静脉-动脉体外膜氧合(venous-arterial extracorporeal membrane oxygenation,VA ECMO)是一种临时机械循环辅助装置,为心源性休克患者提供循环和呼吸支持[1-4].尽管VAECMO能提供短期的循环辅助,部分患者经过体外膜氧合(extracorporeal membrane oxygenation,ECMO)的辅助能过渡到自身恢复或心室辅助装置状态,为下一步治疗提供时间[5-6],但VA ECMO在应用过程中可能出现某些严重并发症且影响患者预后,主要包括:出血、感染及神经系统并发症等[7].

近年来,体外膜氧合(extracorporeal membrane oxygenation,ECMO)广泛应用于各种危重症患者的辅助治疗,其辅助效果与从业人员的能力紧密相关.因此,ECMO从业人员的培训与继续教育对安全开展ECMO项目有着重要意义.由于ECMO的救治对象通常为极危重症患者,且其技术本身复杂、风险较高,还具有地域开展不均衡和需多学科团队协作等特点,故使得ECMO技术的培训与继续教育存在一定特殊性与局限性.目前国内仍然没有较为完整的ECMO培训体系.因此,为加强ECMO专业人才培养,规范化开展ECMO技术培训,近年来,中国体外生命支持组织(Chinese Extracorporeal Life Support Organization,ChECLS)开展了高仿真情景ECMO模拟培训项目,其主要内容包括ECMO的建立、ECMO辅助期间的管理和ECMO的撤机等.学员经过培训后,能够快速安全地进行ECMO的建立与撤除,对辅助期间的突发意外能够做出迅速、准确的判断并积极应对,取得了较好的培训效果.

Objective:To investigate the safety and the efficacy of percutaneous and surgical approach in femoro-femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation.Methods:All consecutive patients implanted with femoro-femoral VA-ECMO between January 2018 and December 2020 in Beijing Anzhen Hospital, Capital Medical University. Propensity score matching was used to compare outcomes of percutaneous and surgical groups while controlling for confounders.Results:Among the 276 patients who received femoro-femoral VA-ECMO (62 surgical and 214 percutaneous), propensity-score matching selected 52 pairs of patients with similar characteristics with mean age of(59.6±13.0)years old, in which 26 patients were female. There were a lower ECMO cannulation-associated complication (28.8% vs. 48.1%, P=0.044) and a lower hospital mortality (42.3% vs. 67.3%, P=0.010) in the percutaneous group. The circuit blood flow after ECMO initiation was similar in both groups[(3.3±0.8)L·min -1·kg -1 in percutaneous group vs. (3.2±0.7)L·min -1·kg -1 in surgical group, P=0.738]. The serum lactate was declined in both group after ECMO initiation[(5.4±5.8)mmol/L vs. (9.2±6.9)mmol/L, P<0.001 in percutaneous group; (6.3±6.2)mmol/L vs. (10.5±7.0)mmol/L, P=0.003 in surgical group]. Conclusion:Percutaneous approach is a safe and efficient technique in emoro-femoral VA-ECMO cannulation. Compared with surgical cannulation, percutaneous approach is associated with lower ECMO cannulation-associated complication and lower hospital mortality.

Objective:To investigate the relationship between serum lactate before initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and in-hospital mortality in adult patients with postcardiotomy refractory cardiogenic shock (PCCS).Methods:We analyzed 144 consecutive adult patients with PCCS received VA-ECMO support between January 2004 and December 2017. Patients were divided into two groups according to the serum lactate level before initiation of xVA-ECMO: low lactate group (LG, 54 cases) and high lactate group (HG, 90 cases). VA-ECMO support parameters and clinical outcomes were compared between the two groups.Results:92 (63.9%) patients were successfully weaned off VA-ECMO, and 52 (36.1%) were discharged. The inotrope scores, sequential organ failure assessment (SOFA) score at VA-ECMO initiation, and renal failure requiring renal replacement therapy during VA-ECMO support in patients with high lactate level were statistically higher ( P<0.05). The successfully wean off VA-ECMO (53.3% vs. 81.5%) and survival to discharge (16.7% vs. 68.5%) was significantly lower among patients in the HG group ( P<0.05). In multivariate analysis, high lactate levels before initiation of VA-ECMO remained the independent predictor of survival (odds ratio 11.9, 95% confidence interval 2.9-48.0, P<0.05). Conclusion:High lactate level(>8.6 mmol/L) before initiation of VA-ECMO is independently related to in-hospital mortality in adult patients with delayed refractory PCCS. This found may help clinicians to use VA-ECMO more effectively for those patients.

