ecm技術(shù)icu.ppt

0,ECMO 技術(shù),歷史和現(xiàn)狀,1,原理和結(jié)果,2,未來的展望,3,中國(guó)何處去,4,內(nèi)容,0,歷史和現(xiàn)狀,0,原理和結(jié)果,用錢向上帝買時(shí)間 用心向死神要生命,等待,MO,Pump,CPB,體外循環(huán)的改善,肝素涂抹技術(shù) 經(jīng)皮插管技術(shù) 泵膜肺的優(yōu)化,肝素涂抹技術(shù),經(jīng)皮插管技術(shù),泵和膜肺優(yōu)化,氧中毒,機(jī)械 損傷,作用 有限,常規(guī)急性呼衰治療的缺陷,全身炎性反應(yīng),支持:,休息:,有效氣體交換,高氧損傷 機(jī)械損傷,ECMO 對(duì)呼吸的作用,降低后負(fù)荷 降低前負(fù)荷 增加心收縮,血供難保證 速度較慢 效果有限,使用大量活性藥,的弊病,弊病,全身炎性反應(yīng),支持:,休息:,維持有效循環(huán), 減少心臟做功 減少藥物應(yīng)用,ECMO對(duì)心臟的作用,心臟移植,供心動(dòng)脈粥樣硬化,取自體血管行CABG術(shù),滲血嚴(yán)重，大量輸血輸液導(dǎo)致心肺功能惡化。少尿,IABP及ECMO,缺血時(shí)間長(zhǎng),心肌收縮仍差,CPB下二次心臟移植，暫停ECMO,術(shù)后呼吸功能未恢復(fù),再次進(jìn)行ECMO輔助,心肺功能改善,PLT低，手臂有出血點(diǎn),停止ECMO,心臟移植和ECMO過程圖,肺,心,腦,功能 恢復(fù),經(jīng)濟(jì) 能力,建立ECMO前必須慎重考慮,經(jīng)費(fèi)預(yù)算,首次運(yùn)行 2.5 3.0 萬 每天維持 0.4 0.6 萬 每例估計(jì) 4.5 6.0 萬,瞳孔 意識(shí) 乳酸 尿量 活性藥,時(shí)機(jī)的判斷,He is life or death ?,what is next step ?,停機(jī),放棄,繼續(xù)轉(zhuǎn)流,心肺移植,ECMO 轉(zhuǎn)歸,適應(yīng)癥,團(tuán)隊(duì),時(shí)機(jī),ECMO 成功關(guān)鍵,0,未來展望,供體（心、肺）,原發(fā)性肺高壓 受體（心、肺） 供體（心）,復(fù)雜先心ECMO無效 受體（心）,天外有天,ECMO pECMO,經(jīng)皮靜脈插管房間隔打孔,AALA bridge to XP: Hoopes, 2009,清醒 ECMO,Rudich SM, et al, Transplantation, 2002,ECS assisted DCD,成人雙腔引流灌注管,ADP,tPA,heparin,thrombomodulin,NO,ADP,PGI2,tissue plasminogen activator,Endothelial Cell,Non-thrombogenic Endothelium,thrombin,Collagen Tissue Factor Fibronectin,PAF,cytokines,Quiescent Platelet,prostaglandin I2,nitric oxide,thrombin,platelet activating factor,platelet activating inhibitor,PAI-1,protein S,PS,TFPI,Effect of Nitric Oxide on Platelets,Direct Effects: directly binds to guanylate cyclase to increase cGMP: inhibits Ca 2+ influx into platelets inhibits phosphorylation of myosin light chains inhibits GpIIb/IIIa expression inhibits phosphorylation by protein kinase C modulates phospholipase A2 and C mediated responses decreases local plasma Ca 2+ Indirect Effects: NO reacts with S-thiols in the blood to create nitrosothiols,NO Releasing and Generating Materials as Thromboresistant Materials,NO flux from the endothelial cell (EC) surface Vaughn, M. W.; et al. Am. J. Physiol. 274 (Heart Circ. Physiol. 43) 1998, H2163. 4.1 10-10 molecm-2min-1 Estimated based on Radomskis experimental data (Biochem. Biophy. Res. Comm. 1987, 148, 1482.) 1.6 10-10 molecm-2min-1(Bradykinin stimulated EC) 0.5 10-10 molecm-2min-1(unstimulated EC) Materials with equal or higher NO flux from their surfaces might be able to help prevent platelet adhesion/activation/aggregation on such materials.,Neonatal Respiratory Cases,Jan 2009,HFOV Surfactant,iNO,Cardiac Cases By Year Under 16 years 1/09,ECMO 和 H1N1,EMERGENCY MEDICINE,0,中國(guó)何處去,ECMO,團(tuán)結(jié)協(xié)作 爭(zhēng)取成功,恢復(fù)室,體外 循環(huán),不斷學(xué)習(xí),加強(qiáng)宣傳 建立網(wǎng)絡(luò) 正規(guī)培訓(xùn) 數(shù)據(jù)庫(kù) 醫(yī)療保險(xiǎn),幾點(diǎn)建議,避免畸形發(fā)展 腳踏實(shí)地工作,心浮虛榮的學(xué)者