20071112 ECMO Cardiopulmonary Support in Critically Ill Children
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Transcript of 20071112 ECMO Cardiopulmonary Support in Critically Ill Children
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Cardiopulmonary support in critically ill children
林盈瑞 醫師
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Lung vs. Heart – presentation
Cyanosis
Tachypnea
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Etiology of cyanosis
• CNS
• Respiratory disease
• Cardiovascular disease
• Methemoglobinemia
• Other – hypoglycemia, adrenogenital syndrome, polycythemia, blood loss,sepsis
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Approach of cyanosis
+
History PE
Lab
Hyperoxitest
PGE1
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Cyanosis in newborn
• TGA – most common• TOF with pulmonary atresia – 1.5-2% of CHD• Tricuspid atresia –1-3 % of CHD• Pulmonary atresia with intact ventricular septum – 1% of
CHD• Persistent Truncus arteriosus – < 1%of CHD• Single ventricle -- <1%,varies degree of cyanosis• TAPVR with and without pulmonary venous obstruction –
1% of CHD• Ebstein’s anomaly – in severe case,cyanosis and CHF d
uring first few days and improving after pulmonary vascualr resistance decrease
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氧氣對心血管影響
• 下降肺血管阻力 右心 afterload 下降 血液更容易到肺部
• 提高血液中氧氣濃度 減少心臟做功及增加冠狀動脈氧氣濃度
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Ventilator 使用對心跳的影響
• PPV 增加 lung volume reflex bradycardia
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Ventilator 使用對右心室功能的影響
• PPV intrathoracic pressure ↑ RA pressure ↑ RV preload ↓ RV output ↓
• PVR 的影響 :End-expiratory lung volume < Functional residual cap
acity hypoxic pulmonary constriction and the tortuous course of large to medium-sized pulmonary vessels PVR ↑
End-expiratory lung volume > Functional residual capacity alveoli hyperexpansion compression of the pulmonary capillaries PVR ↑
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Ventilator 使用對左心室功能的影響
• LV preload ↓ RV volume ↓ RV pressure ↑ LV compression
• LV afterload change↓
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肺高壓 (Pulmonary hypertension)
定義 – 平均肺動脈壓在休息時 > 25 mmHg 或運動時大於 30 mmHg
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肺高壓原因 (1)• Related to Hypoxic Pulmonary Hypertension
– Long-term high altitude dwelling – Restrictive respiratory dysfunction
• Obesity • Kyphoscoliosis • Neuromuscular disorders • Severe pleural fibrosis • Lung resection
– Chronic upper airway obstruction • Congenital webs • Enlarged tonsils • Obstructive sleep apnea
– Chronic lower airway obstruction • Chronic bronchitis • Asthmatic bronchitis • Bronchiectasis • Cystic fibrosis • Emphysema
– Chronic diffuse parenchymal disease • Interstitial fibrosis • Pneumoconioses • Granulomatous disease • Alveolar filling disorders • Connective tissue disorders (scleroderma, rheumatoid lung)
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肺高壓原因 (2)
• Related to Arterial Obstructive Pulmonary Hypertension– Thrombotic disease
• Sickle cell disease • Coagulation disorders
– Embolic disease • Chronic thromboemboli • Tumor emboli • Schistosomiasis
– Connective tissue disorders/vasculitis • Lupus • Systemic sclerosis
– Chronic liver disease (portal hypertension) – Hematologic problems (myeloproliferative abnormalities)
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肺高壓原因 (3)• Related to Pulmonary Venous Hypertension
– Aortic • Coarctation • Supravalvular aortic stenosis
– Left ventricle • Aortic stenosis • Aortic regurgitation • Congenital subaortic stenosis • Hypertrophic cardiomyopathy • Constrictive pericarditis • Restrictive cardiomyopathy • Dilated cardiomyopathy • Mitral stenosis • Mitral regurgitation
– Left atrium • Ball-valve thrombus • Myxoma • Cor triatriatum
– Pulmonary veins • Congenital pulmonary vein stenosis • Mediastinitis • Mediastinal fibrosis • Mediastinal neoplasm • Radiofrequency ablation for atrial fibrillation
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肺高壓原因 (4)
• Related to Pulmonary Hypertension due to Left-to-Right shunts– Patent ductus arteriosus – Aortopulmonary window – Rupture of aortic sinus – Ventricular septal defect – Atrial septal defect
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肺高壓原因 (5)
• Idiopathic Pulmonary Arterial Hypertension
• Familial Pulmonary Arterial Hypertension
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臨床表現• Right side heart failure – 水腫 , 肝脾腫大 , 心率不整 , 昏倒 , cyanosis
