经皮心肺支持治疗猪暴发型脂肪栓塞综合征的疗效观察
摘要
目的:观察经皮心肺支持对猪暴发型脂肪栓塞综合征的抢救治疗效果,从而为临床将经皮心肺支持应用于抢救治疗暴发型脂肪栓塞综合征提供参考依据。
研究方法:将重32.85-46.35 Kg的小型猪12只,随机分配至实验组和对照组。在实施气管插管全麻后,静脉注射致死剂量的脂肪(12ml),两组都给予大剂量激素、扩容、抗凝及升压等常规对症支持治疗。实验组除给予上述治疗外,还给予经皮穿刺股动静脉置管的心肺支持疗法。记录和测定两组在注射脂肪前、注射脂肪后即刻、1小时、2小时、3小时、4小时、5小时、6小时、7小时、8小时、9小时、10小时的平均动脉压(MAP)、中心静脉压(CVP)、呼气末二氧化碳分压(PETCO2)、氧饱和度(SpO2)、血管活性药物的用量、动脉血二氧化碳分压(PaCO2)、血中乳酸浓度、血中游离脂肪酸水平、两组实验动物的生存时间和不同时点的死亡率。
研究结果:实验组注射脂肪液后5小时和10小时的死亡率显著低于对照组(0 Vs 83.3%, P<0.01;0 Vs 100%, P<0.01);对照组的小型猪平均在静脉注射脂肪后184.17±54.81分钟时死亡,各观察指标均恶化。而实验组的小型猪静脉注射致死剂量的脂肪之后,通过经皮心肺支持治疗,可以存活至体外循环10小时之后,并且各项观察指标在恶化后逐渐恢复至正常或接近正常水平。
结论:经皮心肺支持可以使暴发型脂肪栓塞综合征的猪度过最初的极度右心、全心衰竭和酸中毒,可以有效地为全身脏器提供所需的氧耗,为抢救暴发型脂肪栓塞综合征,及进一步呼吸支持治疗创造条件,从而降低死亡率。
Objective: To evaluate the effectiveness of percutaneous cardiopulmonary treatment for massive fat embolism and to explore the feasibility of the technology for clinical pulmonary fat embolism。
Methods: Randomly assigned 12 piglets (weight between 32.85-46.35kg) into 2 groups: control group (II) and test group (I). After tracheal intubation under general anesthesia, the piglets were injected fetal dose of fat (12ml) intravenously. Both groups received supportive treatment such as large dose of steroids, fluids, anticoagulants and positive inotropic agents. But for the test group, percutaneous cardiopulmonary bypass was set up through the femoral vein. MAP ,CVP ,PETCO2 , SpO2 , PaCO2 ,lactic acid (LAC) and free fatty acid were monitored continuously and recorded in before and right after fat injection and then every hour for 10 hours. The total dosage of positive inotropic agents , the survival time and mortality rate were compared between the two groups.
Results: The mortality of 5th hour,10th hour in the test group were much lower than in t -he control group. The average survival time after fetal dose of fat injection in the control g -roup was 184.17±54.807 min with all the monitored vital signs deteriorated dram -atically. While in the test group, the piglets survived more than 10 hours after the fetal fat injection. Moreover, the vital signs and the monitored data returned to or close to the base - line unde -r the percutaneous cardiopulmonary support.
Conclusion: Percutaneous cardiopulmonary support can effectively provide oxygen supply sufficiently for the primary damaged right heart failure and severe acidosis caused by massive pulmonary fat embolism and then it can facilitate the further advanced life support and eventually reduce the mortality and morbidity.
