Abstract | Cilj istraživanja: Cilj ovog istraživanja jest prikazati primjenu tehnike ECMO - komponente uređaja, modalitete rada, indikacije te kliničke i demografske karakteristike bolesnika liječenih ECMO metodom u kardiokirurškoj jedinici intenzivnog liječenja u Kliničkoj bolnici Split od 2013. do 2017. godine.
Ispitanici i metode: Pregledani su protokoli liječenja i povijesti bolesti bolesnika koji su liječeni na jedinici intenzivnog liječenja kardiokirurških bolesnika u razdoblju od listopada 2013. do srpnja 2017. godine. U istraživanje su uključena 33 bolesnika koji su u tom razdoblju liječeni ECMO metodom. U programskim paketima Microsoft Word i Excel obrađeni su podaci te su analizirani parametri dobi, spola, duljine boravka, dijagnoza, provedenih operativnih zahvata, komplikacija te postojanja smrtnog ishoda.
Rezultati istraživanja: Ovo istraživanje bavilo se praćenjem bolesnika koji su bili priključeni na izvantjelesnu membransku oksigenaciju (ECMO) u jedinici intenzivnog liječenja kardiokirurških bolesnika KBC Split. Istraživanje je obuhvatilo ukupno 33 bolesnika. Govoreći o dobno- spolnoj distribuciji, 78,8% (n=26) bolesnika bilo je muškog spola, a prosječna starost bolesnika iznosila je 64,4 godine. Najveći broj bolesnika koji je primljen u jedinicu intenzivnog liječenja imao je koronarnu bolest srca (75,7%, n=25). Akutizacija te bolesti u obliku infarkta miokarda dogodila se u 63,6% slučajeva, a kod 69,7% bolesnika razvio se kardiogeni šok. Osim infarkta miokarda kao najčešćeg uzroka kardiogenog šoka, ishemijsku kardiomiopatiju (39,4%) te insuficijencije i stenoze zalistaka (60,6%) treba spomenuti kao ostale najčešće uzroke hemodinamske nestabilnosti i urušaja. 84,8% bolesnika (n=28) podvrgnuto je kirurškom zahvatu. Najčešće izvođena operacija (46,4%) bilo je aortokoronarno premoštenje (CABG), a potom zamjene zalistaka (28,6%). Prosječna duljina boravka u jedinici intenzivnog liječenja kardiokirurških bolesnika iznosila je 8,9 dana. Najdulji boravak bio je 28 dana, a najkraći svega nekoliko sati. S obzirom na kompleksnost dijagnoza koje su bile razlog hospitalizacije, ali i same izvantjelesne membranske oksigenacije, ne iznenađuje visoki broj komplikacija koje prate bolesnike na ovoj vrsti mehaničke srčane potpore. Najčešća komplikacija kod bolesnika u jedinici intenzivnog liječenja kardiokirurških bolesnika KBC Split u razdoblju od 2013. do 2017. godine bilo je bubrežno zatajenje (66,6%, n=22) praćeno sa poslijeoperacijskim krvarenjem (63,6%, n=21). Od ostalih komplikacija vrijedi navesti heparinom induciranu trombocitopeniju – HIT (21,2%) te upale pluća (18,1%) S obzirom na sve izrečeno, ne iznenađuje prilično visoka stopa smrtnosti koja je iznosila 66,6% (n=22).
