葉克膜用於心臟手術後併發末期心衰竭病人的緩和醫療價值 : 個案系列報告

Value of ECMO Support in Palliative Care for Patients with Postcardiotomy End-stage Heart Failure : A Case Series

曾守黑(Shou-Ho Tseng)

指導教授 ： 蔡宗博 ； 周明智

中山醫學大學/醫學院/醫學研究所/碩士(2019年)

https://doi.org/10.6834/CSMU201900153

摘要

研究目的：
儘管手術技巧、體外循環技術和心肌保護措施的進步，心臟手術後併發心因性休克（PCCS）仍然是一個潛在的併發症。其發生率根據過去文獻報告大概有0.5~6%。而葉克膜(ECMO)在這類的病人是一個相對容易取得，並且普遍被接受的方法。讓心臟和肺臟有恢復的時間，或者能支撐到銜接更進一步的評估與治療決策，如心臟移植。然而，在過去數十年，ECMO對這類患者的治療結果並不理想。有文獻報告指出住院死亡率高達59~84％。ECMO讓這些PCCS的病人的心肺功能有恢復的機會，但是當臨床上沒有顯著的改善而病人又無法接受更進一步的治療選擇時，終止ECMO是合理的。但這也將面臨到移除葉克膜後可預期病人死亡的困境。因此緩和醫療在這類的病人是勢必要面對的課題。因此，我們這篇研究的目的是希望能夠探討心臟手術後心因性休克的病人使用機械式循環輔助在緩和醫療上的價值。

研究方法及資料：
這是一項回顧型觀察個案系列研究。根據中山醫學大學附設醫院病歷與葉克膜記錄單，我們收集了2003年1月至2018年12月間接受心臟手術後發生心因性休克需要機械式循環輔助的病人資料。我們的納入標準有下面三點，第一，該病人是心臟手術後產生心因性休克，需使用葉克膜支持，並且超過5天仍無法移除者、第二，我們的專業緩和醫療團隊曾經介入提供諮詢或支持的病人和家屬、第三，該病人在術後的昏迷指數(Glascow coma scale)的評分中，運動反應(motor response)需大於3分。我們記錄病人的基本資料，例如年齡、性別、術前術後GCS評分、手術方法以及葉克膜使用天數，並分析成功脫離葉克膜的比例、成功存活到出院的比例以及意識恢復到能夠溝通的比例。

研究結果：
由2003年1月到2018年12月之間在我們醫院接受開心手術的病人加起來共有1445位，其中在心臟手術後需要ECMO支持的有59位病人。而在這59個病人中，有26個意識恢復到motor response大於3分，比例是44%。而超過5天仍然無法移除ECMO的病人有5位，且有緩和團隊的介入，符合我們的收案標準。這5個病人ECMO使用時間從8天到50天不等，平均天數19天。他們術前的GCS評分都是滿分15分(E4M6V5)，而術後的GCS評分分別為E3M5Vt、E2M4Vt、E2M4Vt、E4M6V5和E4M6Vt。這5個病人都無法移除機械式循環輔助，並且在血行動力學變得不穩之後再次失去意識。其中一位病人在術後恢復意識期間，曾經在病情告知後處理了遺產分配後才離世。根據現有的護理記錄、病程記錄，家屬對於葉克膜支持與最終結果，多能理解並接受。

結論：
心臟手術後心因性休克的病人，ECMO是一項普遍被接受的方法提供暫時性地循環支持。葉克膜支持的本意是希望病人借由短暫的體外循環輔助，讓心肺功能度過急性期得以恢復或者能銜接到更進一步的評估與治療。但是當我們預期病人無法成功脫離葉克膜或銜接到更進一步的治療時，葉克膜在這類的病人同時也是個有價值的緩和療法替代方案，它提供了病人和家屬有更多時間與道別機會，並支持病人與家屬面對即將到來的死亡與喪親之痛。

