经皮体外动静脉二氧化碳清除可提高呼吸窘迫综合征的生存率：一项成年绵羊的前瞻性随机结局研究。

Percutaneous extracorporeal arteriovenous carbon dioxide removal improves survival in respiratory distress syndrome: a prospective randomized outcomes study in adult sheep.

作者信息

Zwischenberger J B, Alpard S K, Tao W, Deyo D J, Bidani A

机构信息

Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Tex. 77555, USA.

出版信息

J Thorac Cardiovasc Surg. 2001 Mar;121(3):542-51. doi: 10.1067/mtc.2001.112828.

DOI:10.1067/mtc.2001.112828

PMID:11241090

Abstract

OBJECTIVE

Arteriovenous carbon dioxide removal (AVCO(2)R) uses a simple arteriovenous shunt for CO(2) removal to minimize barotrauma/volutrauma from mechanical ventilation. We performed a prospective randomized outcomes study of AVCO(2)R in our new, clinically relevant model of respiratory distress syndrome.

METHODS

Adult sheep (n = 18) received an LD(50) severe smoke inhalation and 40% third-degree burn. When respiratory distress syndrome developed (PaO (2)/FIO (2) < 200 at 40 to 48 hours), animals were randomized to the AVCO(2)R (n = 9) or sham group (n = 9) for 7 days. Ventilator management protocols mandated reductions in minute ventilation, first tidal volume to peak inspiratory pressure less than 30 cm H(2)O, then respiratory rate when PaCO (2) was less than 40 mm Hg. PaO (2) was kept above 60 mm Hg by adjusting FIO (2). When FIO (2) was 0.21, animals were weaned.

RESULTS

The study required 2946 animal-hours of critical care with 696 AVCO(2)R hours. One died in each group during model development. AVCO(2)R flow from 820 mL/min to 970 mL/min (11% to 14% cardiac output) removed CO(2) at a rate of 92 to 116 mL/min (mean 103 mL/min; 93%-97% of CO(2) production). Heart rate, mean arterial pressure, cardiac output, and pulmonary arterial wedge pressure remained relatively constant. Within 48 hours, AVCO(2)R allowed significant ventilator reductions versus baseline in the following measurements: tidal volume (420 to 270 mL), peak inspiratory pressure (25 to 14 cm H(2)O), minute ventilation (13 to 5 L/min), respiratory rate (26 to 16 breaths/min), and FIO (2) (0.88 to 0.35). Ventilator-free days with AVCO(2)R were 3.9 versus 0.2 (P <.01) for sham animals, and ventilator-dependent days with AVCO(2)R were 2.4 versus 6.2 (P <.01) for the 3 sham survivors. All 8 AVCO(2)R animals and 3 of 8 sham animals survived 7 days after randomization.

CONCLUSIONS

Percutaneous AVCO(2)R achieved significant reduction in airway pressures, increased ventilator-free days, decreased ventilator-dependent days, and improved survival in a sheep model of respiratory distress syndrome.

摘要

目的

动静脉二氧化碳清除术（AVCO₂R）采用简单的动静脉分流来清除二氧化碳，以尽量减少机械通气引起的气压伤/容积伤。我们在新的、具有临床相关性的呼吸窘迫综合征模型中对AVCO₂R进行了一项前瞻性随机结果研究。

方法

成年绵羊（n = 18）吸入半数致死量的浓烟并遭受40%的三度烧伤。当呼吸窘迫综合征出现时（40至48小时时动脉血氧分压/吸入氧分数值<200），将动物随机分为AVCO₂R组（n = 9）或假手术组（n = 9），为期7天。呼吸机管理方案要求减少分钟通气量，首先将潮气量至吸气峰压降至低于30 cm H₂O，然后在动脉血二氧化碳分压低于40 mmHg时降低呼吸频率。通过调整吸入氧分数值使动脉血氧分压保持在60 mmHg以上。当吸入氧分数值为0.21时，对动物进行撤机。

结果

该研究需要2946小时的重症监护，其中AVCO₂R治疗时间为696小时。在模型建立过程中，每组各有1只死亡。AVCO₂R的血流量从820 mL/分钟增加到970 mL/分钟（心输出量的11%至14%），以92至116 mL/分钟的速率清除二氧化碳（平均103 mL/分钟；二氧化碳产生量的93% - 97%）。心率、平均动脉压、心输出量和肺动脉楔压保持相对稳定。在48小时内，与基线相比，AVCO₂R在以下测量值方面使呼吸机设置有显著降低：潮气量（420至270 mL）、吸气峰压（25至14 cm H₂O）、分钟通气量（13至5 L/分钟）、呼吸频率（26至16次/分钟）和吸入氧分数值（0.88至0.35）。AVCO₂R组的无呼吸机天数为3.9天，而假手术组动物为0.2天（P <.01），对于3只假手术组存活动物，AVCO₂R组的呼吸机依赖天数为2.4天，而假手术组为6.2天（P <.01）。随机分组后，所有8只接受AVCO₂R治疗的动物和8只假手术组动物中的3只存活了7天。