(体外膜肺ECMO课件)-ECMO.ppt
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- 关 键 词:
- 体外膜肺ECMO课件 体外 ECMO 课件
- 资源描述:
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1、uEXTRA CORPOREAL MEMBRANE OXGENATIONuPROVIDES PROLONGED RESPIRATORY AND CARDIAC SUPPORTuDOES NOT TREAT UNDERLYING PATHOLOGYuALLOWS SUPPORT WHILST DISEASE RESOLVES OR REVERSESuONLY APPROPRIATE IF UNDERLYING PATHOLOGY IS POTENTIALLY REVERSIBLEuAspiration pneumoniauARDS traumauARDS sepsisuARDS obstetri
2、cuPneumonia viral bacterial atypicaluPancreatitisuDrowninguBurns-smoke inhalationuPulmonary embolusuTricyclic Antidepressant ODuViral myocarditisuPost CPB failure to weanuCapillary leakuHyaline membranesuSurfactant depletionuCollapse/consolidationuVQ mismatchuReduced complianceuNeutrophil infiltrati
3、on and cytokine release u1916-MACLEAN-HEPARIN(JH)u1930-JOHN GIBBON-FIRST INVESTIGATION INTO ECLSu1944-KOLFF AND BERK-BLOOD OXYGENATION IN CELLOPHANE CHAMBERS OF ARTIFICIAL KIDNEYu1950-EARLY DEVELOPEMENTS OF CPBu1956-CLOWES-INVENTED MENBRANE OXGENATORu1957-KAMMERMEYER-INVENTED SILICONE-MEMBRANE LUNGD
4、r&Mrs Gibbon with their CPB machineu1960-EXPERIMENTS INTO PROLONGED CPBu1972-HILL-FIRST ADULT ECMO-AORTIC RUPTUREu1975-BARTLETT-FIRST SUCCESSFUL NEONATAL ECMO u1986-USA 18 CENTRES ECMOu1986-GATTINONI-50%SURVIVAL IN ADULT ECCO2Ru1989-ELSO REGISTRYu2001-120 CENTRES WORLD WIDEuNeonatal 40 cases per yea
5、ruPaediatric 20 cases per yearuAdult 40 cases per yearuCardiac(v.small number)NO RESERVOIR;BLADDER SERVOREGULATOR NO CENTRIFUGAL PUMP(haemolysis)NO MICROPROUS OXYGENATOR VENO-VENOUS PREFERRED WITH ADEQUATE CARDIAC FUNCTION NORMOTHERMIA HEPARIN ACT 160-200 NOT 500+NO ARTERIAL FILTER NOT HAEMODILUTED
6、HB 14g/dl;HCT 40 NO AUTOTRANSFUSIONuVeno-venous(v=28Fr;a=21 to 28Fr)uVeno-arterialuPercutaneousuOpenuSemi-SeldingeruDouble lumenuSingle lumen21F percutaneous return cannula in adult Rt femoral veinuPulmonary vasodilation(corr.Of hypoxia and acidosisuMyocardial oxygenationuMaintained pulmonary blood
7、flowuMinimally invasiveuNot affected by PDAuMore difficultuSlower stabilisationuNo circulatory supportuRe-circulationuEasy to useuCirculatory supportuInstant stabilisationuHuge experienceuRight heart offloaded and resteduCarotid ligationuJugular ligationuRaised LV afterloaduReduced pulmonary blood f
8、lowuHypoxic coronary perfusionuStun-high LV afterloaduDuctuFIO2-0.3uPEEP 10cm H20uPEAK INSPIRATORY PRESSURE 20cm H2OuRATE 5-10/minuTHEREFORE REDUCE:BAROTRAUMA VOLUTRAUMA OXYGEN TOXICITY MYOCARDIAL DEPRESSIONuMULTIPLE TRANSFUSIONuHYPOALBUMINAEMIC-SEPSIS,DILUTIONuCAPILLARY LEAK SYDROMEuRENAL FAILURE-S
9、EPSISuFLUID OVERLOAD FROM CIRCUIT PRIMEuDIURESIS TO DRY WEIGHTvDOPAMINEvFRUSEMIDE INFUSIONvAMINOPHYLLINEv40%CVVHFuPercutaneous Veno-venous Cannulation.uLow range heparinisation;ACT 160-200uLung Rest(20/10,RR10,FIO2 30%).uNormothermia.uDiuresis to dry weight.uHb 14g/dl.uNIH Adult ECMO Trial Zapol et
10、al JAMA 242:2193-96,1979uPCIRV vs ECCO2R Morris et al,Am J Respir Crit Care Med 1994;149:295-305.uZapol,:(NIH Trial)(VA ECMO+ventilation and ventilation only)Severe ARF.A Randomized Prospective Study.JAMA 1979:242:2193-6)u90 patients,9 US centres,1974-77uSurvival 20,Peak 45-55 cmH2)uFrequent severe
11、bleeding complications(leading to discontinuation of ECCO2R in 7/19 cases)BOTH TRIALS HAVE LITTLE RELEVANCE TO CURRENT ECMO REGIMENSPaO2/FIO2 65mmhgMurray Score=3.4DiagnosisNSurvival%Survival.Pneumonia261973%ARDS201365%Other4125%Total503366%uLFPPV with ECCO2R in severe acute respiratory failure,Gatt
12、inoni L et al,JAMA 1986 256;7:881-6(50%survival)uECLS for 100 adult patients with severe respiratory failure.PaO2/FiO2=55mmHg Kolla S et al,Ann Surg 1997;226:544-64(survival 54%)uConventional patients 8/28 Survived (28.5%)uECMO patients39/57 Survived(68.4%)up=0.001uSome centres in the US and Europe
13、have been quite successful at providing ECMO for severe adult respiratory failure (Ann Arbor,Michigan,Berlin,Marburg,Munich,Glenfield Hospital,Leicester etc.)uECMO has become standard treatment for severe Neonatal Respiratory Failure and Persistent Pulmonary Hypertension of the NewbornuMichigan-66%u
14、Leicester-80%uBerlin-77%uVienna-80%uHF JET VENTILATION-Romand 1995uHF OSCILLATING-Moller 1995uINHALED NITIC OXIDE-Gerlach 1993uNEBULISED PROSTACYCLIN-Zwissler 1996uPCIRV-Morris 1994uPERMISSIVE HYPERCAPNOEA-Gentilello 1995(91%n=11,survival in trauma pts)uPRONE VENTILATION-Stoller 1990;Pappert 1994uLI
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