關鍵字

機械式循環輔助 ； 葉克膜 ； 心室輔助器 ； 心臟手術 ； 心臟衰竭 ； 心因性休克 ； 安寧照護

並列摘要

Objective：
Despite improvements of cardiac surgery in the areas of surgical technique, cardiopulmonary bypass, and myocardial protection, postcardiotomy cardiogenic shock (PCCS) remains a potential complication, about 0.5–6% of incidence according to previous reports. Extracorporeal membrane oxygenation (ECMO) is an easily applicable and widely accepted option, allowing cardiac and pulmonary recovery or bridging for further evaluation and decision making. However, in past decades, the results of ECMO support in these patients have not been satisfactory. The in-hospital mortality rate was hight to 59% to 84%. ECMO gives those PCCS patients at least the chance for cardiac or respiratory recovery. But, if there is no rapid clinical improvement and further therapeutic alternatives are not suitable for the patients, termination of ECMO is warranted. But we will face the dilemma of death of those patients as expected after weaning off the ECMO. Therefore, palliative care in such patients is an important issue. The purpose of our study is to investigate the value of palliative care of mechanical circulation assistance support in patients with PCCS.

Methods and Materials：
This is a retrospective observational case series study. We collected the datas of patients received cardiac surgery and developed postcardiotomy cardiogenic shock need mechenical circulatory support in Chung Shan Medical University Hospital (CSMUH), during Jan. 2003-Dec. 2018, according to the medical records and ECMO records. The inclusion criterias are 1.The patients had postcardiotomy cardiogenic shock s/p ECMO support over 5 days, 2.Our expert palliative team had provided spiritual support to the patients and families, 3.The patient had more than 3 points of motor response of Glasgow Coma Scale (GCS). We will record the patients’ basic datas, such as age, sex, GCS, operative method and postoperative ECMO duration and analyze the ratio of successful to remove ECMO, survival to hospital discharge and recovery conscious to be able to communicate.

Results：
There were 59 out of 1,445 cardiac surgical patients developed postcardiotomy cardiogenic shock, requiring mechanical circulatory support during Jan. 2003-Dec. 2018 in our hospital. Among them, 26 patients (26/59, 44%) had more than 3 points of motor response of GCS after surgery and 5 patients could not wean off ECMO in 5 days and had received palliative intervention by our expert palliative team, meeting our inclusion criterias. The mean ECMO duration was 19 days (8-50 days). Their preoperative GCS scores were all 15 (E4M6V5) and the postoperative GCS scores were E3M5Vt, E2M4Vt, E4M6V5 and E4M6Vt, respectively. All 5 patients were not weaned off from ECMO, until they fell unconscious again and became hemodynamically unstable. One patient who gained consciousness but failed to wean off ECMO decided the inheritance and then loss consciousness later. According to the medical records, their families all could understand and accept the result after intervention of ECMO support.

Conclusion：
For patients with PCCS, ECMO support is an widely accepted option for temporary mechanical circulatory support. The initial intention of using ECMO support is to get more time to restore the cardiac or pulmonary function through this acute phase or bridging to further therapeutic alternatives. But, when we predicted ECMO couldn’t be weaned off and the patients can’t receive further therapeutic options, ECMO is also a spiritually valuable alternative of palliative intervention to provide patients and their families more time to say goodbye and face the dying and the bereavement period.

並列關鍵字

Mechanical Circulatory Support ； MCS ； Extracorporeal Membrane Oxygenation ； ECMO ； Ventricular Assist Device ； VAD ； Heart surgery ； End-Stage Heart Failure ； Cardiogenic shock ； Palliative Care

參考文獻

參考文獻

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2.Doll N, Kiaii B, Borger M, et al. Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock. The Annals of thoracic surgery. 2004;77:151-157; discussion 157.

3.Rastan AJ, Dege A, Mohr M, et al. Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. The Journal of thoracic and cardiovascular surgery. 2010;139:302-311, 311 e301.

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