ECMO治疗成人严重ARDS的系统性评价--课件
Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO治疗成人严重 ARDS的系统性评价 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 问题的提出 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ARDS的治疗 Management of predisposing factors Improvement of ventilation and oxygen delivery Control of systemic inflammation response Surfactant Replacement Therapy Inhaled Nitric Oxide Negative fluid balance Nutrition Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ARDS通气策略 Lung Protective Ventilation low tidal volume pressure limited ventilation VT6 8ml kg Pplat 32 cm H2O Open Lung Strategy Positive End Expiratory Pressure Sigh The prone position Inverse ratio Ventilation IRV High Frequency Oscillatory Ventilation Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 传统的治疗手段可以解决通气问 题 能完全解决氧供问题吗 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO技术始于上世纪70年代 1972年 Hill等首先报道了1例成 人多脏器损伤合并衰竭的患者采 用长时间ECMO支持的成功经验 Hill JD O Brien TG Murray JJ Dontigny L Bramson ML Osborn JJ Gerbode F Prolonged extracorporeal oxygenation for acute posttraumatic respiratory failure shock lung syndrome use of the Bramson membrane lung N Engl J Med 1972 286 12 629 634 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 后来其他医院陆续报道采用同样 方法救治心功能不全和呼吸功能不全 患者 目前为止 全世界已经有100余 所医院建立ECMO治疗中心 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO的工作原理 ECMO由一系列复杂的血管插管环 路 管路 泵 氧合器 热交换器和 监视系统构成 用以进行呼吸支持 V V ECMO 或心肺支持 V A ECMO Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO的原理 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO呼吸支持的适应症 1 可逆性的极重度呼吸衰竭 如严重ARDS FiO2 1 0 2h PaO2 50mmHg 或 FiO2 0 6 12h PaO2 50mmHg 对常规和非常规治疗措施均无 反应 2 可逆性的严重低痒血症 伴或不伴有CO2潴留 同时有为机械通气禁忌症的患者 3 如果不采用ECMO患者就会很快死亡 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO呼吸支持的禁忌症 1 体重小于2kg 或胎龄不足32周 的新生儿 在ECMO肝素化后有80 发 生颅内出血 2 有颅内出血或出血征象的患者 3 不能治愈的不可逆的肺损伤 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO呼吸支持的并发症 1 出血 2 脑损伤 3 血栓 4 其它 以出血最多见 其中脑出血最为严重 晚 期并发症以脑缺血最常见 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time ECMO已成为治疗新生儿呼吸衰竭的 标准治疗方法 ECMO的使用 使得合 并呼吸衰竭的新生儿的成活率由早期 的20 上升至目前的 82 Zwushenberrger 1993 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 那么ECMO救治成人呼吸衰竭的效果如 何 与常规治疗手段比较 能显著降低患 者病死率吗 ECMO作为中国重症加强治疗 病房 ICU 建设与管理指南 2006 推荐 的选配设备 值得在ICU普及和推广吗 还是让我们通过循证医学的方法来寻 找答案吧 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 解决问题的方法 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 1 1 方法 方法 提出问题 寻找证据 评价证据 整合证提出问题 寻找证据 评价证据 整合证 据 得出结论据 得出结论 2 2 证据来源 证据来源 检索PubMed SCI EMBASE Cochrane Library 中国生物医学文献数据库 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 3 证据的级别 Grade 1 RCTGrade 1 RCT Grade 2 Grade 2 设计良好的 前瞻性研究 设计良好的 前瞻性研究 Grade 3 Grade 3 回顾性的研究报告 回顾性的研究报告 Grade Grade 4 4 临床个案报告 无 临床个案报告 无RCTRCT报告支持的委报告支持的委 员会或专家意见 以疾病疗效为目的的动物员会或专家意见 以疾病疗效为目的的动物 实验 实验 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 结果和评价 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time RESPIRATORY CARE JULY 2004 VOL 49 NO 7 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 在1970年代早期 对于难治性低氧血 症的患者通常采用ECMO改善全身氧供 减 低气道压力和吸入氧分数 FIO2 第一例采用ECMO治疗的患者给人们留 下了深刻的印象 Hill JD O Brien TG Murray JJ Dontigny L Bramson ML Osborn JJ Gerbode F Prolonged extracorporeal oxygenation for acute posttraumatic respiratory failure shock lung syndrome use of the Bramson membrane lung N Engl J Med 1972 286 12 629 634 Our greatest weakness lies in giving up The most certain way to succeed is always to try just one more time 但后来报道的150例接受ECMO治疗的患者病 死率却大于85 Gille JP Respiratory support by extracorporeal circulation with a membrane artificial lung Bull Physiopathol Respir Nancy 1974 10 3 373 410 article in French Our greatest weakness lies in giving up The most certain way to succeed is always to try just 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