ecm技術(shù)icu王培棟課件

0ECMO技術(shù)歷史和現(xiàn)狀1原理和結(jié)果2未來(lái)的展望3中國(guó)何處去4內(nèi)容0原理和結(jié)果用錢(qián)向上帝買(mǎi)時(shí)間用心向死神要生命等待ECMO的作用體外循環(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)

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常規(guī)重癥心衰治療方法和缺陷全身炎性反應(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(guò)程圖經(jīng)費(fèi)預(yù)算首次運(yùn)行 2.5–3.0萬(wàn)每天維持 0.4–0.6萬(wàn)每例估計(jì) 4.5–6.0萬(wàn)瞳孔意識(shí)乳酸尿量活性藥時(shí)機(jī)的判斷適應(yīng)癥團(tuán)隊(duì)時(shí)機(jī)ECMO成功關(guān)鍵0未來(lái)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(wú)效受體（心）天外有天ECMOpECMO經(jīng)皮靜脈插管房間隔打孔AALAbridgetoXP:Hoopes,2009清醒ECMORudichSM,etal,Transplantation,2002ECSassistedDCD

成人雙腔引流灌注管ADPtPAheparinthrombomodulinNOADPPGI2tissueplasminogenactivatorEndothelialCellNon-thrombogenicEndotheliumthrombinCollagenTissueFactorFibronectinPAFcytokinesQuiescentPlateletprostaglandinI2nitricoxidethrombinplateletactivatingfactorplateletactivatinginhibitorPAI-1proteinSPSTFPIEffectofNitricOxideonPlateletsDirectEffects:directlybindstoguanylatecyclasetoincreasecGMP:inhibitsCa2+influxintoplateletsinhibitsphosphorylationofmyosinlightchainsinhibitsGpIIb/IIIaexpressioninhibitsphosphorylationbyproteinkinaseCmodulatesphospholipaseA2

andCmediatedresponsesdecreaseslocalplasma[Ca2+]IndirectEffects:NOreactswithS-thiolsinthebloodtocreatenitrosothiolsNOReleasingandGeneratingMaterialsasThromboresistantMaterialsNOreleasing/generatingmaterials(hydrophobic)NONONONONONOPlateletRedbloodcellNOfluxfromtheendothelialcell(EC)surfaceVaughn,M.W.;etal.Am.J.Physiol.274(HeartCirc.

Physiol.43)1998,H2163. 4.1×10-10mole·cm-2·min-1EstimatedbasedonRadomski’sexperimentaldata(Biochem.Biophy.Res.Comm.1987,148,1482.) 1.6×10-10mole·cm-2·min-1(BradykininstimulatedEC) 0.5×10-10mole·cm-2·min-1(unstimulatedEC)MaterialswithequalorhigherNOfluxfromtheirsurfacesmightbeabletohelppreventplateletadhesion/activation/aggregationonsuchmaterials.NeonatalRespiratoryCasesJan2009HFOVSurfactantiNOCardiacCasesByYear

Under16years1/09ECMO和H1N1EMERGENCYMEDICINE0中國(guó)何處去ECMO團(tuán)結(jié)協(xié)作爭(zhēng)取成功內(nèi)外科恢復(fù)室體外循環(huán)護(hù)理不斷學(xué)習(xí)加強(qiáng)宣傳

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