• Left side heart failure – 因左心 preload 下降及右心室壓迫左心室造成 – 昏倒 , 咳血 , 胸悶 , 頭痛 , 易疲倦
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治療•去除 underline disease
矯正心臟疾病矯正上呼吸道阻塞問題矯正肺部疾病
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治療• 避免上升肺壓及處理併發症
避免劇烈運動 , 避免到高山區 視需要給予氧氣 利尿劑 控制心衰竭 給予避免血小板凝集藥物 (如 aspirin) 治療心率不整 打流感疫苗 避免增加肺血管收縮因子 – 如 alveolar hypoxemia, acidosis, hypercapnia, vasoconstrictor drugs, fat emulsions, hypothermia, and high PEEP
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治療• 使肺壓下降
改善 O2, Hyperventilation inotropic agent vasodilator High-dose Ca-block + anticoagulants benefit in ad
ult patients NO useContinuous IV or inhalation prostacycline (PGI2) Bosentan transplantation
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如何使肺高壓下降• PH↑
• PaCO2↓
• PaO2 and PAO2↑
• 適當的 intrathoracic pressure (PEEP)
• Inhaled NO
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肺壓對心臟病人的影響• L-to-R shunt – ASD, VSD, PDA 肺壓下降會使分流增
加 心衰竭情況可能加劇• Left side obstruction 的 PDA dependent CHD – Crit
ic CoA, interrupted aorta, hypoplastic left heart 肺壓下降會使血流不易從肺動脈經動脈導管到周邊 周邊組織灌流不足
• Parallel flow 的 PDA dependent CHD – TGA 肺壓下降會使左心面對低的後負荷 久了可能造成左心室心肌退化之後無法接受全矯正
• Right side obstruction 的 PDA dependent CHD – TOF, Pulmonary atresia, Tricuspid atresia 肺壓下降會使肺血流增加 Cyanosis 改善
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ECMO(Extracorporeal Membrane Oxygenato
r)
體 外 循 環 機( 葉 克 膜 )
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What is ECMO?
• First from 1971
• Oxygenation outside the body
• Support heart and/or lung function
• Similar to bypass used in the operating room but can be used for longer periods of time
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How ECMO Works ?
• Pumping blood out of the body; oxygen is added to the blood and carbon dioxide is removed before it is returned to the patient.
• Pumping a steady amount of blood through the ECMO machine each minute. We call this the ECMO flow rate.
• As the patient improves, we may decrease the flow rate and let their heart and lungs do more of the work.
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Are there different types of ECMO?
• veno-arterial or VA ECMO
• veno-venous or VV ECMO
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VA ECMO
可取代心臟及肺臟功能
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VV ECMO
只能取代肺部功能
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Babies will usually have a
cranial ultrasound study: bleeding around the brain?
cardiac ultrasound study: heart function which type of ECMO to use (VA or VV).
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What is the goal of ECMO?
•確定身體有足夠氧氣應供應• ECMO 並不能治療心臟及肺臟疾病本身 ,只是爭取時間來恢復其功能
•使用期間可降低呼吸器設定條件以避免肺部再受傷害
•可降低強心藥物的劑量及種類
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Why ECMO?
• Severe pulmonary hypertension - high blood pressure in the lungs
• Pneumonia
• Respiration failure from trauma or severe infections
• Heart failure
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體外膜肺之使用參考: (91/12/01 生效 )
一、 心因休克(一) 心臟手術重建後,造成右心室衰竭併可回復性肺高壓危機。(二) Bridge :為準備心臟手術或心室輔助器或心臟移植,而暫代之。(三) 心臟手術後暫時左心室功能喪失( stunned heart )常見於 prolong bypass 。 (四) 可回復性的心肌病變,如心肌炎、冠狀動脈暫時性痙攣。(五) 先天性心臟病疾病手術重建後,心輸出量不足造成單側或雙側心衰竭。(六) 肺栓塞或肺梗塞( pulmonary embolism or infarction )。
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二、 呼吸衰竭(一) ARDS (成人呼吸窘迫症候群)1. Qsp/Qs>30﹪( intrapulmonary R to L shunt ): normal<5﹪2. Peak airway pressure>45cmH2O3. TSLCs<30ml/ cmH2O ( Total Static Lung Compliance )4. ARDS Typical X-ray and/or CT scan5. FiO2: 1.0, PaO2<50mmHg, PEEP> 5cmH2O
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(二) 小兒及新生兒1. 吸入性胎便肺炎症候群( MAS; Meconium aspiration syndrome )2. 呼吸窘迫症候群( Hyaline membrane disease )3. 先天性橫膈膜疝氣( CDH; Congenital diaphragm hernia )
4. 新生兒頑固性肺高壓( PPHN ; persistent pulmonary hypertension of neonate )
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(一) 外科手術或外傷後 24小時內(二) 頭部外傷併顱內出血 72小時內(三) 缺氧致腦部受損(四) 惡性腫瘤患者(五) ARDS 併 COPD(六) 病患在放置 ECMO前有明顯不可逆轉之病況(七) 已證實不可逆轉之腦傷害(八) 持續進展之退化性全身性疾病
禁忌症
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Exclusion Criteria:
• Lethal chromosomal anomaly
• <34 weeks gestational age
• <2000gms
• Coagulopathy that is ongoing/uncorrectable
• Mechanical ventilation for > 14 days
• Severe neurologic insult or asphyxiaUniversity of Minnesota Department of Pediatrics
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Risk of ECMO
•出血•感染 •輸血反應•血栓•血管傷害•中風•機器故障
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What happens on ECMO?
