在使用股動脈插管的體外維生系統中去識別產生肢體缺血的風險因素與預防

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題名:	在使用股動脈插管的體外維生系統中去識別產生肢體缺血的風險因素與預防 To Identify the Risk Factor and Prevention of Limb Ischemia in Extracorporeal Membrane Oxygenation with Femoral Artery Cannulation
作者:	顏至謙 Yen, Chih-Chien
貢獻者:	蔡行瀚
關鍵詞:	體外膜肺氧合（葉克膜）；肢體缺血；遠端灌注導管 Extracorporeal membrane oxygenation (ECMO)；Limb ischemia；Distal perfusion catheter (DPC)
日期:	2016-05-20
上傳時間:	2019-07-16 11:51:37 (UTC+8)
摘要:	目的: 體外膜肺氧合（葉克膜），用於生命維持中的應用已被廣泛用於復甦的各個領域。當成年人使用總股動脈插管的葉克膜支持過程中通常會導致遠端肢體缺血的併發症。遠端灌注導管的放置可以減少肢體缺血的發生率，並增加肢體保存的可能性，但選擇標準是不確定的。方法: 這是一項回顧性研究。資料來源來自於一家醫學中心在2008年1月至2014年6月之間使用經皮總股動脈插管葉克膜支持的病人。研究區分為無肢體缺血與肢體缺血兩組。兩組差異研究採用年齡，性別，身高，體重，體表面積，套管尺寸，股動脈直徑，合併慢性疾病，急性生理和慢性健康評估分數，血管活性正性肌力分數和死亡率進行了分析比較。採用多普勒來測量足背和脛後動脈的遠端脈搏跳動。在符合選擇標準的病人中，經皮遠端灌注導管被預防性的放置在淺股動脈中來提供肢體血流。結果: 共有139（43.6％）位病人被納入在這次的研究中，其中46位病人有肢體缺血的發生。在無缺血與有缺血兩組比較中有統計上顯著差異的包含年齡（55.5±14.2 VS63.2±13.2;P <0.001），總股動脈直徑（0.82±0.14 VS0.63±0.17，P <0.001），已知周邊動脈阻塞疾病（9％和24％; P<0.001）及血管活性正性肌力分數（12.1±8.1 VS15.8±10.1; P <0.001）。在缺血組中有較高的死亡率（46％比26％; P <0.001）。在符合選擇標準的 11例患者均採用預防性遠端灌注導管置放，皆沒有缺血肢體的發生。結論: 在使用經皮總股動脈插管葉克膜支持的病人中，有較小的總股動脈直徑（<=6.3cm），或已知有周邊動脈阻塞疾病或有較高的血管活性正性肌力分數（>=15.8），或在插管前或插管後或插管後4小時量測不到遠端脈動的病人有較高的風險產生肢體缺血。當肢體缺血發生時死亡率和發病率皆會增加。在符合選擇標準高危險的病人中，遠端灌注導管應被預防性置放。 Objective: Application of extracorporeal membrane oxygenation (ECMO) for life support has been widely used in various fields of resuscitation. When the common femoral artery (CFA) is used during cannulation for ECMO support in adults is often complicated by limb ischemia. Placement of distal perfusion catheter (DPC) can reduce the incidence of limb ischemia and increases the likelihood of limb preservation, but selection criteria is uncertain. Methods: This is a retrospective study. Data was reviewed of patients in one medical center who were supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO) via CFA cannulation percutaneously between January 2008 and June 2014. Two groups were divided as no-ischemia and ischemic limb. Age, sex, height, weight, body surface area (BSA), cannula size, femoral artery diameter, co-morbidity, acute physiology and chronic health evaluation (APACHE) II score, vasoactive-inotropic score (VIS) and mortality rate were analysed. Doppler was used by measuring the distal pulsation in the dorsalis pedis and posterior tibial artery to select the patients. A DPC was prophylactic inserted percutaneously into the superficial femoral artery for antegrade flow to the extremity in the patient with selection criteria. Result: 139 (43.6%) patients were included in the study and limb ischemia occurred in 46 (33%) of 139. There was a significant difference between the no-ischemia group and the ischemia group in age (55.5±14.2 vs 63.2±13.2 ; P < .001 ), Common femoral artery diameter (0.82±0.14 vs 0.63±0.17 ; P < .001 ), known peripheral artery occlusive disease (9% vs 24% ; P < .001) and VIS (12.1±8.1 vs 15.8±10.1 ; P < .001). Mortality rate was higher in the ischemia group (46% vs 26% ; P < .001). 11 patients are used DPC prophylactic inserted with selection criteria and they were no ischemia limb occurred. Conculsion: Smaller common femoral artery diameter (<= 6.3 cm) or known peripheral arterial occlusive disease or higher VIS (>=15.8) or absence of distal pulsation pre-cannulation or post-cannulation immediately or 4 hrs later have higher risk of limb ischemia when CFA cannulation for VA ECMO. Due to the mortality and morbidity rate were increased when limb ischemia occurred. A DPC should be prophylactic inserted in the high risk patients with selection criteria.
描述:	碩士指導教授-蔡行瀚委員-邱文達委員-蔡建松
資料類型:	thesis
顯示於類別:	[傷害防治學研究所] 碩博士論文

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