Objective To identified the impact of extracorporeal cardiopulmonary resuscitation (ECPR) on survival and neurologic outcome in adults with refractory in-hospital cardiac arrest (IHCA).Methods All 74 adult patients who underwent ECPR for IHCA were enroued from July 2012 to December 2017 in Beiing Anzhen Hospital,Capital Medical University.Survival to discharge and cerebral performance category (CPC) scale were evaluated.The independent high-risk factors were determined using multivariate regression analysis models.Results Patients were discharged alive with favorable neurologic outcomes (CPC 1-2).Compared with patients in the SG group,the value of blood gas pH and extracellular residual alkaloids in the DG group were statistically lower (with P values below 0.05).The incidence of renal function failure requiring continuous renal replacement treatment (CRRT) and severe neurological complications were statistically higher in DG group patients.Multivariate regression analysis suggested that advanced age (age ≥ 65 years),renal function failure requiring CRRT,and severe neurological complications were independent high-risk factors for hospital death.Conclusions ECMO can provide stable hemodynamic support to inhospital cardiac arrest patients and save the lives of some patients.ECMO should be actively implanted when the cause of cardiac arrest is expected to be recoverable.

Objective To evaluate the efficacy and safety of preoperative intra-aortic balloon pump(IABP) insertion in acute myocardial infarction(AMI) without cardiogenic shock(CS) patients receiving off-pump coronary artery bypass grafting ( OPCABG).Methods 444 consecutive AMI patients who underwent isolated OPCABG from January 2009 to December 2016 were enrolled.158 patients who underwent preoperative IABP placement(IABP group) and the other of 286 patients who did not have IABP placement(control group).The in-hospital mortality rate, postoperative complications, mechanical ventilation time, ICU stay and hospital length were compared between the two groups.Results The overall mortality was 5.0%.135 pairs of patients were matched.The preoperative IABP insertion showed benefits in postoperative survival rate compared with the control group(0 vs.5.9%, P＝0.004).However, patients with preoperative IABP were more likely to prolong duration of mechanical ventilation and ICU stay.The postoperative length of stay in hospital didn't show significant difference between the two groups.Conclusion Survival advantage was observed from preoperative IABP insertion in AMI patients without CS under-going OPCABG.

Objective:To analysis the clinical characteristics of Acute compartment syndrome after cardiovascular surgery,and to deepen the understanding of this disease.Methods:Retrospective the clinical datas of patients undergoing the acute compartment syndrome after cardiac and aortic surgery from Jan.2009 to May.2016 in Beijing Anzhen Hospital.Results:The initial symptoms of all the patients are calf swelling and tense on the affected side,with the signs of limbs ischemia,like pallor,cyanosis.Compared with the patients undergoing coronary artery bypass graft,patients who take the Bentall + Sun's surgery present the symptoms earlier.Patients are generally with poor prognosis.Conclusion:Acute compartment syndrome is an extremely rare complication after cardiovascular surgery,with multiply pathogenic factors,and is difficult to diagnosis at the onset.Early diagnosis to increase the blood supply on affected limbs,and timely operations make great significance to the prognosis and life quality of life.

目的:研究主动脉内气囊反搏(IABP)在经股动静脉体外膜式氧合(ECMO)患者中对四肢不同区域微循环状态的影响.方法:采用前瞻性、观察性研究,选取因为心源性休克而使用经股动静脉ECMO辅助联合使用IABP患者14例,使用近红外光谱分析(NIRS)在四肢进行血管阻断实验观察IABP开启与关闭时对于微循环状态及血流动力学的影响.IABP使用时以及IABP停止30分钟后分别记录心率、血压、周围组织血氧去饱和斜率及再饱和斜率等试验数据.结果:停止IABP后患者动脉舒张压[(53.86±8.65)vs.(63.29±9.54) mmHg,P=0.001(1mmHg=0.133kPa)]升高,脉压差[(28.14±13.96)vs.(17.93±10.41) mmHg,P=0.001]降低,患者四肢不同区域的组织氧饱和度(StO2)和组织血氧去饱和斜率及再饱和斜率在IABP使用与停止时没有明显改变.结论:IABP的应用产生的搏动灌注没有明显影响ECMO患者不同区域微循环状态.

Objective To evaluate whether cell saver used in pediatric patients undergoing cardiac surgery would decrease the number of post-operative allogeneic RBCs transfusions and possibly improve the clinical outcomes. Methods A total of 100 pediatric patients with congenital heart disease received elective cardiac surgery in our hospital from Aug. 2014 to Dec. 2014 were studied. Sub?jects were randomized to a cell saver transfusion group where cell saver blood was available for transfusion up to the end of the opera?tion, or to a control group, n =50 in each group. Blood product transfusions, and clinical outcomes were compared between groups. Results Children randomized to the cell saver group had significantly fewer RBC transfusions ( P<0.05) , and significantly fewer do?nor exposures ( P<0.05) . There were no significant clinical outcome differences. Conclusion Cell saver can reduce post-operative allogeneic RBC transfusion in pediatric patients undergoing cardiac surgery.