研究方法:将重32.85-46.35 Kg的小型猪12只,随机分配至实验组和对照组。在实施气管插管全麻后,静脉注射致死剂量的脂肪(12ml),两组都给予大剂量激素、扩容、抗凝及升压等常规对症支持治疗。实验组除给予上述治疗外,还给予经皮穿刺股动静脉置管的心肺支持疗法。记录和测定两组在注射脂肪前、注射脂肪后即刻、1小时、2小时、3小时、4小时、5小时、6小时、7小时、8小时、9小时、10小时的平均动脉压(MAP)、中心静脉压(CVP)、呼气末二氧化碳分压(PETCO2)、氧饱和度(SpO2)、血管活性药物的用量、动脉血二氧化碳分压(PaCO2)、血中乳酸浓度、血中游离脂肪酸水平、两组实验动物的生存时间和不同时点的死亡率。
研究结果:实验组注射脂肪液后5小时和10小时的死亡率显著低于对照组(0 Vs 83.3%, P<0.01;0 Vs 100%, P<0.01);对照组的小型猪平均在静脉注射脂肪后184.17±54.81分钟时死亡,各观察指标均恶化。而实验组的小型猪静脉注射致死剂量的脂肪之后,通过经皮心肺支持治疗,可以存活至体外循环10小时之后,并且各项观察指标在恶化后逐渐恢复至正常或接近正常水平。
结论:经皮心肺支持可以使暴发型脂肪栓塞综合征的猪度过最初的极度右心、全心衰竭和酸中毒,可以有效地为全身脏器提供所需的氧耗,为抢救暴发型脂肪栓塞综合征,及进一步呼吸支持治疗创造条件,从而降低死亡率。
Objective: To evaluate the effectiveness of percutaneous cardiopulmonary treatment for massive fat embolism and to explore the feasibility of the technology for clinical pulmonary fat embolism。
Methods: Randomly assigned 12 piglets (weight between 32.85-46.35kg) into 2 groups: control group (II) and test group (I). After tracheal intubation under general anesthesia, the piglets were injected fetal dose of fat (12ml) intravenously. Both groups received supportive treatment such as large dose of steroids, fluids, anticoagulants and positive inotropic agents. But for the test group, percutaneous cardiopulmonary bypass was set up through the femoral vein. MAP ,CVP ,PETCO2 , SpO2 , PaCO2 ,lactic acid (LAC) and free fatty acid were monitored continuously and recorded in before and right after fat injection and then every hour for 10 hours. The total dosage of positive inotropic agents , the survival time and mortality rate were compared between the two groups.
Results: The mortality of 5th hour,10th hour in the test group were much lower than in t -he control group. The average survival time after fetal dose of fat injection in the control g -roup was 184.17±54.807 min with all the monitored vital signs deteriorated dram -atically. While in the test group, the piglets survived more than 10 hours after the fetal fat injection. Moreover, the vital signs and the monitored data returned to or close to the base - line unde -r the percutaneous cardiopulmonary support.
Conclusion: Percutaneous cardiopulmonary support can effectively provide oxygen supply sufficiently for the primary damaged right heart failure and severe acidosis caused by massive pulmonary fat embolism and then it can facilitate the further advanced life support and eventually reduce the mortality and morbidity.
引文
[1] Capan LM, Miller SM, Patel KP. Fat embolism. Anesthesiol Clin North A -merica1993;11(1):25–54.
[2] Taviloglu K, Yanar H. Fat embolism syndrome. Surg Today 2007;37(1):5–8.
[3] Warthin AS. Traumatic lipemia and fatty embolism. Int Clin 1913;4:171– 227.
[4] Gauss H (1924) The pathology of fat embolism. Arch Surg;9:592 605.
[5] Lehman EP, Moore RM (1927) Fat embolism, including experimental production without trauma. Arch Surg; 14(3):621 662.
[6] Akhtar, S., Fat embolism. Anesthesiol Clin, 2009. 27(3): p. 533-50, table of contents.
[7] Levy D. The fat embolism syndrome. A review. Clin Orthop Relat Res 19 90;(261):281–6.
[8] Al-Khuwaitir TS, Al-Moghairi AM, Sherbeeni SM, et al. Traumatic fat e -mbolism syndrome. Saudi Med J 2002;23(12):1532–6.