• Turn the ventilator settings down to "rest" settings.
• Turn down many of the heart medicines.
• Daily routine; chest x-ray each morning, weight and bath, blood samples (labs) and constant monitoring of vital signs.
• Let the patients rest as much as possible
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Medications
• Pain medication • Heparin • Antibiotics prophylaxis • Dopamine, Dobutamine….• TPN or enteral nutrition when possible
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測 ABG :– Pulse oximeter放右手,右手的 SaO2 反應病人自己的心肺功能;左手的 SaO2 比較反應出 ECMO 之 SaO2。
– VV mode :一般不用調整設定, FiO2: 1.0, gas flow: 10L/min 。
– VA mode :在調整穩定後,只要 ECMO SaO2 沒有變化,不用測 ECMO ABG 。
–病人之 ABG :依醫囑測。
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病例介紹•年齡 : 13 歲小女孩•到院主訴症狀 :意識障礙
最近 1~2 天有輕微感冒現象入院前 1天有胸痛情形在學校出現全身無力、冒冷汗等症狀且合併意識障礙而被送至本院急診
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過去病史• 無個人心臟方面疾病• 無家族心臟方面疾病• 無服用藥物病史
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住院過程•急診心電圖顯示心室頻脈 •對電擊 , 給藥及心臟按摩沒反應•予以插管及裝上體外心肺循環機• 3 天後順利移除體外心肺循環機及插管•目前病人恢復狀況良好
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95-08-30 08:32
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95-08-30 17:10
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95-09-04 11:52
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95-09-01
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95-09-04
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題目 1•下列所述何者不是新生兒發紺 (Cyanosis) 的原因 ?
(A) 先天性肺炎 (B) 法洛氏四合症 (C) 腦部損傷 (D) 以上皆會造成發紺
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題目 2•針對使肺壓下降的方法 ,下列何者為非 ? (A) Hyperventilation (B) NO 使用 (C) 調高 PEEP (D) 使 PH值上昇
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題目 3• 太高的正壓呼吸對心臟的影響下列何者為非 ?
(A) 會使心跳變慢 (B) 使右心室輸出血量減少 (C) 使左心室前負荷下降 (D) 以上皆對
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題目 4• 對於 ECMO 之敘述何者為非 ? (A) ECMO 可取代肺部功能 (B) ECMO 可取代心臟功能 (C) ECMO 可治療心肌炎 (D) ECMO 使用期間可降低 ventilator setting 條件
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題目 5•下列何種病人不適合使用 ECMO (A) 猛爆性心肌炎 (B) Duchenne muscular dystrophy 病人合併心肌病變所致之心臟衰竭
(C) 成人呼吸窘迫症候群 (D) 新生兒頑固性肺高壓
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History
maternal history( drugs, DM…), prenatal history( PROM, polyhydramnios oligohydramnios,CS or NSD, Meconium aspiration ,asphysia ), family history, intermittent or persistent cyanosis or sudden onset.
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Physical examination
• central or peripheral cyanosis, respiratory distress ( RR, retraction, nasal flaring,grunting ) or not,airway patency, heart murmur, differential of cyanosis or not, BT, vital signs, abdomen, neurologic
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Lab
CxR, ABG, pulse oximeter, CBC/DC, sugar
methemoglobin level, EKG, hyperoxic test, Brain echo, echocardiography
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HyperoxitestFiO2=0.21
PaO2(%Sat)
FiO2=1.00
PaO2(%Sat)
PaCO2
Normal 70 (95) >200(100) 40
Pul. disease 50(85) >150(100) 50
Neurologic disease 50(85) >150(100) 50
Methemoglogulinemia 70(95) >200(100) 35
Cardiac disease
Parallel circulation
Restricted PBF
Complete mixing without restricted PBF
<40(<75)
<40(<75)
50-60(85-93)
<50(<85)
<50(<85)
<150(<100)
35
35
35
PPHN
PFO,no R-to-L shunt
PFO,with R-to-L shunt
Preductal Postductal
70(95) <40(<75)
<40(<75) <40(<75)
Variable
Variable
35-50
35-50
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PGE1
• Starting dose : 0.05-0.1 ug/kg/min
• Therapeutic effective ( PaO2 15-20 mmHg)
• If no effect double dose, upto 0.4 ug/kg/min
• Adverse reaction – fever (14%), Apnea (12%), flush ( 10%),hypotension, seizure, arrythmia
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