本文選題：體外膜肺氧合 + 急性心肌梗死�。� 參考：《天津醫(yī)科大學(xué)》2016年博士論文

【摘要】：一、體外膜肺氧合搶救非外科術(shù)后心臟驟停目的評價(jià)傳統(tǒng)心肺復(fù)蘇(conventional cardiopulmonary resuscitation,CCPR)無效的非外科術(shù)后心臟驟停采用體外膜肺氧合(extracorporeal membrane oxygenation,ECMO)的效果。方法回顧2009年1月至2015年7月CCPR無效后接受ECMO的非外科術(shù)后心臟驟停患者資料,比較不同預(yù)后組的臨床指標(biāo)。結(jié)果納入25例患者,CCPR平均時(shí)間47.4 min,ECMO復(fù)蘇成功率100%。ECMO撤機(jī)率和存活率分別為36%和28%。和死亡組相比,存活組監(jiān)護(hù)室停留時(shí)間更長[(20.0±13.2)d vs(5.5±6.3)d]、24小時(shí)[(91.1±20.4)mm Hg vs(73.2±20.1)mm Hg]及48小時(shí)動(dòng)脈平均壓[(86.6±18.0)mm Hg vs(63.0±16.7)mm Hg]更高、72小時(shí)血小板計(jì)數(shù)[(97.3±31.5)×109/L vs(57.0±30.1)×109/L]更高(P0.05)。急性心梗亞組(n=20)均成功接受直接經(jīng)皮冠脈介入治療,存活組CCPR時(shí)間更短[(29.2±4.9)min vs(51.0±24.5)min]、罪犯血管中右冠脈比例更高(50%vs 7.1%)、前降支比例更低(16.7%vs 57.1%)、ECMO撤機(jī)率更高(100%vs 14.3%)、48小時(shí)平均動(dòng)脈壓更高[(87.9±19.4)mm Hg vs(101.7±32.7)mm Hg)]、動(dòng)脈血乳酸水平更低[(1.74±0.85)mmol/l vs(6.41±5.65mmol/l)](P0.05)。結(jié)論ECMO是CCPR無效的非外科術(shù)后心臟驟停有效治療手段。E-CPR前低灌注時(shí)間、48小時(shí)內(nèi)血流動(dòng)力學(xué)狀態(tài)、72小時(shí)血小板計(jì)數(shù)及心�；颊叩淖锓秆芊植加兄陬A(yù)測存活率。二、體外膜肺氧合-常規(guī)體外轉(zhuǎn)換在高危冠脈旁路移植術(shù)的應(yīng)用目的比較在ECMO-常規(guī)體外轉(zhuǎn)流轉(zhuǎn)換(實(shí)驗(yàn)組)和非停跳下施行高危冠脈旁路移植術(shù)的圍術(shù)期特點(diǎn)及結(jié)局。方法回顧分析2010年1月至2014年12月實(shí)驗(yàn)組和非停跳冠脈旁路移植術(shù)(off-pump coronary artery bypass grafting,OPCABG,對照組)資料,隨訪遠(yuǎn)期無主要心血管不良事件(major adverse cardiovascular event,MACE)生存率。結(jié)果實(shí)驗(yàn)組26例,年齡(73.5±3.1)歲;OPCABG組24例,年齡(71.8±4.2)歲。術(shù)前Euroscore評分分別為11.7±2.4和10.9±2.0。和OPCABG組相比,實(shí)驗(yàn)組完全再血管化率更高(66.7%vs 96.2%),術(shù)中液體平衡控制更理想[(135.0±593.5)mlvs[(606.0±615.5)ml],術(shù)后ECMO輔助時(shí)間[(33.1±23.6)h vs(80.8±18.5)h]、監(jiān)護(hù)室停留時(shí)間[(4.8±1.1)d vs(10.2±9.0)d]和住院時(shí)間[(17.7±6.3)d vs(28.2±17.5)d]更短(P0.05),存活率有更高趨勢(P=0.093)。隨訪(45.4±15.2)個(gè)月,實(shí)驗(yàn)組無MACE生存率優(yōu)于OPCABG組(P=0.028)。結(jié)論ECMO-常規(guī)體外轉(zhuǎn)換模式可能更有利于高�；颊邔�(shí)現(xiàn)冠脈完全再血管化,縮短術(shù)后住院時(shí)間,提高遠(yuǎn)期無MACE生存率。三、ECMO治療重癥成人呼吸窘迫綜合征目的:評價(jià)ECMO救治重癥成人呼吸窘迫綜合征(adult respiratory distress syndrome,ARDS)的效果,并對多個(gè)生存預(yù)測模型做外部驗(yàn)證。方法:回顧2009年1月至2015年7月年23例機(jī)械通氣無效后接受ECMO的重癥ARDS患者資料,分析影響預(yù)后的臨床指標(biāo),并計(jì)算PRESERVE、ECMOnet、RESP、Roch、APACHEⅡ、SOFA評分系統(tǒng)得分。結(jié)果:啟用ECMO后血流動(dòng)力學(xué)和氧合指標(biāo)均顯著改善。存活出院率56.5%。單因素分析顯示APACHEⅡ評分(r=-0.439,P=0.041)、更換膜式氧合器(r=-0.516,P=0.014)、急性腎損傷(r=-0.574,P=0.005)、多臟器功能不全(r=-0.633,P=0.002)和存活出院顯著相關(guān)。尿素氮、血小板和纖維蛋白原的前72小時(shí)演變特點(diǎn)有助于判斷預(yù)后。ECMO院間轉(zhuǎn)運(yùn)的存活率和常規(guī)轉(zhuǎn)運(yùn)及非轉(zhuǎn)運(yùn)患者相當(dāng)(P=1.000)。RESP和APACHEⅡ評分具有良好預(yù)測能力,曲線下面積分別為0.835(95%CI0.659-1.010,P=0.007)和0.762(95%CI 0.558-0.965,P=0.035)。