[9] Nijsten MW, Hamer JP, ten Duis HJ, et al. Fat embolism and patent foram -en ovale [letter]. Lancet 1989;1 (8649):1271.
[10] Byrick RJ, Kay JC, Mazer CD, et al. Dynamic characteristics of cerebral lipid microemboli: ideomicroscopy studies in rats. Anesth Analg 2003;9 7(6):1789–94.
[11] Meyer N, Pennington WT, Dewitt D, et al. Isolated cerebral fat emboli syndrome in multiply injured patients: a review of three cases and the li -terature. J Trauma2007;63(6):1395–402.
[12] Igarashi M., Kita A., Nishikawa K., et al., Use of percutaneous cardiopulmonary support in catastrophic massive pulmonary fatembolism. Br J Anaesth, 2006. 96(2): p. 213-5.
[13]张卫兴,胡兵,王爱忠等,猪脂肪栓塞模型的经食管超声心动图实验研究[J].中国超声医学杂志.2007.23(1):p.9-11.
[14] Fabian TC , Hoots AV, Stanford DS,et al., Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med, 1990. 18(1): p. 42-6.
[15] Pell, A.C., et al., The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br, 1993. 75(6): p. 921-5.
[16] Hofmann S, Hopf R, Mayr G,et al., In vivo femoral intramedullary pressure during uncemented hip arthroplasty. Clin Orthop Relat Res, 1999(360): p. 136-46.
[17] Lane GJ,Hozack WJ,Shah S,et al., Simultaneous bilateral versus unilateral total knee arthroplasty. Outcomes analogy.Clin Orthop 1997,345:106-112.
[18] Batra P. The fat embolism syndrome. J Thorac Imaging 1987;2(3):12–7.
[19] Peltier LF. Fat embolism. III. The toxic properties of neutral fat and free fatty acids. Surgery, 1956. 40(4): p. 665-70.
[20] Peltier LF. Fat embolism. A perspective. Clin Orthop Relat Res 1988;(2 32):263–70.
1.White, T., B.A. Petrisor, and M. Bhandari, Prevention of fat embolism syndrome. Injury, 2006.374: S59-67.
2.Pell, A.C., Christie, J. Keating, J. F. et al., The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br, 1993. 75(6): p. 921-5.
3.Charles, M., Barr, T. Clokie, C. M. et al., Fat embolism following posterior iliac graft harvest for jaw reconstruction: managing the complications of major surgery. J Can Dent Assoc, 2007. 73(1): 67-70.
4.Watanabe, S., Terazawa, K. Matoba, K. et al., An autopsy case of intraoperative death due to pulmonary fat embolism--possibly caused by release of tourniquet after multiple muscle-release and tenotomy of the bilateral lower limbs. Forensic Sci Int, 2007. 171(1): 73-7.
5.Choi, J.A., Oh, Y. W. Kim, H. K.et al., Nontraumatic pulmonary fat embolism syndrome: radiologic and pathologic correlations. J Thorac Imaging, 2002. 17(2): 167-9.
6.Fabian, T.C., Hoots, A. V. Stanford, D. S. et al., Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med, 1990. 18(1): 42-6.
7.Akhtar, S., Fat embolism. Anesthesiol Clin, 2009. 27(3): 533-50, table of contents.
8.Robinson, C.M., Current concepts of respiratory insufficiency syndromes after fracture. J Bone Joint Surg Br, 2001. 83(6): 781-91.
9.Pape, H.C., Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res, 2008. 26(11): 1478-84.
10.Pape, H.C. and P. Giannoudis, The biological and physiological effects of intramedullary reaming. J Bone Joint Surg Br, 2007. 89(11): 1421-6.
