成人心肺衰竭患者体外膜肺氧合的临床研究

发布时间：2018-05-22 16:03

本文选题：体外膜肺氧合 + 急性心肌梗死　；参考：《天津医科大学》2016年博士论文

【摘要】：一、体外膜肺氧合抢救非外科术后心脏骤停目的评价传统心肺复苏(conventional cardiopulmonary resuscitation,CCPR)无效的非外科术后心脏骤停采用体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)的效果。方法回顾2009年1月至2015年7月CCPR无效后接受ECMO的非外科术后心脏骤停患者资料,比较不同预后组的临床指标。结果纳入25例患者,CCPR平均时间47.4 min,ECMO复苏成功率100%。ECMO撤机率和存活率分别为36%和28%。和死亡组相比,存活组监护室停留时间更长[(20.0±13.2)d vs(5.5±6.3)d]、24小时[(91.1±20.4)mm Hg vs(73.2±20.1)mm Hg]及48小时动脉平均压[(86.6±18.0)mm Hg vs(63.0±16.7)mm Hg]更高、72小时血小板计数[(97.3±31.5)×109/L vs(57.0±30.1)×109/L]更高(P0.05)。急性心梗亚组(n=20)均成功接受直接经皮冠脉介入治疗,存活组CCPR时间更短[(29.2±4.9)min vs(51.0±24.5)min]、罪犯血管中右冠脉比例更高(50%vs 7.1%)、前降支比例更低(16.7%vs 57.1%)、ECMO撤机率更高(100%vs 14.3%)、48小时平均动脉压更高[(87.9±19.4)mm Hg vs(101.7±32.7)mm Hg)]、动脉血乳酸水平更低[(1.74±0.85)mmol/l vs(6.41±5.65mmol/l)](P0.05)。结论ECMO是CCPR无效的非外科术后心脏骤停有效治疗手段。E-CPR前低灌注时间、48小时内血流动力学状态、72小时血小板计数及心梗患者的罪犯血管分布有助于预测存活率。二、体外膜肺氧合-常规体外转换在高危冠脉旁路移植术的应用目的比较在ECMO-常规体外转流转换(实验组)和非停跳下施行高危冠脉旁路移植术的围术期特点及结局。方法回顾分析2010年1月至2014年12月实验组和非停跳冠脉旁路移植术(off-pump coronary artery bypass grafting,OPCABG,对照组)资料,随访远期无主要心血管不良事件(major adverse cardiovascular event,MACE)生存率。结果实验组26例,年龄(73.5±3.1)岁;OPCABG组24例,年龄(71.8±4.2)岁。术前Euroscore评分分别为11.7±2.4和10.9±2.0。和OPCABG组相比,实验组完全再血管化率更高(66.7%vs 96.2%),术中液体平衡控制更理想[(135.0±593.5)mlvs[(606.0±615.5)ml],术后ECMO辅助时间[(33.1±23.6)h vs(80.8±18.5)h]、监护室停留时间[(4.8±1.1)d vs(10.2±9.0)d]和住院时间[(17.7±6.3)d vs(28.2±17.5)d]更短(P0.05),存活率有更高趋势(P=0.093)。随访(45.4±15.2)个月,实验组无MACE生存率优于OPCABG组(P=0.028)。结论ECMO-常规体外转换模式可能更有利于高危患者实现冠脉完全再血管化,缩短术后住院时间,提高远期无MACE生存率。三、ECMO治疗重症成人呼吸窘迫综合征目的:评价ECMO救治重症成人呼吸窘迫综合征(adult respiratory distress syndrome,ARDS)的效果,并对多个生存预测模型做外部验证。方法:回顾2009年1月至2015年7月年23例机械通气无效后接受ECMO的重症ARDS患者资料,分析影响预后的临床指标,并计算PRESERVE、ECMOnet、RESP、Roch、APACHEⅡ、SOFA评分系统得分。结果:启用ECMO后血流动力学和氧合指标均显著改善。存活出院率56.5%。单因素分析显示APACHEⅡ评分(r=-0.439,P=0.041)、更换膜式氧合器(r=-0.516,P=0.014)、急性肾损伤(r=-0.574,P=0.005)、多脏器功能不全(r=-0.633,P=0.002)和存活出院显著相关。尿素氮、血小板和纤维蛋白原的前72小时演变特点有助于判断预后。ECMO院间转运的存活率和常规转运及非转运患者相当(P=1.000)。RESP和APACHEⅡ评分具有良好预测能力,曲线下面积分别为0.835(95%CI0.659-1.010,P=0.007)和0.762(95%CI 0.558-0.965,P=0.035)。截断值分别为3.5级和35.5分,敏感性和特异性均为70%和84.6%。SOFA评分在肺炎亚组有良好预测能力,曲线下面积为0.790(95%CI 0.571-1.009,P=0.038)。结论:ECMO是抢救机械通气无效的重症ARDS的一种有效手段。RESP、APCHAEⅡ和SOFA评分有助于对存活出院做出预测。四、超高效液相色谱质谱对ST段抬高型心肌梗死年轻患者血浆代谢轮廓及通路分析目的:采用超高效液相色谱质谱(Ultra-performance Liquid Chromatography and Mass Spectrometry,UPLC/MS)对ST段抬高型心肌梗死(ST-elevated myocardial infarction,STEMI)建立疾病区分模型,寻找特征代谢物及代谢通路,评价对预后的预测价值。方法:自2013年8月至2014年8月前瞻性连续纳入47例STEMI患者(年轻23例、老年24例)和48例同期健康对照人群(年轻24例、老年24例)。年轻组发病1年后随访再次取血(22例,1例失访)。借助UPLC/MS鉴定特征代谢物及代谢通路。建立ROC曲线评价其对出院后1年结局的预测价值。结果:成功建立偏最小二乘区分模型(R2X=71.2%,R2Y=79.6%,Q2=55.9%)并筛选24种代谢物离子。鞘脂(Sphingolipid)代谢是年轻患者发病最重要的通路。ROC曲线分析显示该通路的神经酰胺[Cer(d18:0/12:0),Cer(t18:0/16:0)]和二氢鞘氨醇对预测出院后主要不良心血管事件有良好敏感性和特异性,曲线下面积分别为0.671、0.750和0.711,发病1年后的曲线下面积分别为0.778、0.833和0.806。结论:通过UPLC/MS成功建立同时区分疾病状态和年龄两种因素的模型。鞘脂代谢是年轻患者发病最重要的通路,可作为判断预后及改善疗效的潜在靶点。
