心脏骤停患者的福音：建设多科室合作的体外肺膜氧合(ED ECMO)项目

                                       心脏骤停患者的福音：

                                                            ——建设多科室合作的体外肺膜氧合(ED ECMO)项目可显著提高患者神经有利性生存机率

   Despite advances inthe medical and surgical management of cardiovascular disease, greater than350,000 patients experience out-of-hospital cardiac arrest in the United Statesannually, with only a 12% neurologically favorable survival rate. 

     Of these patients,23% have an initial shockable rhythm of ventricular fibrillation/pulselessventricular tachycardia (VF/VT), a marker of high probability of acute coronaryischemia (80%) as the precipitating factor. However, few patients (22%) willexperience return of spontaneous circulation and sufficient hemodynamicstability to undergo cardiac catheterization and revascularization.

    Previous case series and observationalstudies have demonstrated the successful application of intra-arrestextracorporeal life support, including to out-of-hospital cardiac arrestvictims, with a neurologically favorable survival rate of up to 53%. 

    Forpatients with refractory cardiac arrest, strategies are needed to bridge themfrom out-of-hospital cardiac arrest to the catheterization laboratory andrevascularization. To address this gap, we expanded our ICU and perioperativeextracorporeal membrane oxygenation (ECMO) program to the emergency department(ED) to reach this cohort of patients to improve survival.

     尽管人类在心血管疾病的医学和外科治疗上取得了进展，但美国每年仍有超过350000名患者经历了院外心脏骤停，且对神经系统预后有利的存活率只有12%。其中23％的患者具有室颤或者无脉性室性心动过速(VF/VT)的初始可电击心律，这有80%的机率诱发急性冠状动脉缺血，因此可作为其发病的标志。

    然而，很少有患者（22％）会经历自主循环恢复以及拥有足够的血液动力学稳定性来进行心脏导管术和血运重建。过往病例分析和观察性研究已经证明内骤停后成功应用体外生命支持的患者，包括院外心脏骤停患者，可以将对神经系统预后有利生存率提高到53％。

     对于难治性心脏骤停患者，需要采取的策略是将他们从院外心脏骤停与导管室以及血运重建连接起来。为了缩小这一差距，该研究团队提倡将ICU和围术期应用体外膜肺氧合（ECMO）的项目扩展到急诊科（ED），以期提高患者的生存率。

    A primary goal of this program was thedevelopment of a multidisciplinary system to coordinate patient care acrossmultiple silos within our medical system, ranging from emergency medicalservices (EMS), emergency department (ED), cardiac catheterization laboratory,cardiothoracic surgery, and ICU. 

    The author strongly believes thatmultidisciplinary support is essential for good outcomes, and the team observedthat their multidisciplinary program resulted in a high rate of successfulinitiation of ECMO during cardiac arrest in the ED. 

    This article primallyintroduces the research team’s experience of design and implementation of acomprehensive and multidisciplinary program of ED ECMO as a template forinstitutions interested in building their own ED ECMO programs.

     该项目的主要目标是开发一个多科室系统，用以协调医疗系统内多个科室的患者护理，包括紧急医疗服务（EMS），急诊科（ED），心导管室，心胸外科和重症监护室（ICU）。

     作者认为多学科支持对能否取得良好的治疗效果至关重要,并且发现他们开展的多科室合作项目能提高急诊科对心脏骤停患者实施ECMO的成功率。本文主要介绍作者及其团队开展综合性且多科室合作的ED ECMO流程，以此作为其他机构有意建立ED ECMO项目的实施模板。    

     The process about ED ECMO program carried outin the University of Utah is showed in the Figure1. The program has evaluationand activation levels with associated page groups. The “EVAL” page is initiatedby the ED charge nurse in conjunction with the ED attending physician; theyreceive base calls from EMS and identify any patients who meet the inclusioncriteria. 

   The EVAL page goes out before patient arrival and includes the cardiothoracicsurgeon on call, the in-house cardiovascular ICU intensivist, theinterventional cardiologist, the cardiovascular ICU charge nurse or ECMO chargenurse, the house supervisor, and the ED echocardiography group. Meanwhile, thepreparation for ED resuscitation room should be completed.