11.Babalis, G.A., Yiannakopoulos, C. K. Karliaftis, K. et al., Prevention of posttraumatic hypoxaemia in isolated lower limb long bone fractures with a minimal prophylactic dose of corticosteroids. Injury, 2004. 35(3): 309-17.
12.S. Samuel Bederman, Mohit Bhandari,Michael D. McKee, et al. Do corticosteroids reduce the risk of fat embolism syndrome in patients with long-bone fractures?A meta-analysis. Can J Surg, 2009.52(5):386-393.
13.Kaza, A.K., Cope, J. T. Fiser, S. M.et al., Elimination of fat microemboli during cardio -pulmonary bypass. Ann Thorac Surg, 2003. 75(2): 555-9; discussion 559.
14.Habashi, N.M., P.L. Andrews, and T.M. Scalea, Therapeutic aspects of fat embolism syndrome. Injury, 2006. 37 Suppl 4: S68-73.
15.刘安庆等,脂肪栓塞综合征的预防与诊治.中华创伤杂志, 2007. 23(7): 527-530.
16.王基等,纠正凝血-纤溶功能的紊乱治疗脂肪栓塞综合征.创伤外科杂志, 2002. 4(6): 369.
17.李青等,连续性静-静脉血液滤过在脂肪栓塞综合征治疗中的应用.中华创伤杂志, 2006. 22(9): 716-717.
18.Igarashi, M., Kita, A. Nishikawa, K. et al., Use of percutaneous cardiopulmonary suppo -rt in catastrophic massive pulmonary fat embolism. Br J Anaesth, 2006. 96(2): 213-5.
1.孟庆云,柳顺锁,刘志双,等.神经阻滞学.人民卫生出版社, ISBN 7-117-05728-9/ R·5729,2003: 356,.
2.Greher M, Kapral S. Is regional anesthesia simply an exercise in applied sonoanat-omy: aiming at higher frequ -encies of ultrsonographic imaging? [J]. nesthesiol-ogy, 2003,99(2): 1-2.
3.Chan VW. Applying Ultrasound imaging to interscalene brachial plexus block[J]. Reg Anesth pain Med, 2003, 28(4): 340-343.
4.Marhofer P, Schrogendorfer K, Wallner Y, et al. Ultrasonographic guidance reduces the amount of local an -esthetic for 3-in-1 blocks[J]. Reg Anesth pain Med,1998, 23(6): 584-588.
5.Hara K, Sakura S, Nomura T, et al. Ultrasound guided thoracic paravertebral block in breast surgery. Anaes -thesia. 2009 Feb;64(2):223-5.
6.Davies RG, Myles PS, Graham JM. A comparison of theanalgesic efficacy and side-e -ffects of paravertebral vs epiduralblockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth 200 6;96:418–26.
7.Joshi GP, Bonnet F, Shah R, et al.A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107:1026–40.
8.Ong CK, Lirk P, Seymour RA, et al. The efficacy of preemptive analgesia for acute postoperative pain manage -ment: a meta-analysis. Anesth Analg,2005,100(3): 757-773.
9.Viscusi ER. Patient-controlled drug delivery for acute postoperative pain management: a review of current and emerging technologies. Reg Anesth Pain Med, 2008, 33(2):146-58.
10.Exadaktylos AK, Buggy DJ, Moriarty DC, et al. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006 Oct;105(4):66 0-4.
11.Hohlrieder M,Brimacombe J,Eseheazhuber S,et a1.A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postope -rative analgesia requirements following gynaec -ologieal laparoseopie surgery.Anaestha -sia, 2007, 62(9): 913-918.
[2] Taviloglu K, Yanar H. Fat embolism syndrome. Surg Today 2007;37(1):5–8.
[3] Warthin AS. Traumatic lipemia and fatty embolism. Int Clin 1913;4:171– 227.
[4] Gauss H (1924) The pathology of fat embolism. Arch Surg;9:592 605.
[5] Lehman EP, Moore RM (1927) Fat embolism, including experimental production without trauma. Arch Surg; 14(3):621 662.
