰竭导致的休克应用ECMO治疗效果较好；因感染导致外周血管阻力下降的休克ECMO治疗效果欠佳33顽固性感染性休克的ECMO治疗Thanksforyourattion!34顽固性感染性休克的ECMO治疗