摘要目的 探讨体外膜肺氧合(ECMO)治疗成人重度ARDS患者的临床疗效及相关影响因素.方法 采用回顾性分析研究,收集并分析2012年8月至2015年6月郑州大学第二附属医院重症医学科(综合ICU)收治的达到ECMO标准的58例成人重度ARDS患者临床资料,根据是否应用ECMO分为ECMO组和对照组;以应用ECMO后3个月为观察点,将ECMO组分为生存组和死亡组.采用SPSS 17.0统计分析各组治疗前后的临床资料.结果 共28例患者接受静脉-静脉ECMO(VV-ECMO)治疗,其中男22例,女6例,年龄34～61岁,平均(49±8)岁.所有患者在ECMO治疗前均已行有创机械通气,平均为(71 ±25)h.ECMO组和对照组在疾病病因构成及治疗前主要指标(最低氧合指数、最高PEEP、最低pH值、最高PaCO2、最高乳酸、APACHEⅡ评分、Murray评分和SOFA评分),差异均无统计学意义(均P ＞0.05).3组患者治疗前各项指标(除ECMO生存组和死亡组之间pH值、心率和平均动脉压外)比较差异均无统计学意义(均P＞0.05).与对照组相应时间比较,在应用ECMO后2h和第1天,ECMO组各项指标显著改善(均P＜0.05);在随后的第2天各项指标(除平均动脉压外)均好于对照组,差异有统计学意义(均P ＜0.05),ECMO死亡组平均动脉压较对照组明显降低(t=2.433,P=0.019);但在第3天,ECMO生存组各项指标(除平均动脉压外)均好于对照组,差异有统计学意义(均P＜0.05),但ECMO死亡组各项指标(除血乳酸和平均动脉压外)与对照组差异均无统计学意义(均P＞0.05),血乳酸水平高于对照组(t=-3.156,P=0.003)而平均动脉压低于对照组(t=3.578,P=0.001).28例ECMO患者中18例成功撤离ECMO,3个月无残疾生存15例,ECMO组与对照组生存率(分别为53.57％和43.33％)差异无统计学意义(x2=0.608,P=0.436).结论 VV-ECMO是治疗成人重度ARDS的有效支持手段,当符合ECMO指征时应尽早应用.年龄、应用ECMO前的机械通气时间、发病至应用ECMO时间和心率、平均动脉压、血乳酸水平和血降钙素原水平等是影响患者预后的重要因素.

abstractsObjective To investigate the clinical experience and associated factors of extracorporeal membrane oxygenation(ECMO) for adult patients with severe acute respiratory distress syndrome (ARDS).Methods The clinical data of 58 adult patients with severe ARDS,which met the criteria for ECMO and treated in comprehensive intensive care unit of the Second Affiliated Hospital of Zhengzhou University from August 2012 to June 2015,were retrospectively collected and analyzed.The patients were divided into the ECMO group and the control group according to whether ECMO support was used.The ECMO group was further divided into the survival group and the non-survival group according to outcomes 3 months after the initiation of ECMO.The statistics software of SPSS 17.0 was used for data analysis.Results Of the 58 patients,28 were treated with VV-ECMO.There were 22 males and 6 females,aged from 34 to 61 years,with a mean age of (49 ± 8) years.Mean time of mechanical ventilation before ECMO therapy was (71 ± 25) h.The main factors(the lowest PaO2/FiO2 and pH,the highest PEEP,PaCO2 and serum lactate level,the grade of APACHE Ⅱ,Murray and SOFA) between the ECMO group and the control group were not significantly different(all P ＞ 0.05).There were no significant differences in the factors before therapy (all P ＞0.05),except pH,heart rate (HR) and mean arterial pressure (MAP) between the ECMO survival group and the ECMO non-survival group.Compared with the factors at the same time point in the control group,those of the ECMO group were significantly improved after ECMO running 2 hours and 1 day (all P ＜ 0.05).Most factors of the ECMO group were also significantly improved after ECMO running 2 days (all P ＜0.05) except MAP;the MAP of the ECMO non-survival group being lower than the control group (t =2.433,P =0.019).After ECMO running 3 days,most factors of the ECMO survival group were better than those of the control group (all P ＜ 0.05) except MAP,but most factors between the ECMO non-survival group and the control group were not significantly different (all P ＞ 0.05),while the serum lactate level was higher (t =-3.156,P =0.003) and the MAP lower (t =3.578,P =0.001).Eighteen patients were successfully weaned from ECMO,and 15 patients survived to 3 months without severe disability.The survival rate between the ECMO group and the control group was not significantly different(53.57％ and 43.33％,x2=0.608,P =0.436).Conclusions Our experience suggests that VV-ECMO may be an effective life support treatment for severe ARDS and should be used as early as possible when the ECMO criteria are met.Indexes such as age,time of mechanical ventilation before ECMO therapy,time between disease onset and ECMO therapy,HR,MAP,serum lactate level and serum procalcitonin level,may be the risk factors for prognosis.