截?cái)嘀捣謩e為3.5級(jí)和35.5分,敏感性和特異性均為70%和84.6%。SOFA評分在肺炎亞組有良好預(yù)測能力,曲線下面積為0.790(95%CI 0.571-1.009,P=0.038)。結(jié)論:ECMO是搶救機(jī)械通氣無效的重癥ARDS的一種有效手段。RESP、APCHAEⅡ和SOFA評分有助于對存活出院做出預(yù)測。四、超高效液相色譜質(zhì)譜對ST段抬高型心肌梗死年輕患者血漿代謝輪廓及通路分析目的:采用超高效液相色譜質(zhì)譜(Ultra-performance Liquid Chromatography and Mass Spectrometry,UPLC/MS)對ST段抬高型心肌梗死(ST-elevated myocardial infarction,STEMI)建立疾病區(qū)分模型,尋找特征代謝物及代謝通路,評價(jià)對預(yù)后的預(yù)測價(jià)值。方法:自2013年8月至2014年8月前瞻性連續(xù)納入47例STEMI患者(年輕23例、老年24例)和48例同期健康對照人群(年輕24例、老年24例)。年輕組發(fā)病1年后隨訪再次取血(22例,1例失訪)。借助UPLC/MS鑒定特征代謝物及代謝通路。建立ROC曲線評價(jià)其對出院后1年結(jié)局的預(yù)測價(jià)值。結(jié)果:成功建立偏最小二乘區(qū)分模型(R2X=71.2%,R2Y=79.6%,Q2=55.9%)并篩選24種代謝物離子。鞘脂(Sphingolipid)代謝是年輕患者發(fā)病最重要的通路。ROC曲線分析顯示該通路的神經(jīng)酰胺[Cer(d18:0/12:0),Cer(t18:0/16:0)]和二氫鞘氨醇對預(yù)測出院后主要不良心血管事件有良好敏感性和特異性,曲線下面積分別為0.671、0.750和0.711,發(fā)病1年后的曲線下面積分別為0.778、0.833和0.806。結(jié)論:通過UPLC/MS成功建立同時(shí)區(qū)分疾病狀態(tài)和年齡兩種因素的模型。鞘脂代謝是年輕患者發(fā)病最重要的通路,可作為判斷預(yù)后及改善療效的潛在靶點(diǎn)。
[Abstract]:Objective to evaluate the effect of extracorporeal membrane pulmonary oxygenation (extracorporeal membrane oxygenation, ECMO) in non surgical cardiac arrest after traditional cardiopulmonary resuscitation (conventional cardiopulmonary resuscitation, CCPR) after extracorporeal membrane pulmonary oxygenation (CPR) for nonsurgical cardiac arrest. The data of patients with ECMO after non surgical cardiac arrest were compared with the clinical indexes of different prognosis groups. The results were included in 25 cases, the average time of CCPR was 47.4 min, the rate of 100%.ECMO withdrawal and survival rate of ECMO resuscitation were 36% and 28%., respectively, and the stay time of the survival group was longer [(20 + 13.2) d vs (5.5 + 6.3) d], 24 hours. 91.1 + 20.4) mm Hg vs (73.2 + 20.1) mm Hg] and 48 hour arterial mean pressure [(86.6 + 18) mm Hg vs (63 + 16.7) mm Hg] higher, 72 hours platelet count [97.3 + 31.5) * 109/L vs (57 + 5) * * *. Vs (51 + 24.5) min], the proportion of right coronary artery in the offender's blood vessels is higher (50%vs 7.1%), the proportion of anterior descending branch is lower (16.7%vs 57.1%), the rate of ECMO withdrawal is higher (100%vs 14.3%), the average arterial pressure is higher in 48 hours [87.9 + 19.4) mm Hg vs (101.7 + 32.7) mm Hg)], and the level of lactic acid in arterial blood is lower [(1.74 + 0.85) mmol/l] It is an effective treatment for CCPR ineffective non surgical cardiac arrest by.E-CPR anterior low perfusion time, hemodynamic state within 48 hours, 72 hours platelet count and the distribution of criminal