Objective To explore the effect of preoperative prophylactic use of intraa-ortic balloon pump on myocardial bio?markers and lactate after off-pump artery bypass grafting in the high-risk coronary diease patients. Methods Clinical data of 284 crit?ical CAD patients who underwent off-pump coronary artery bypass grafting from January 2011 to December 2013 were retrospective ana?lysed.These patients were divided into two groups 132 patients in IABP group, and 152 patients in control group. The postoperative CK?MB,cTnI and lactate were compared between the two groups. Results The inhospital mortality was significantly lower in IABP groups. CKMB, cTnIlevels at 8 h,48 h,72 h postoperative than the control groupe ( P<0.05) andand the lactate level of IABP group was also lowerthan the control group at 12 h,24 h,36 h,48 h and 72 h ( P<0.05) . The postoperative hospital stay and total hospital stay were shorter in the IABP group( P<0.05).Transfusion amounts were significantly fewer in IABP groupe ( P<0.05). Conclusion Preoper?ative prophylactic use of IABP in the high-risk CAD patients can alleviate the postoperative myocardial injury,supress the rise of lactate level postoperative and reduce the inhospital mortality.Besides,it can improve postoperative recovery without increasing the incidence of complications.

Objective o retrospectively study the outcome of extracorporeal membrane oxygenation (ECMO) in elderly pa?tients with refractory postoperative cardiogenic shock ( PCS) after coronary artery bypass grafting ( CABG) from our center, and to ana?lyze the possible risk factors. Methods A total of 119 consecutive patients treated with ECMO because of PCS after CABG or unsuc?cess fully weaning from cardiopulmonary bypass ( CPB) during surgery from January 2011 to December 2014 were reviewed. Logistic a?nalysis was performed to identify the risk factors of the clinical outcome. Results There were 42 elderly patients (>=65years) with a mean age of 69.4±3.5 years. Twenty cases (47.6%) success fully weaned from ECMO and ten cases (23.8%) were discharged from hospital. There were 77 non-elderly patients (<65 years) with a mean age of 55.1±6.6 years. Forty-one (53.2%) cases success fully weaned from ECMO and 33 (42.9%) cases were discharged from hospital. Between the elderly and non-elderly patients, significant difference was noted in lower limb ischemia (21.4% vs 6.5%), renal failure (42.9% vs 16.9%) and the frequency of dialysis (31.0%vs 13.0%) . Logistic analysis found that renal failure and lower limb ischemia wereindependent risk factors associated with theclinical outcome of patients. Conclusions ECMO is an effective treatment for eldely patients with PCS after CABG; Renal failure and lower limb ischemia are indepedent risk factors of the outcome of ECMO support.

目的:总结体外支持心肺复苏(ECPR)治疗院内心脏骤停(IH-CA)效果及风险因素.方法:回顾2004年6月至2014年12月,本中心IH-CA的ECPR患者,按体外膜肺氧合(ECMO)辅助结果分为出院存活组和死亡组,统计分析所收集的基本临床资料,采用多因素Logistic回归分析可能影响辅助结果的预测指标.结果:共46例患者,37例男性(80.4％),平均年龄(58.2±12.8)岁,平均辅助时间(107.9±56.6)小时.25例成功脱机(54.3％),其中13例存活出院(28.3％).ECMO辅助后12小时[(6.2±2.0)vs.(10.6±4.6)小时,P＜0.05]和24小时[(4.6±3.2)vs.(7.2±4.7)小时,P＜0.05]出院存活组乳酸均明显低于死亡组,另外,出院存活组急性肾损伤(acute kidney injury,AKI)的发生率明显低于死亡组(P＜0.05).多因素Logistic回归分析发现ECMO后,12小时乳酸是影响ECMO辅助结果的独立危险因素(OR =0.21,95％ CI:0.05 ～0.87,P＜0.05).结论:相比传统心肺复苏(CCPR),ECPR可明显提高IH-CA患者的生存率.ECMO辅助早期(24小时内)高乳酸以及辅助期间并发AKI可能与ECPR患者预后有关,另外,辅助后12小时乳酸是影响ECPR患者预后的独立风险因素.