[6] Akhtar, S., Fat embolism. Anesthesiol Clin, 2009. 27(3): p. 533-50, table of contents.
[7] Levy D. The fat embolism syndrome. A review. Clin Orthop Relat Res 19 90;(261):281–6.
[8] Al-Khuwaitir TS, Al-Moghairi AM, Sherbeeni SM, et al. Traumatic fat e -mbolism syndrome. Saudi Med J 2002;23(12):1532–6.
[9] Nijsten MW, Hamer JP, ten Duis HJ, et al. Fat embolism and patent foram -en ovale [letter]. Lancet 1989;1 (8649):1271.
[10] Byrick RJ, Kay JC, Mazer CD, et al. Dynamic characteristics of cerebral lipid microemboli: ideomicroscopy studies in rats. Anesth Analg 2003;9 7(6):1789–94.
[11] Meyer N, Pennington WT, Dewitt D, et al. Isolated cerebral fat emboli syndrome in multiply injured patients: a review of three cases and the li -terature. J Trauma2007;63(6):1395–402.
[12] Igarashi M., Kita A., Nishikawa K., et al., Use of percutaneous cardiopulmonary support in catastrophic massive pulmonary fatembolism. Br J Anaesth, 2006. 96(2): p. 213-5.
[13]张卫兴,胡兵,王爱忠等,猪脂肪栓塞模型的经食管超声心动图实验研究[J].中国超声医学杂志.2007.23(1):p.9-11.
[14] Fabian TC , Hoots AV, Stanford DS,et al., Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med, 1990. 18(1): p. 42-6.
[15] Pell, A.C., et al., The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br, 1993. 75(6): p. 921-5.
[16] Hofmann S, Hopf R, Mayr G,et al., In vivo femoral intramedullary pressure during uncemented hip arthroplasty. Clin Orthop Relat Res, 1999(360): p. 136-46.
[17] Lane GJ,Hozack WJ,Shah S,et al., Simultaneous bilateral versus unilateral total knee arthroplasty. Outcomes analogy.Clin Orthop 1997,345:106-112.
[18] Batra P. The fat embolism syndrome. J Thorac Imaging 1987;2(3):12–7.
[19] Peltier LF. Fat embolism. III. The toxic properties of neutral fat and free fatty acids. Surgery, 1956. 40(4): p. 665-70.
[20] Peltier LF. Fat embolism. A perspective. Clin Orthop Relat Res 1988;(2 32):263–70.
1.White, T., B.A. Petrisor, and M. Bhandari, Prevention of fat embolism syndrome. Injury, 2006.374: S59-67.
2.Pell, A.C., Christie, J. Keating, J. F. et al., The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing. A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br, 1993. 75(6): p. 921-5.
3.Charles, M., Barr, T. Clokie, C. M. et al., Fat embolism following posterior iliac graft harvest for jaw reconstruction: managing the complications of major surgery. J Can Dent Assoc, 2007. 73(1): 67-70.
4.Watanabe, S., Terazawa, K. Matoba, K. et al., An autopsy case of intraoperative death due to pulmonary fat embolism--possibly caused by release of tourniquet after multiple muscle-release and tenotomy of the bilateral lower limbs. Forensic Sci Int, 2007. 171(1): 73-7.
5.Choi, J.A., Oh, Y. W. Kim, H. K.et al., Nontraumatic pulmonary fat embolism syndrome: radiologic and pathologic correlations. J Thorac Imaging, 2002. 17(2): 167-9.
6.Fabian, T.C., Hoots, A. V. Stanford, D. S. et al., Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med, 1990. 18(1): 42-6.
7.Akhtar, S., Fat embolism. Anesthesiol Clin, 2009. 27(3): 533-50, table of contents.
8.Robinson, C.M., Current concepts of respiratory insufficiency syndromes after fracture. J Bone Joint Surg Br, 2001. 83(6): 781-91.
