Effect of extracorporeal membrane oxygenation aided by color Doppler ultrasonography on the prognosis of respiratory failure patients
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摘要:
目的 探讨在彩色多普勒超声辅助下调整体外膜肺氧合（ECMO）管道位置、离心泵转速等可变指标，能否优化患者组织氧供及改善预后。 方法 将经机械通气效果不佳的呼吸衰竭患者随机分为观察组（n=10）及对照组（n=9），观察组根据血流动力学结果，调整离心泵转速等指标，让远端桡动脉血氧分压>90 mmHg；对照组接受常规治疗，比较两组的工作负荷指标及预后的差异。 结果 观察组ECMO优化后在血流动力学（肺动脉楔压及心脏指数）及氧动力学方面（桡动脉氧分压）均大于对照组（P<0.05）；观察组中含有造影剂的膜肺血流到达的位置较对照组远（P<0.05）；观察组中肾脏和肝脏的形态结构基本处于正常，而对照组肾脏和肝脏均存在萎缩和肿胀的现象，差异有统计学意义（P<0.05）；观察组ECMO优化后总住院时间少于对照组（P<0.05），病死率低于对照组（10%vs 55.6%，χ2=4.550，P<0.05）。 结论 利用彩色多普勒超声辅助下，调整ECMO管道位置、离心泵转速等可变指标，可以减少无效“小循环”的发生，提高组织器官氧供，减少酸中毒和器官衰竭的发生，从而缩短ICU住院时间，降低病死率。 Abstract:Objective To evaluate the effect of extracorporeal membrane oxygenation aided by color Doppler ultrasonography on the prognosis of respiratory failure patients. Color Doppler ultrasonography was used to measure the cardiac output and the hemodynamic results of ECMO, so as to optimize oxygen supply. Methods 19 severe respiratory failure patients who underwent failure of conventional ventilation therapy were randomly divided into two groups, i.e., observation group (n=10) and control group (n=9). According to hemodynamic parameters of the observation group, indexes including the position of the pipeline and the rotational speed of the centrifugal pump were adjusted, and the blood oxygen pressure of distal radial artery was adjusted to over 90 mmHg; in contrast, the control group received conventional therapy. The workload indicators and prognosis of both groups were compared. Results The ECMO of the observation group was significantly higher than that of the control group in terms of hemodynamic parameters (pulmonary artery wedge pressure and cardiac index) and oxygen dynamics (radial artery oxygen pressure)(P<0.05); besides, blood containing contrast dye in the observation group flows farther after extracorporeal oxygenation than that in the control group(P<0.05). The morphological structure of kidney and liver in the observation group remained normal, while atrophy and swelling of kidney and liver occurred in the control group, the differences were significant(P<0.05). In addition, the total hospitalization time of the observation group was significantly shorter than that of the control group(P<0.05), and the mortality rate of observation group was significantly lower than that of the control group(10%vs 55.6%, χ2=4.550, P<0.05). Conclusion The adjustment of variable indicators, such as ECMO pipeline position and centrifugal pump rotating speed, aided by color Doppler ultrasound, can reduce the occurrence of invalid "small cycle", improve the oxygen supply to tissues and organs, and reduce the incidence rate of acidosis and organ failure, thus shortening hospitalization stay in ICU and decreasing the fatality rate. -
图 1 病例一，50岁女性，重症肺炎，V-V ECMO
A：注射造影剂前下腔静脉B超图像；B、C：为膜后注射造影剂后B超提示有一部造影剂会进入下腔静脉，再次进入ECMO管路内，形成无效“小循环”；D：注射造影剂后下腔静脉B超图像.
图 2 病例二，36岁男性，重症肺炎，V-V ECMO
A：注射造影剂前下腔静脉B超图像；B，C：为膜后注射造影剂后B超提示有一部造影剂会经右心房进入下腔静脉，再次进入ECMO管路内，形成无效“小循环”; D：注射造影剂后下腔静脉B超图像.
表 1 两组患者的一般情况比较（Mean±SD）
分组 年龄（岁） 男/女 PaCO2（kPa） PaO2（kPa） APACHE Ⅱ（分） 观察组（n=10） 51±15 6/4 50.4±6.5 56.7±15.6 17.1±6.7 对照组（n=9） 49±18 6/3 48.4±7.9 54.7±17.3 16.0±8.3 P 0.518 0.764 0.379 0.308 0.211 
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表 2 两组间工作负荷指标变化（Mean±SD）
组别 肺动脉氧分压（mmHg） 桡动脉氧分压（mmHg） 肺动脉压（kPa） 肺动脉楔压（kPa） 心脏指数[L/（min·m2）] 平均动脉压（mmHg） 观察组（n=10） 127.6±25.4 92.3±22.5 15.5±5.3 1.4±0.4 4.9±0.8 78.8±8.0 对照组（n=9） 122.7±22.7 54.3±17.2 14.7±4.3 1.1±0.5 3.8±0.6 69.8±7.5 t 0.984 3.909 2.331 3.370 3.024 0.867 P 0.126 0.000 0.023 0.000 0.007 0.315
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表 3 两组间含有造影剂的膜肺血流最远端达到的位置对比（n）
组别 对侧锁骨下动脉 对侧肱动脉 对侧桡动脉近端 对侧桡动脉远端 观察组（n=10） 10 10 9 8 对照组（n=9） 8 6 3 2 χ2 0.003 1.848 4.328 4.237 P 0.957 0.174 0.037 0.040
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表 4 两组间肾脏、肝脏形态及入口血管直径对比（n）
组别 肾脏形态 肝脏形态 肾动脉内径（Mean±SD，mm） 肝门静脉直径（Mean±SD，cm） 萎缩 正常 肿胀 萎缩 正常 肿胀 观察组（n=10） 0 9 1 0 10 0 4.8±1.1 0.6±0.3 对照组（n=9） 3 2 4 4 3 2 3.3±0.8 0.3±0.2 t/χ2 1.569 6.363 1.394 3.273 6.902 0.685 –3.171 –4.335 P 0.210 0.012 0.238 0.070 0.009 0.408 0.001 0.000
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表 5 两组间预后情况比较（Mean±SD）
组别 n ECMO转机时间（d） ICU总住院时间（d） APACHE Ⅱ（分） 死亡例数（n） 观察组 10 20.5±2.5 32.8±3.5 6.7±3.1 1 对照组 9 21.1±3.0 45.0±5.7 10.6±4.9 5 t/χ2 –0.845 –2.336 –3.995 4.550 P 0.217 0.016 0.000 0.033
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