blood vessels in patients with myocardial infarction to predict survival rate. Two, the application of extracorporeal membrane pulmonary oxygenation conventional cardiopulmonary bypass in high risk coronary bypass grafting is compared in E CMO- the perioperative characteristics and outcomes of high risk coronary bypass grafting under conventional cardiopulmonary bypass (experimental group) and non stop jump. Methods a retrospective analysis of the data from January 2010 to December 2014 and non stop jump coronary bypass grafting (off-pump coronary artery bypass grafting, OPCABG, control group) was performed, and no major cardiovascular outcomes were followed up. Major adverse cardiovascular event (MACE) survival rate. Results the experimental group 26 cases, age (73.5 + 3.1) years, OPCABG group 24 cases, age (71.8 + 4.2) years of age. Preoperative Euroscore score was 11.7 + 2.4 and 10.9 + 2.0. and OPCABG, respectively, the experimental group was higher (66.7%vs 96.2%), the liquid balance control in the operation is more ideal. 135 + 593.5) mlvs[(606 + 615.5) ml], postoperative ECMO auxiliary time [(33.1 + 23.6) H vs (80.8 + 18.5) h], the stay time of the guardianship [(4.8 + 1.1) d vs (10.2 + 9) d] and hospital time [(17.7 +] d VS) d] was shorter, the survival rate was more Gao Qushi. =0.028) conclusion ECMO- routine cardiopulmonary bypass mode may be more beneficial to high risk patients to achieve complete revascularization of coronary artery, shorten the time of postoperative hospitalization and improve the long-term non MACE survival rate. Three, ECMO for severe adult respiratory distress syndrome (ECMO) for severe adult respiratory distress syndrome (adult respiratory distress syndrome, A). The effect of RDS) and the external verification of multiple survival prediction models. Methods: review the data of severe ARDS patients receiving ECMO after 23 cases of mechanical ventilation from January 2009 to July 2015, analyze the clinical indicators that affect the prognosis, and calculate the scores of PRESERVE, ECMOnet, RESP, Roch, APACHE II, SOFA scoring system. Results: the hemodynamics after ECMO was enabled. The survival discharge rate 56.5%. single factor analysis showed that APACHE II score (r=-0.439, P=0.041), membrane oxygenation (r=-0.516, P=0.014), acute renal injury (r=-0.574, P=0.005), multiple organ dysfunction (r=-0.633, P=0.002) were significantly related to survival and discharge. The first 72 small amounts of urea nitrogen, platelet and fibrinogen The characteristics of the time evolution were