[Abstract]:Objective to evaluate the effect of extracorporeal membrane pulmonary oxygenation (extracorporeal membrane oxygenation, ECMO) in non surgical cardiac arrest after traditional cardiopulmonary resuscitation (conventional cardiopulmonary resuscitation, CCPR) after extracorporeal membrane pulmonary oxygenation (CPR) for nonsurgical cardiac arrest. The data of patients with ECMO after non surgical cardiac arrest were compared with the clinical indexes of different prognosis groups. The results were included in 25 cases, the average time of CCPR was 47.4 min, the rate of 100%.ECMO withdrawal and survival rate of ECMO resuscitation were 36% and 28%., respectively, and the stay time of the survival group was longer [(20 + 13.2) d vs (5.5 + 6.3) d], 24 hours. 91.1 + 20.4) mm Hg vs (73.2 + 20.1) mm Hg] and 48 hour arterial mean pressure [(86.6 + 18) mm Hg vs (63 + 16.7) mm Hg] higher, 72 hours platelet count [97.3 + 31.5) * 109/L vs (57 + 5) * * *. Vs (51 + 24.5) min], the proportion of right coronary artery in the offender's blood vessels is higher (50%vs 7.1%), the proportion of anterior descending branch is lower (16.7%vs 57.1%), the rate of ECMO withdrawal is higher (100%vs 14.3%), the average arterial pressure is higher in 48 hours [87.9 + 19.4) mm Hg vs (101.7 + 32.7) mm Hg)], and the level of lactic acid in arterial blood is lower [(1.74 + 0.85) mmol/l] It is an effective treatment for CCPR ineffective non surgical cardiac arrest by.E-CPR anterior low perfusion time, hemodynamic state within 48 hours, 72 hours platelet count and the distribution of criminal blood vessels in patients with myocardial infarction to predict survival rate. Two, the application of extracorporeal membrane pulmonary oxygenation conventional cardiopulmonary bypass in high risk coronary bypass grafting is compared in E CMO- the perioperative characteristics and outcomes of high risk coronary bypass grafting under conventional cardiopulmonary bypass (experimental group) and non stop jump. Methods a retrospective analysis of the data from January 2010 to December 2014 and non stop jump coronary bypass grafting (off-pump coronary artery bypass grafting, OPCABG, control group) was performed, and no major cardiovascular outcomes were followed up. Major adverse cardiovascular event (MACE) survival rate. Results the experimental group 26 cases, age (73.5 + 3.1) years, OPCABG group 24 cases, age (71.8 + 4.2) years of age. Preoperative Euroscore score was 11.7 + 2.4 and 10.9 + 2.0. and OPCABG, respectively, the experimental group was higher (66.7%vs 96.2%), the liquid balance control in the operation is more ideal. 135 + 593.5) mlvs[(606 + 615.5) ml], postoperative ECMO auxiliary time [(33.1 + 23.6) H vs (80.8 + 18.5) h], the stay time of the guardianship [(4.8 + 1.1) d vs (10.2 + 9) d] and hospital time [(17.7 +] d VS) d] was shorter, the survival rate was more Gao Qushi. =0.028) conclusion ECMO- routine cardiopulmonary bypass mode may be more beneficial to high risk patients to achieve complete revascularization of coronary artery, shorten the time of postoperative hospitalization and improve the long-term non MACE survival rate. Three, ECMO for severe adult respiratory distress syndrome (ECMO) for severe adult respiratory distress syndrome (adult respiratory distress syndrome, A). The effect of RDS) and the external verification of multiple survival prediction models. Methods: review the data of severe ARDS patients receiving ECMO after 23 cases of mechanical ventilation from January 2009 to July 2015, analyze the