成人感染性休克患者使用V-A ECMO

Abstract

Septic shock is associated with significant morbidity and mortality, but a subset of patients with sepsis will experience transient myocardial depression, termed sepsis-associated cardiomyopathy, which markedly increases observed mortality. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support in medically refractory sepsis, survival in patients with VA-ECMO for sepsis has been historically poor. Concerns regarding numerous potential harms associated with VA-ECMO, including further seeding of infection, exacerbation of inflammation and vasoplegia, bleeding, thrombosis, and distal limb ischemia have further tempered enthusiasm in the setting of sepsis. However, there may be a subset of patients with profound sepsis refractory to medical therapy that could potentially derive some benefit from VA-ECMO. This review provides an overview of the pathophysiology, diagnosis, and treatment of sepsis-associated cardiomyopathy and then focuses on the utility of VA-ECMO in this patient population. A summary of the scant published outcomes of VA-ECMO in sepsis-associated cardiomyopathy is provided, followed by a discussion of important management considerations to optimize outcomes in these extremely sick patients, and finally the pros and cons of VA-ECMO in the setting of sepsis are presented. Using available published data and current state-of-the-art practice, we conclude that VA-ECMO may be a reasonable consideration in highly selected patients with low ejection fraction sepsis-associated cardiomyopathy and refractory hypoperfusion in appropriately equipped health care systems, but more supportive data are required before VA-ECMO can be generally recommended in patients with septic shock.

脓毒性休克与显著的发病率和死亡率相关，但在脓毒症患者中有一部分会经历短暂的心肌抑制，称为脓毒症相关心肌病（sepsis-associated cardiomyopathy），这显著增加了观察到的死亡率。尽管静脉-动脉体外膜肺氧合（VA-ECMO）可以在药物难治性脓毒症中提供临时的机械循环支持，但历史上使用VA-ECMO治疗脓毒症患者的生存率一直较差。关于VA-ECMO可能带来的诸多潜在危害的担忧——包括进一步播散感染、加重炎症和血管麻痹、出血、血栓形成以及远端肢体缺血——进一步削弱了其在脓毒症治疗中的应用热情。然而，可能存在一部分对药物治疗反应极差的严重脓毒症患者，他们可能从VA-ECMO中获益。本综述概述了脓毒症相关心肌病的病理生理学、诊断和治疗，然后重点讨论了VA-ECMO在这一患者群体中的效用。本文总结了目前已发表的关于VA-ECMO在脓毒症相关心肌病中的有限结果，并讨论了优化这些危重患者治疗效果的重要管理考虑因素，最后提出了VA-ECMO在脓毒症治疗中的优缺点。基于现有发表的数据和当前最先进的实践，我们得出结论：在设备完善的医疗系统中，对于低射血分数的脓毒症相关心肌病且存在难治性灌注不足的高度选择患者，VA-ECMO可能是一个合理的治疗选择，但在普遍推荐VA-ECMO用于脓毒性休克患者之前，还需要更多的支持性数据。

中文翻译详见：https://mp.weixin.qq.com/s/_CeE7VRdUul7kAju9QLHtQ