helpful to determine the survival rate of the inter hospital transport in.ECMO and the normal transport and non transshipment patients (P=1.000).RESP and APACHE II scores with good predictive ability. The area under the curve was 0.835 (95%CI0.659-1.010, P=0.007) and 0.762 (95%CI 0.558-0.965, P=0.035). The truncated values were 3.5 and 35.5, respectively. The specificity of the 70% and 84.6%.SOFA scores in the pneumonia subgroup has a good predictive ability, the area under the curve is 0.790 (95%CI 0.571-1.009, P=0.038). Conclusion: ECMO is an effective means of saving mechanical ventilation invalid severe ARDS.RESP, APCHAE II and SOFA score is helpful to predict survival and discharge. Four, ultra high performance liquid chromatography-mass spectrometry of ST Plasma metabolic profile and pathway analysis in young patients with segment elevation myocardial infarction (Ultra-performance Liquid Chromatography and Mass Spectrometry, UPLC/MS) to establish a disease differentiation model for ST segment elevation myocardial infarction (ST-elevated myocardial infarction, STEMI), and to search for characteristic metabolites. The prognostic value of the metabolic pathway was evaluated. Methods: from August 2013 to August 2014, 47 patients with STEMI (23 young, 24 elderly) and 48 healthy controls (24 young and 24 elderly) were enrolled in the same period. The young group was followed up for 1 years after 1 years (22 cases, 1 cases lost). The characteristics of metabolites and generations were identified by UPLC/MS. The ROC curve was established to evaluate the predictive value of the 1 year outcome after discharge. Results: the partial least squares (R2X=71.2%, R2Y=79.6%, Q2=55.9%) and the screening of 24 metabolites were successfully established. Sphingolipid metabolism was the most important pathway of.ROC curve analysis in young patients, which showed the pathway of ceramide [Cer (d18:0). /12:0), Cer (t18:0/16:0)] and two hydrogen sphingosine have a good sensitivity and specificity for predicting major adverse cardiovascular events after discharge. The area under the curve is 0.671,0.750 and 0.711 respectively. The area under the curve after 1 years is 0.778,0.833 and 0.806., respectively. By UPLC/MS, two factors are successfully established to distinguish the disease state and age. Sphingolipid metabolism is the most important pathway in the pathogenesis of young patients. It can be used as a potential target for judging prognosis and improving curative effect.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R541.78

