Kolla S, Awad S S, Rich P B, Schreiner R J, Hirschl R B, Bartlett R H
Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109-0331, USA.
Ann Surg. 1997 Oct;226(4):544-64; discussion 565-6. doi: 10.1097/00000658-199710000-00015.
The authors retrospectively reviewed their experience with extracorporeal life support (ECLS) in 100 adult patients with severe respiratory failure (ARF) to define techniques, characterize its efficacy and utilization, and determine predictors of outcome.
Extracorporeal life support maintains gas exchange during ARF, providing diseased lungs an optimal environment in which to heal. Extracorporeal life support has been successful in the treatment of respiratory failure in infants and children. In 1990, the authors instituted a standardized protocol for treatment of severe ARF in adults, which included ECLS when less invasive methods failed.
From January 1990 to July 1996, the authors used ECLS for 100 adults with severe acute hypoxemic respiratory failure (n = 94): paO2/FiO2 ratio of 55.7+/-15.9, transpulmonary shunt (Qs/Qt) of 52+/-22%, or acute hypercarbic respiratory failure (n = 6): paCO2 84.0+/-31.5 mmHg, despite and after maximal conventional ventilation. The technique included venovenous percutaneous access, lung "rest," transport on ECLS, minimal anticoagulation, hemofiltration, and optimal systemic oxygen delivery.
Overall hospital survival was 54%. The duration of ECLS was 271.9+/-248.6 hours. Primary diagnoses included pneumonia (49 cases, 53% survived), adult respiratory distress syndrome (45 cases, 51 % survived), and airway support (6 cases, 83% survived). Multivariate logistic regression modeling identified the following pre-ECLS variables significant independent predictors of outcome: 1) pre-ECLS days of mechanical ventilation (p = 0.0003), 2) pre-ECLS paO2/FiO2 ratio (p = 0.002), and 3) age (years) (p = 0.005). Modeling of variables during ECLS showed that no mechanical complications were independent predictors of outcome, and the only patient-related complications associated with outcome were the presence of renal failure (p < 0.0001) and significant surgical site bleeding (p = 0.0005).
Extracorporeal life support provides life support for ARF in adults, allowing time for injured lungs to recover. In 100 patients selected for high mortality risk despite and after optimal conventional treatment, 54% survived. Extracorporeal life support is extraordinary but reasonable treatment in severe adult respiratory failure. Predictors of survival exist that may be useful for patient prognostication and design of future prospective studies.
作者回顾性分析了100例严重呼吸衰竭（ARF）成年患者接受体外生命支持（ECLS）的经验，以确定技术方法，描述其疗效和应用情况，并确定预后的预测因素。
体外生命支持可在ARF期间维持气体交换，为患病的肺脏提供最佳的愈合环境。体外生命支持已成功用于治疗婴幼儿呼吸衰竭。1990年，作者制定了成人严重ARF的标准化治疗方案，当侵入性较小的方法无效时包括ECLS。
1990年1月至1996年7月，作者对100例严重急性低氧性呼吸衰竭成年患者（n = 94）使用了ECLS：动脉血氧分压/吸入氧分数值（PaO2/FiO2）为55.7±15.9，肺内分流（Qs/Qt）为52±22%，或急性高碳酸血症性呼吸衰竭成年患者（n = 6）：尽管进行了最大程度的传统通气，动脉血二氧化碳分压（PaCO2）仍为84.0±31.5 mmHg。该技术包括经皮静脉-静脉通路、肺“休息”、ECLS转运、最小化抗凝、血液滤过和优化的全身氧输送。
总体医院生存率为54%。ECLS持续时间为271.9±248.6小时。主要诊断包括肺炎（49例，53%存活）、成人呼吸窘迫综合征（45例，51%存活）和气道支持（6例，83%存活）。多因素逻辑回归模型确定了以下ECLS前变量是预后的显著独立预测因素：1）ECLS前机械通气天数（p = 0.0003），2）ECLS前PaO2/FiO2比值（p = 0.002），3）年龄（岁）（p = 0.005）。ECLS期间变量的模型显示，没有机械并发症是预后的独立预测因素，与预后相关的唯一患者相关并发症是肾衰竭的存在（p < 0.0001）和手术部位明显出血（p = 0.0005）。
体外生命支持为成年ARF患者提供生命支持，使受损肺脏有时间恢复。在100例尽管接受了最佳传统治疗但死亡风险仍很高的患者中，54%存活。体外生命支持在严重成人呼吸衰竭中是一种特殊但合理的治疗方法。存在生存预测因素，可能有助于患者预后评估和未来前瞻性研究的设计。
