Service de Réanimation Médicale, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris 6, Paris, France.
Intensive Care Med. 2011 Nov;37(11):1738-45. doi: 10.1007/s00134-011-2358-2. Epub 2011 Oct 1.
Detailed extracorporeal membrane oxygenation (ECMO) weaning strategies and specific predictors of ECMO weaning success are lacking. This study evaluated a weaning strategy following support for refractory cardiogenic shock to identify clinical, hemodynamic, and Doppler echocardiography parameters associated with successful ECMO removal.
Hemodynamically stable patients underwent ECMO flow reduction trials to <1.5 L/min under clinical and Doppler echocardiography monitoring. When a patient had partially or fully recovered from severe cardiac dysfunction, tolerated the weaning trial, and had left ventricular ejection fraction (LVEF) >20-25% and aortic time-velocity integral (VTI) >10 cm under minimal ECMO support, device removal was considered.
Among the 51 patients (34 males, aged 54 ± 14 years) who received ECMO for medical (n = 27), postcardiotomy (n = 11), or posttransplantation (n = 5) cardiogenic shock, 38 tolerated at least one ECMO flow reduction trial and 20 were ultimately weaned. Compared with the 13 patients who tolerated the trial but were not deemed weanable, those successfully weaned had, at each ECMO flow level, higher arterial systolic and pulse pressures, VTI, LVEF, and lateral mitral annulus peak systolic velocity (TDSa). All weaned patients had aortic VTI ≥10 cm, LVEF >20-25%, and TDSa ≥6 cm/s at minimal ECMO flow support. These Doppler echocardiography parameters better separated weaned and nonweaned patients than any other parameters tested.
Patients who tolerated a full ECMO weaning trial and had aortic VTI ≥10 cm, LVEF >20-25%, and TDSa ≥6 cm/s at minimal ECMO flow were all successfully weaned. However, further studies are needed to validate these simple and easy-to-acquire Doppler echocardiography parameters as predictors of subsequent ECMO weaning success in patients recovering from severe cardiogenic shock.
缺乏详细的体外膜肺氧合（ECMO）脱机策略和 ECMO 脱机成功的具体预测因素。本研究评估了一种支持难治性心源性休克后的脱机策略，以确定与 ECMO 成功移除相关的临床、血液动力学和多普勒超声心动图参数。
血液动力学稳定的患者在临床和多普勒超声心动图监测下进行 ECMO 流量减少试验，至<1.5 L/min。当患者从严重心功能障碍部分或完全恢复、耐受脱机试验且在最低 ECMO 支持下左心室射血分数（LVEF）>20-25%和主动脉时间-速度积分（VTI）>10 cm 时，考虑移除设备。
在接受 ECMO 治疗的 51 名患者（34 名男性，年龄 54±14 岁）中，有 27 名患有药物性、11 名患有心脏手术后或 5 名患有移植后心源性休克，其中 38 名患者至少耐受了一次 ECMO 流量减少试验，20 名患者最终成功脱机。与耐受试验但被认为不可脱机的 13 名患者相比，成功脱机的患者在每个 ECMO 流量水平下的动脉收缩压和脉搏压、VTI、LVEF 和侧二尖瓣环收缩期峰值速度（TDSa）更高。所有脱机患者在最低 ECMO 流量支持下均具有主动脉 VTI≥10 cm、LVEF>20-25%和 TDSa≥6 cm/s。这些多普勒超声心动图参数比任何其他测试参数更好地分离了脱机和未脱机患者。
在最低 ECMO 流量下耐受完整 ECMO 脱机试验且主动脉 VTI≥10 cm、LVEF>20-25%和 TDSa≥6 cm/s 的患者均成功脱机。然而，需要进一步的研究来验证这些简单且易于获得的多普勒超声心动图参数作为预测严重心源性休克后患者随后 ECMO 脱机成功的指标。