目的::评价主动脉内球囊反搏(IABP)在低射血分数冠心病患者冠状动脉旁路移植术(CABG)前预防性应用的临床效果.方法:回顾性分析北京安贞医院2011年1月至2013年6月,接受单纯非体外循环冠状动脉旁路移植术(OPCABG)的低射血分数(LVEF≤35％)冠心病患者临床资料,根据术前是否预防性使用IABP分为预防应用组(P组,n=108)和对照组(C组,n=107),比较两组患者术后恢复情况.结果:P组患者术后30天病死率低于对照组(1.9％vs.9.4％),差异有统计学意义(P=0.036).P组术后机械通气时间和术后中位住院时间分别为28.5(18.25,49.75)小时和8(6,11)天,均较C组53(26,99)小时和10(7,14)天有所缩短,均差异具有统计学意义(P＜0.05).P组和C组术后随访时间分别为(18.71±5.31)个月和(17.66±4.67)个月,两组患者远期生存率及心血管事件发生率,差异无统计学意义(P＞0.05).结论:冠心病左心功能低下的高危患者在OPCABG术前预防应用IABP可以降低术后病死率,促进患者术后恢复.

Objective To report the outcome of patients with refractory postoperative cardiogenic shock (PCS) after coronary artery bypass grafting ( CABG) treated with extracorporeal membrane oxygenation ( ECMO) in our center, and to analyze the risk fac?tors of clinical outcomes. Methods From 2004 June to 2013 December, the condition of 58 patients treated with ECMO because of PCS after CABG or unsuccessfully weaning from cardiopulmonary bypass ( CPB) during surgery were systematicly reviewed, and the risk factors possibly associated with these patients'outcome were analyzed. Results In all these ECMO assisting patients, there were 43 males (76%) and 15 females (24%), with the mean age of 60 ± 9.5 years and the mean ECMO support duration of 105.9±53.2 h. Among them, 45 cases successfully weaned from ECMO (77.6%) and 28 cases discharged from hospital. Logistic analysis revealed that cardiopulmonary resuscitation ( CPR) before ECMO was an independent risk factor affected clinical outcomes of these patients ( OR:0. 21, 95% CI:0.05~0.87, P<0.05) . Conclusion ECMO is an effective measure for patients occurred PCS after CABG. Male, youn?ger and patients with larger body surface area may be more likely to survive in these ECMO patients. In addition, CPR before ECMO is an independent risk factor affecting ECMO support outcomes.

目的 评估主动脉内球囊反搏(IABP)在对行心脏术后难治性心源性休克外周体外膜肺氧合(ECMO)循环辅助患者大脑血流量(CBF)的影响.方法 选取北京安贞医院2012年10月至2013年12月间10例冠脉搭桥术后心源性休克接受静脉-动脉(V-A) ECMO联合IABP辅助治疗患者,采用经颅多普勒超声(TCD)测定开/关(暂停15 min)IABP情况下大脑中动脉血流流速,评估CBF变化.根据脉压大小将CBF数据分为两组(脉压＞10 mm Hg为P组和脉压≤10 mm Hg为N组).结果 所有患者成功脱离ECMO辅助,其中6例存活出院(60.0％).ECMO联合IABP辅助时大脑CBF为(240.30±73.03)ml/min,暂停IABP单独ECMO辅助时CBF为(239.75±74.24)ml/min,差异并无统计学意义(P=0.894).N组中与单独EC-MO辅助大脑血流量(246.56±91.19) ml/min相比较,ECMO联合IABP辅助时CBF较低(229.50±90.32) ml/min,差异具有明显统计学意义(P=0.00).P组中与单独ECMO辅助相比较,ECMO联合IABP辅助时CBF较高[(256.23±77.62)ml/min vs(238.91±42.16) ml/min],差异具有明显统计学意义(P=0.00).结论 ECMO联合IABP辅助,心脏功能状态决定IABP对大脑血流量影响.心肌顿抑时IABP减少CBF,心脏功能有所恢复情况下,联合IABP治疗可明显增加CBF.

Objective To describe our experience with extracorporeal membrane oxygenation(ECMO) for cardiorespiratory support of 141 patients in Beijing Anzhen Hospital.Methods We retrospectively reviewed the medical files of 141 patients treated with ECMO for cardiorespiratory assistance because of acute and refractory cardiogenic shock at our institution from Jun.2004 to Dec.2012.The patients were divided into two groups defined by clinical outcomes(in-hospital death group,NG and survival to discharge group,SG).Results Ninety-eight patients(69.50%) successfully weaned from ECMO and fifty-one patients(36.17%) survived to discharge.The mean duration of ECMO support was 110.64 ± 84.96(range 1 to 600) hours.Compared with the survivor group,the nonsurvivor group had higher blood lactate level pre-ECMO,higher ECMO blood flow rate,and shorter hospital stay(P < 0.05).Conclusion ECMO is an effective mechanical assistant therapy method for cardiac and pulmonary failure.Earlier usage of ECMO for heart or lung failure patients and avoiding the main organs from un-recovery trauma are still the key points of successful ECMO.