    图1展示了作者及其团队在犹他大学开展的ED ECMO项目的流程。该项目具有评估和激活水平的相关页面。“EVAL”页面由ED护士长与ED主治医师共同管理;他们接受来自EMS的调用，并确定符合标准的患者。 

    EVAL页面在患者到来之前将被发送给待命的心胸外科医生，心血管重症监护室专科医生，心内科医生，心血管重症监护室护士长或者ECMO护士长，医院主管以及ED心脏超声组。同时，应完成ED复苏室的准备工作。

    For the process to move from evaluation toactivation, confirmation of the availability of a cardiovascular ICU chargenurse or ECMO charge nurse (both bed and staffing availability),a catheterization laboratory bythe interventional cardiologist, and a cardiothoracic surgeon for initialcannulation should be made. 

   All 3 individuals must agree on the appropriatenessof the patient for ECMO. Once determination of candidate appropriateness ismade, the second-tier activation process activates the catheterizationlaboratory and anesthesia. Then the ECMO for patients start to be performed.

      流程由评估阶段进入激活阶段，心血管重症监护室护士长或者ECMO护士长以及床位与人力资源的可用性需要得到确认，导管室的可用性由心脏病介入治疗专家确认，以及负责患者初始穿刺的心胸外科医生可用性需要得到确认。以上3个人必须就患者是否适合实施ECMO达成一致。 一旦确定候选人符合要求，第二层激活程序激活导管室和麻醉室。然后对患者实施ECMO治疗。

     Once flow is adequate, vasopressors andinotropes are adjusted and the patient is transported to the catheterizationlaboratory for angiography, assessment of left ventricular function withdecompression (as needed), and establishment of distal limb perfusion.

    一旦患者血流量充足，调整血管加压剂和强心剂的使用量，并将患者转移到导管室进行血管造影，通过减压（根据需要）评估左心室功能，并建立远端肢体灌注。

     On arrival in the cardiovascular ICU,patients are managed at the bedside by an ECMO-trained charge nurse, withdirection from the ICU intensivist and cardiothoracic surgeon. We attempt towean ECMO during 3 to 7 days, or as rapidly as possible, to achieve an“ECMO-free” assessment of patients’ postarrest cardiac and neurologic function.Neurology and neurocritical care consultants provide neuroprognostication,which, for patients not waking up spontaneously.

     患者转到心血管重症监护室后，由接受培训的ECMO护士长在重症监护室特护医生和心胸外科医生指导下进行临床护理。我们尽可能快地在3至7天内停止ECMO治疗，以实现对患者心脏和神经功能的“无ECMO”评估。对于不自发醒来的患者,神经病学和神经临床护理顾问提供神经损伤的评估。

    The value of an ED ECMO program lies in theability to temporally bridge the patient with adequate organ perfusion to atherapeutic intervention, such as percutaneous coronary intervention. Without aclear therapeutic goal and interventions to achieve it, the application of EDECMO adds only cost and prolongation of the end of life. Conversely, theappropriate measured application of ED ECMO to select victims ofout-of-hospital cardiac arrest in conjunction with practiced efforts to reversethe inciting cause of arrest may offer one of greatest possible increases insurvival of any bundled medical therapy.

      ED ECMO项目的价值在于能够通过适当的器官灌注暂时性地将患者桥接到干预性治疗，如冠脉介入治疗。如果没有明确的治疗目标和干预措施，ED ECMO的应用只是增加了成本和推迟患者死亡的期限。相反，采用合适的标准选择院外心脏骤停患者进行 ED ECMO 治疗，再辅以熟练的技巧可以逆转造成心脏骤停的病因，从而有可能得到医药配合治疗下最大的生存率提高。

    Annals of EmergencyMedicine: Development and Implementation of a Comprehensive, MultidisciplinaryEmergency Department Extracorporeal Membrane  Oxygenation Program.

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