摘要
目的评估早期采用体外膜肺氧合(ECMO)治疗急性光气中毒致急性呼吸窘迫综合征(ARDS)重症患者肺的保护作用及其疗效。方法回顾性分析2018年4月江西省人民医院重症医学科(ICU)收治的4例急性光气中毒致ARDS患者的救治过程。收集患者ECMO治疗前及治疗后1、3、7 d的治疗参数,包括动脉血pH值、二氧化碳分压(PaCO2)、氧分压(PaO2)、血乳酸(Lac)和外周血管阻力指数(SVRI)、心排血指数(CI)、血管外肺水指数(ELWI)、平台压(Pplat)、呼气末正压(PEEP)、驱动压(ΔP),以及急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、ICU住院时间、ECMO治疗天数及机械通气时间。结果 4例重症患者入院后均行气管插管和呼吸机辅助通气,但呼吸机支持条件高,氧合及内环境难以稳定,故于入科次日行ECMO治疗,治疗后氧合明显改善,呼吸机支持条件可明显下调,包括3~6 mL/kg小潮气量、8~10 cmH2O (1 cmH2O=0.098 kPa)的PEEP、0.30的吸入氧浓度(FiO2)等肺保护休息策略。ECMO治疗后各参数明显改善,与治疗前比较,ECMO治疗后1 d起PaO2、SVRI即明显升高,Lac、ELWI、Pplat、PEEP、ΔP、APACHE Ⅱ评分即明显下降〔PaO2(mmHg,1 mmHg=0.133 kPa):85.5±10.7比54.2±4.5,SVRI(kPa·s·L-1·m-2):153.6±9.4比118.0±12.6,Lac(mmol/L):2.15±0.19比4.93±0.96,ELWI(mL/kg):17.73±2.99比20.45±4.13,Pplat(cmH2O):19.25±2.21比35.75±2.22,PEEP(cmH2O):9.0±1.2比13.5±1.7,ΔP(cmH2O):10.25±1.26比22.25±3.86,APACHEⅡ(分):17.25±2.22比26.50±2.08,均P<0.05〕;治疗后3 d起pH值、CI即明显升高,PaCO2即明显下降〔pH值:7.43±0.05比7.21±0.13,CI(mL·s-1·m-2):64.35±3.17比59.51±3.17,PaCO2(mmHg):42.0±2.2比55.0±8.5,均P<0.05〕。4例患者均救治成功,好转出院,ICU住院时间8~27 d,平均(13.5±9.0) d;ECMO治疗时间6~12 d,平均(8.0±2.7) d;机械通气时间6~20 d,平均(10.75±6.19) d。结论早期行ECMO治疗,可明显改善急性光气中毒致重症ARDS患者的氧合,清除体内过高的CO2,减轻呼吸机相关性肺损伤,从而改善预后。
Objective To evaluate the protective effect and curative effect of early treatment with extracorporeal membrane oxygenation (ECMO) in severe patients with acute respiratory distress syndrome (ARDS) caused by acute phosgene poisoning. Methods The course of treatment of 4 cases of ARDS caused by acute phosgene poisoning admitted to intensive care unit (ICU) of Jiangxi Provincial People's Hospital in April 2018 was retrospectively analyzed. The treatment parameters in patients before and after the ECMO treatment at 1, 3, 7 days were collected, including pH of the arterial blood, arterial partial pressure of carbon dioxide (PaCO2), arterial partial pressure of oxygen (PaO2), blood lactic acid (Lac) and systemic vascular resistance index (SVRI), cardiac index (CI), extravascular lung water index (ELWI), plateau pressure (Pplat), positive end-expiratory pressure (PEEP), driving pressure (ΔP), and acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ), the length of ICU stay, the treatment duration of ECMO and the duration of mechanical ventilation. Results After admitted in hospital, the 4 patients were all put on tracheal intubation and ventilator, but the ventilator support conditions were high, the oxygenation and internal environment were unstable. Therefore, ECMO therapy was performed on the next day after admission. Oxygenation was improved obviously after treatment, ventilator support conditions could be obviously reduced, including 3-6 mL/kg of the small tidal volume, 8-10 cmH2O (1 cmH2O = 0.098 kPa) of the PEEP, 0.30 of the inhaled oxygen concentration (FiO2), and other lung protection rest strategies. The parameters were improved obviously after the ECMO treatment compared with before, from the 1st day after the ECMO treatment, PaO2, SVRI rose obviously, Lac, ELWI, Pplat, PEEP,ΔP, APACHEⅡ were significantly decreased [PaO2(mmHg, 1 mmHg = 0.133 kPa): 85.5±10.7 vs. 54.2±4.5, SVRI (kPa·s·L-1·m-2): 153.6±9.4 vs. 118.0±12.6, Lac (mmol/L): 2.15±0.19 vs. 4.93±0.96, ELWI (mL/kg): 17.73±2.99 vs. 20.45±4.13, Pplat (cmH2O): 19.25±2.21 vs. 35.75±2.22, PEEP (cmH2O): 9.0±1.2 vs. 13.5±1.7,ΔP (cmH2O): 10.25±1.26 vs. 22.25±3.86, APACHEⅡ: 17.25±2.22 vs. 26.50±2.08, all P <0.05];pH and CI were significantly increased after 3 days treatment, and PaCO2 was significantly decreased [pH: 7.43±0.05 vs. 7.21±0.13, CI (mL·s-1·m-2): 64.35±3.17 vs. 59.51±3.17, PaCO2 (mmHg): 42.0±2.2 vs. 55.0±8.5,all P < 0.05]. All the 4 patients were treated successfully and discharged after improvement. The length of ICU stay was 8-27 days, with an average (13.5±9.0) days;the treatment duration of ECMO was 6-12 days, with an average (8.0±2.7) days;the duration of mechanical ventilation was 6-20 days, with an average (10.75±6.19) days. Conclusion Early treatment with ECMO can significantly improve the oxygenation of severe ARDS caused by acute phosgene poisoning, eliminate excessive CO2 in the body, reduce ventilator-associated lung injury, and improve the prognosis.
作者
何招辉
杨小刚
杨春丽
He Zhaohui;Yang Xiaogang;Yang Chunli(Department of Critical Care Medicine, Jiangxi Provincial People's Hospital, Nanchang 330006, Jiangxi, China)
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2019年第2期232-235,共4页
Chinese Critical Care Medicine
基金
江西省卫生计生委中医药课题(2017A324).
关键词
体外膜肺氧合
急性光气中毒
急性呼吸窘迫综合征
Extracorporeal membrane oxygenation
Acute phosgene poisoning
Acute respiratory distress syndrome
作者简介
通信作者:杨春丽Email:ycl121@163.com.