clinical indicators that affect the prognosis, and calculate the scores of PRESERVE, ECMOnet, RESP, Roch, APACHE II, SOFA scoring system. Results: the hemodynamics after ECMO was enabled. The survival discharge rate 56.5%. single factor analysis showed that APACHE II score (r=-0.439, P=0.041), membrane oxygenation (r=-0.516, P=0.014), acute renal injury (r=-0.574, P=0.005), multiple organ dysfunction (r=-0.633, P=0.002) were significantly related to survival and discharge. The first 72 small amounts of urea nitrogen, platelet and fibrinogen The characteristics of the time evolution were helpful to determine the survival rate of the inter hospital transport in.ECMO and the normal transport and non transshipment patients (P=1.000).RESP and APACHE II scores with good predictive ability. The area under the curve was 0.835 (95%CI0.659-1.010, P=0.007) and 0.762 (95%CI 0.558-0.965, P=0.035). The truncated values were 3.5 and 35.5, respectively. The specificity of the 70% and 84.6%.SOFA scores in the pneumonia subgroup has a good predictive ability, the area under the curve is 0.790 (95%CI 0.571-1.009, P=0.038). Conclusion: ECMO is an effective means of saving mechanical ventilation invalid severe ARDS.RESP, APCHAE II and SOFA score is helpful to predict survival and discharge. Four, ultra high performance liquid chromatography-mass spectrometry of ST Plasma metabolic profile and pathway analysis in young patients with segment elevation myocardial infarction (Ultra-performance Liquid Chromatography and Mass Spectrometry, UPLC/MS) to establish a disease differentiation model for ST segment elevation myocardial infarction (ST-elevated myocardial infarction, STEMI), and to search for characteristic metabolites. The prognostic value of the metabolic pathway was evaluated. Methods: from August 2013 to August 2014, 47 patients with STEMI (23 young, 24 elderly) and 48 healthy controls (24 young and 24 elderly) were enrolled in the same period. The young group was followed up for 1 years after 1 years (22 cases, 1 cases lost). The characteristics of metabolites and generations were identified by UPLC/MS. The ROC curve was established to evaluate the predictive value of the 1 year outcome after discharge. Results: the partial least squares (R2X=71.2%, R2Y=79.6%, Q2=55.9%) and the screening of 24 metabolites were successfully established. Sphingolipid metabolism was the most important pathway of.ROC curve analysis in young patients, which showed the pathway of ceramide [Cer (d18:0). /12:0), Cer (t18:0/16:0)] and two hydrogen sphingosine have a good sensitivity and specificity for predicting major adverse cardiovascular events after discharge. The area under the curve is 0.671,0.750 and 0.711 respectively. The area under the curve after 1 years is 0.778,0.833 and 0.806., respectively. By UPLC/MS, two factors are successfully established to distinguish the disease state and age. Sphingolipid metabolism is the most important pathway in the pathogenesis of young patients. It can be used as a potential target for judging prognosis and improving curative effect.
【学位授予单位】：天津医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R541.78

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