【相似文獻(xiàn)】

相關(guān)期刊論文 前10條

1 孫麗娜;王寧夫;;體外膜肺氧合的臨床應(yīng)用進(jìn)展[J];心血管病學(xué)進(jìn)展;2013年03期

2 馬傳根,趙冬梅,趙景霞;體外膜肺氧合治療重度一氧化碳中毒(附6例報(bào)告)[J];急診醫(yī)學(xué);2000年04期

3 范全心;體外膜肺氧合[J];山東醫(yī)藥;2003年06期

4 章曉華,陳萍,周成斌,羅智超,肖學(xué)鈞;體外循環(huán)心臟手術(shù)后體外膜肺氧合肺支持[J];中國體外循環(huán)雜志;2004年04期

5 劉功儉;;體外膜肺氧合技術(shù)的臨床應(yīng)用進(jìn)展[J];國外醫(yī)學(xué).麻醉學(xué)與復(fù)蘇分冊;2005年05期

6 李欣;徐凌峰;郭震;王華;;體外膜肺氧合臨床應(yīng)用與團(tuán)隊(duì)建設(shè)——附17例臨床報(bào)告[J];中國體外循環(huán)雜志;2005年04期

7 肖倩霞;張志剛;李斌飛;趙湛元;毛凱紅;程周;;體外膜肺氧合治療重癥急性呼吸窘迫綜合征的臨床研究[J];中國醫(yī)師進(jìn)修雜志;2006年13期

8 李景文;龍村;高國棟;黑飛龍;于坤;;體外膜肺氧合技術(shù)支持治療期間患者血乳酸濃度及其預(yù)后[J];中國組織工程研究與臨床康復(fù);2007年18期

9 王仕剛;黑飛龍;龍村;胡盛壽;宋云虎;于坤;孫寒松;李景文;劉平;孫立忠;;成人體外膜肺氧合循環(huán)支持19例[J];中華胸心血管外科雜志;2007年05期

10 李云;張銀英;龐群英;楊紅麗;;體外膜肺氧合治療重癥急性呼吸窘迫綜合征的護(hù)理[J];護(hù)理學(xué)雜志;2007年17期

相關(guān)會(huì)議論文 前10條

1 劉松橋;金輝;黃英姿;郭鳳梅;劉玲;楊從山;楊毅;邱海波;;體外膜肺氧合對成人急性呼吸窘迫綜合征患者預(yù)后影響的薈萃分析和系統(tǒng)評價(jià)[A];中華醫(yī)學(xué)會(huì)第五次全國重癥醫(yī)學(xué)大會(huì)論文匯編[C];2011年

2 桑寶珍;黃永貴;;標(biāo)準(zhǔn)化護(hù)理程序在實(shí)施體外膜肺氧合技術(shù)中的應(yīng)用[A];全國外科護(hù)理學(xué)術(shù)交流暨專題講座會(huì)議、全國神經(jīng)內(nèi)、外科護(hù)理學(xué)術(shù)交流暨專題講座會(huì)議論文匯編[C];2010年

3 郭震;李欣;徐凌峰;;體外膜肺氧合與Goodpasture綜合征：一例病例報(bào)道和經(jīng)驗(yàn)討論[A];中華醫(yī)學(xué)會(huì)第七次全國胸心血管外科學(xué)術(shù)會(huì)議暨2007中華醫(yī)學(xué)會(huì)胸心血管外科青年醫(yī)師論壇論文集心血管外科分冊[C];2007年

4 馮正義;;體外膜肺氧合在小兒心臟術(shù)后急性心肺功能衰竭中的應(yīng)用[A];中國心臟大會(huì)（CHC）2011暨北京國際心血管病論壇論文集[C];2011年

5 胡堅(jiān);包飛潮;泮輝;楊運(yùn)海;王志田;;體外膜肺氧合技術(shù)的臨床應(yīng)用[A];2013中國器官移植大會(huì)論文匯編[C];2013年

6 江勇;王浩;逄坤靜;孫欣;;超聲心動(dòng)圖在體外膜肺氧合對心臟支持中的應(yīng)用價(jià)值[A];第九屆全國超聲醫(yī)學(xué)學(xué)術(shù)會(huì)議論文匯編[C];2006年

7 王世磊;黑飛龍;;體外膜肺氧合支持期間細(xì)胞炎性因子的變化[A];中國心臟大會(huì)（CHC）2011暨北京國際心血管病論壇論文集[C];2011年

8 李宏亮;李保順;杜紅艷;朱曦;郭利民;孫凌波;張U，

本文編號(hào)：1922735