Muellenbach R M, Kredel M, Wunder C, Küstermann J, Wurmb T, Schwemmer U, Schuster F, Anetseder M, Roewer N, Brederlau J
University of Wuerzburg, Department of Anaesthesiology, Wuerzburg, Germany.
Eur J Anaesthesiol. 2008 Nov;25(11):897-904. doi: 10.1017/S0265021508004870. Epub 2008 Jul 29.
Pumpless arteriovenous extracorporeal lung assist is increasingly used as a rescue therapy in acute respiratory distress syndrome. Arteriovenous extracorporeal lung assist is highly efficient in eliminating carbon dioxide and allows the application of ventilator techniques that prioritize lung protection and aim to reduce ventilator-induced lung injury and remote organ dysfunction.
Retrospective data analysis performed in a 12-bed university hospital ICU. In all, 22 patients with acute respiratory distress syndrome refractory to standard care were included. Arteriovenous extracorporeal lung assist as central part of a multimodal treatment concept was combined with tidal volume (VT) reduction below 4 mL kg-1 predicted body weight, a positive end-expiratory pressure titrated to optimize oxygenation and continuous axial rotation.
Hypercapnia was reversed within 24 h in survivors (39 mmHg (35-42) (median and interquartile range) vs. 65 mmHg (54-72), P < 0.05) and non-survivors (5.2 kPa (5.5-6.0) vs. 10 kPa (6.9-13.9), P < 0.05). Oxygenation was significantly improved in survivors after 24 h (PaO2/FiO2 ratio 20.7 kPa (17.4-22.7) vs. 11.7 kPa (7.3-20.8), P < 0.05). All patients required norepinephrine infusion and volume resuscitation. The overall complication rate was 23%, predominantly due to reversible lower limb ischaemia. One patient (5%) was permanently disabled due to amputation of a seriously injured lower leg 9 days after initiation of arteriovenous extracorporeal lung assist therapy; however, the patient survived without neurological deficits despite an initial oxygenation index of 4.4 kPa. The overall mortality rate was 27%.
A multimodal treatment concept with arteriovenous extracorporeal lung assist as its central part provides reversal of hypercapnia and stabilization of oxygenation. In an attempt to maximize lung protection and potentially reduce ventilator-induced lung injury, a further VT reduction below 4 mL kg(-1) predicted body weight combined with a high mean airway pressure and continuous axial rotation is safely possible.
无泵动静脉体外肺辅助越来越多地被用作急性呼吸窘迫综合征的挽救治疗方法。动静脉体外肺辅助在清除二氧化碳方面效率很高，并允许应用优先保护肺且旨在减少呼吸机诱导的肺损伤和远处器官功能障碍的通气技术。
在一家拥有12张床位的大学医院重症监护病房进行回顾性数据分析。总共纳入了22例对标准治疗无效的急性呼吸窘迫综合征患者。作为多模式治疗理念核心部分的动静脉体外肺辅助与将潮气量（VT）降至低于预测体重4 mL/kg、滴定呼气末正压以优化氧合以及持续轴性旋转相结合。
幸存者在24小时内高碳酸血症得到逆转（39 mmHg（35 - 42）（中位数和四分位间距）对比65 mmHg（54 - 72），P < 0.05），非幸存者也是如此（5.2 kPa（5.5 - 6.0）对比10 kPa（6.9 - 13.9），P < 0.05）。24小时后幸存者的氧合得到显著改善（动脉血氧分压/吸入氧分数值比值为20.7 kPa（17.4 - 22.7）对比11.7 kPa（7.3 - 20.8），P < 0.05）。所有患者都需要去甲肾上腺素输注和容量复苏。总体并发症发生率为23%，主要原因是可逆性下肢缺血。1例患者（5%）在开始动静脉体外肺辅助治疗9天后因严重受伤的小腿截肢而永久致残；然而，尽管初始氧合指数为4.4 kPa，但该患者存活且无神经功能缺损。总体死亡率为27%。
以动静脉体外肺辅助为核心部分的多模式治疗理念可实现高碳酸血症的逆转和氧合的稳定。为了最大限度地保护肺并潜在地减少呼吸机诱导的肺损伤，将潮气量进一步降至低于预测体重4 mL/kg（-1）并结合高平均气道压和持续轴性旋转是安全可行的。