Zaključci provedenog istraživanja: Izvantjelesna membranska oksigenacija oblik je akutne mehničke potpore cirkulacije i respiracije. Osim centralnog ECMO modaliteta koji zahtijeva sternotomiju, postoji i periferni oblik umetanja kanila u krvne žile što omogućuje jednostavno i brzo postavljnje sustava te izbjegavanje sternotomije. Može se izvoditi i tijekom kardiopumonalne reanimacije te je dokazano povećana stopa preživljenja bolesnika kojima je osim KPR priključen i ECMO. VA- ECMO kod bolesnika sa akutnim srčanim zatajenjem služi kao most do oporavka ili uvođenja trajnijeg oblika liječenja kao što je transplantacija srca ili VAD. Također, ekonomski je prihvatljiviji od ostalih oblika mehaničke cirkulacijske potpore. Ipak, unatoč svim naporima da se usavrši tehnika i brzina postavljanja procjenjenog modaliteta te educira osoblje, stopa smrtnosti je još uvijek jako visoka. Potrebna su daljnja istraživanja na širem geografskom području i na različitim grupama bolesnika da bi se moglo objektivnije i sa više sigurnosti raspravljati o ovom složenom obliku mehaničke cirkulacijske potpore. |
Abstract (english) | Objectives: The main objective of this research is to show application of ECMO technique- indications, device components and cannulation strategies as well as to define demographic and clinical characteristics of postcardiotomic patients treated with ECMO at the cardiac surgery Intensive Care Unit at the Department of Anesthesiology, Reanimatology and Intensive Care of the University Hospital Split from 2013 till 2017.
Patients and methods: Protocols of treatments at the Intensive Care Unit for cardiac surgery patiens in Clinical Hospital Centre Split as well as medical histories of patients treated with extracorporeal membrane oxigenation were examined retrospectively in the period of October of 2013 till July of 2017. 33 patients treated with ECMO support were included in this research.
Results: This rsearch included 33 patients who were treated with ECMO support from October of 2013 till July of 2017. The largest amount of them were on ECMO support in 2014 (n=11) with total percentage of 33,3%, while the smallest amount (n=3) were in 2013. However, it should be noted that ECMO support was used in Split in October 2013 for the first time. 78,8% (n=26) patients were male, while the average age was 64,4 years. The largest amount of patients admitted to Intensive Care Unit had coronary artery disease (75,7%, n=25). Acute exacerbation of the disease in form of myocardial infarction happened in 63,6% of cases, while 69,7% of patients developed cardiogenic shock. Except for the myocardial infarction as the most common cause of cardiogenic shock, ishemic cardiomyopathy (39,4%) and valvular stenosis as well as insufficiencies (60,6%) should be mentioned as other most common causes of haemodynamic instability and shock. 84,8% (n=28) of patients have undergone surgical procedure. The most commonly performed surgery was coronary artery bypass graft (46,4%). It is important to mention valve replacement procedureds (28,6%) as valvular heart disease is one of more common diagnosis (in total 60%) in this research. The average duration of in-hospital stay of the patients treated with ECMO support at the Intensive Care Unit was 8,9 days. The longest stay was 28 days, while the shortest one was only a few hours. Considering the complexity of diagnosis that were the reason for admission to the hospital and extracorporeal membrane oxygenation, the high number of complications that follow these patients is not surprising. The most common complication in patients treated with ECMO in the Intensive Care Unit was acute renal failure (66,6%, n=22) followed by postoperative bleeding (63,6%, n=21). Of other complications it is worth to mention heparin-induced thrombocytopenia (HIT) and pneumonia. Considering all facts, the mortality rate is quite high, accounting for 66,6% (n=22) of deaths.
Conclusions: Extracorporeal membrane oxygenation is a form of acute mechanical circulatory and respiratory support. Besides central ECMO modality that demands sternotomy, there is also a peripheral form of canulla insertion that allows for a simplier and easier setting avoiding sternotomy. ECMO can be used during cardiopulmonary resuscitation with higher survival rates compared to patients without ECMO support. VA- ECMO in patients with acute heart failure serves as a bridge to recovery or initiation of a more permanent therapy form such as heart transplantation or ventricular assist device. Furthermore, it is more economically acceptable compared to other forms of mechanical circulatory support. Nevertheless, despite all efforts to improve the technique and timing as well as educate staff, the mortality rate is still very high. Further researche on a wider geographical area is required to be able to discuss more objectively and with more certainty about this form of mechanical circulatory support. |