9.Pape, H.C., Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res, 2008. 26(11): 1478-84.
10.Pape, H.C. and P. Giannoudis, The biological and physiological effects of intramedullary reaming. J Bone Joint Surg Br, 2007. 89(11): 1421-6.
11.Babalis, G.A., Yiannakopoulos, C. K. Karliaftis, K. et al., Prevention of posttraumatic hypoxaemia in isolated lower limb long bone fractures with a minimal prophylactic dose of corticosteroids. Injury, 2004. 35(3): 309-17.
12.S. Samuel Bederman, Mohit Bhandari,Michael D. McKee, et al. Do corticosteroids reduce the risk of fat embolism syndrome in patients with long-bone fractures?A meta-analysis. Can J Surg, 2009.52(5):386-393.
13.Kaza, A.K., Cope, J. T. Fiser, S. M.et al., Elimination of fat microemboli during cardio -pulmonary bypass. Ann Thorac Surg, 2003. 75(2): 555-9; discussion 559.
14.Habashi, N.M., P.L. Andrews, and T.M. Scalea, Therapeutic aspects of fat embolism syndrome. Injury, 2006. 37 Suppl 4: S68-73.
15.刘安庆等,脂肪栓塞综合征的预防与诊治.中华创伤杂志, 2007. 23(7): 527-530.
16.王基等,纠正凝血-纤溶功能的紊乱治疗脂肪栓塞综合征.创伤外科杂志, 2002. 4(6): 369.
17.李青等,连续性静-静脉血液滤过在脂肪栓塞综合征治疗中的应用.中华创伤杂志, 2006. 22(9): 716-717.
18.Igarashi, M., Kita, A. Nishikawa, K. et al., Use of percutaneous cardiopulmonary suppo -rt in catastrophic massive pulmonary fat embolism. Br J Anaesth, 2006. 96(2): 213-5.
1.孟庆云,柳顺锁,刘志双,等.神经阻滞学.人民卫生出版社, ISBN 7-117-05728-9/ R·5729,2003: 356,.
2.Greher M, Kapral S. Is regional anesthesia simply an exercise in applied sonoanat-omy: aiming at higher frequ -encies of ultrsonographic imaging? [J]. nesthesiol-ogy, 2003,99(2): 1-2.
3.Chan VW. Applying Ultrasound imaging to interscalene brachial plexus block[J]. Reg Anesth pain Med, 2003, 28(4): 340-343.
4.Marhofer P, Schrogendorfer K, Wallner Y, et al. Ultrasonographic guidance reduces the amount of local an -esthetic for 3-in-1 blocks[J]. Reg Anesth pain Med,1998, 23(6): 584-588.
5.Hara K, Sakura S, Nomura T, et al. Ultrasound guided thoracic paravertebral block in breast surgery. Anaes -thesia. 2009 Feb;64(2):223-5.
6.Davies RG, Myles PS, Graham JM. A comparison of theanalgesic efficacy and side-e -ffects of paravertebral vs epiduralblockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth 200 6;96:418–26.
7.Joshi GP, Bonnet F, Shah R, et al.A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107:1026–40.
8.Ong CK, Lirk P, Seymour RA, et al. The efficacy of preemptive analgesia for acute postoperative pain manage -ment: a meta-analysis. Anesth Analg,2005,100(3): 757-773.
9.Viscusi ER. Patient-controlled drug delivery for acute postoperative pain management: a review of current and emerging technologies. Reg Anesth Pain Med, 2008, 33(2):146-58.
10.Exadaktylos AK, Buggy DJ, Moriarty DC, et al. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006 Oct;105(4):66 0-4.
11.Hohlrieder M,Brimacombe J,Eseheazhuber S,et a1.A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postope -rative analgesia requirements following gynaec -ologieal laparoseopie surgery.Anaestha -sia, 2007, 62(9): 913-918.