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[临床决策]:ECMO治疗重症ARDS
2018年09月15日 临床话题, 模拟诊室 暂无评论

CLINICAL DECISIONS

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome

Michael Y. Mi, Michael A. Matthay, and Alan H. Morris

N Engl J Med 2018; 379:884-887

DOI: 10.1056/NEJMclde1804601

Case Vignette: A Man With Severe ARDS

Mr. Jackson is a 36-year-old man whom you are caring for in the intensive care unit (ICU). Before this hospitalization, he was healthy and took no medications. He has never smoked, and he drinks three or four beers every week. A week ago, a couple of coworkers in his office had respiratory illnesses, and a day later, he started having fever, chills, cough, and generalized weakness. Two nights ago, he presented to the emergency department with confusion and rapidly progressive dyspnea; urgent endotracheal intubation was performed because of acute respiratory failure. Testing for influenza virus A was positive.

杰克逊先生是一名36岁男性ICU患者。住院前,患者身体健康,无长期服药史。患者不吸烟,每周喝3-4瓶啤酒。一周前,办公室的几位同事罹患呼吸道疾病,一天后,患者出现发热,寒战,咳嗽及全身乏力。2天前,患者因意识模糊及迅速进展的呼吸困难到急诊就诊;并因急性呼吸功能衰竭行气管插管。甲型流感检测阳性。

In the ICU, you have been treating him for severe acute respiratory distress syndrome (ARDS) caused by influenza pneumonia. After initial lung-protective ventilation, worsening hypoxemia developed. Despite neuromuscular blockade with deep sedation and prone positioning for the past 24 hours, his respiratory status has continued to deteriorate rapidly.

你负责患者在ICU的诊治。尽管采用了肺保护性通气策略,患者低氧血症仍进行性加重。你使用了深镇静、肌松药及俯卧位通气,但患者的呼吸状况仍迅速恶化。

His heart rate is 124 beats per minute, and his blood pressure is 92/58 mm Hg. His height is 178 cm, and he weighs 75 kg. He is currently receiving ventilation with volume-assist control at a tidal volume of 400 ml (5.5 ml per kilogram of predicted body weight), a respiratory rate of 32 breaths per minute, positive end-expiratory pressure (PEEP) of 15 cm of water, and a fraction of inspired oxygen (Fio2) of 1.0. The measured plateau pressure is approximately 30 cm of water. For the past 4 hours, he has had persistent hypoxemia, with arterial oxygen saturation between 80 and 82%. The most recent arterial blood gas measurement shows a pH of 7.22, partial pressure of oxygen (Pao2) of 50 mm Hg, and partial pressure of carbon dioxide (Paco2) of 62 mm Hg. You know that venovenous extracorporeal membrane oxygenation (ECMO) is an option for patients like Mr. Jackson who have severe ARDS, but its use has been controversial, and you are not sure whether it will be beneficial.

患者HR 124 bpm,BP 92/58 mmHg。身高178 cm,体重75 kg。呼吸机设置:容量控制通气,潮气量400 ml (5.5 ml/kg IBW),呼吸频率32 bpm,PEEP 15 cmH2O,FiO2 1.0。测定平台压约30 cmH2O。在过去4个小时内,患者低氧血症持续未缓解,SaO2 80-82%。最近一次血气分析结果pH 7.22,PaO2 50 mmHg,PaCO2 62 mmHg。你知道,对于杰克逊先生这种重度ARDS患者,可以选择vv-ECMO进行治疗,但是,ECMO的使用存在争议,你对于ECMO是否有益也不确定。

Treatment Options

Which one of the following approaches would you recommend for this patient? Base your choice on the published literature, your own experience, guidelines, and other sources of information, as appropriate.

根据发表文献、你自己的临床经验、指南以及其他信息,你会推荐以下哪种措施进行治疗?

  1. Recommend initiation of venovenous ECMO. 推荐开始vv-ECMO

  2. Continue current treatment with other therapies. 继续目前治疗

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