ECMO Sırasında Mekanik Ventilasyon Yönetimi
Özet
28 yaşında erkek hasta göğüs ağrısı şikayeti ile acil servise başvurdu. Yapılan tetkiklerinde miyokardit ön planda düşünülen hastaya tanısal amaçlı koroner anjiografi yapıldı. İşlem sırasında komplikasyon gelişen hasta orotrakeal entübe halde koroner yoğun bakım ünitesine alındı. Yatışının 3. gününde mekanik ventilasyon %100 O2 desteğine rağmen spo2: %85. Çekilen akciğer grafisinde yaygın bilateral pulmoner infiltrasyonlar görüldü. Yatışının 5. gününde kan gazı değerleri PaO2: 70 mm Hg, PaCO2:45 mm Hg; ve laktat 4 mmol/L. Mekanik ventilasyon destekleri arttırıldı. Peep titrasyonu yapıldı. Yeterli oksijenizasyon sağlanamadığı için prone pozisyon uygulandı. Yatışının 9. gününde mekanik ventilasyon ve prone pozisyona rağmen hipoksik seyreden hasta venovenöz ekstrakorporeal membran oksijenasyonuna (VV-ECMO) bağlandı. 14 günlük ECMO desteği boyunca, ECMO kan akımı 3,5 ile 5 L/dk ve süpürme gazı akımı 2 ile 6 L/dk arasında değişti, membran O2 fraksiyonu %100 olarak ayarlandı. ECMO’da akciğer koruyucu ventilasyon stratejisi ile akciğerin dinlendirilmesi hedeflendi. Hastaya tidal volüm (TV) ideal kilonun kilogramı başına <4 ml, plato basıncı <25 cmH2O, PEEP'i 5-15 cmH2O aralığında olacak şekilde ve düşük solunum sayısı ayarlandı. VV-ECMO sırasında hastanın mekanik ventilasyon ihtiyacı giderek azaldı. Hasta uyanık bir şekilde ECMO’nun 4.gününde başarılı bir şekilde ekstübe edildi. Fizyoterapist eşliğinde yatakta günlük aktif fiziksel ve solunum egzersizleri yaptırıldı. VV-ECMO’dan ise 14. gün ayırıldı. 18.gününde yoğun bakımdan kardiyoloji servisine devredildi. Kardiyoloji servisinde nazal o2 desteği ile 5 gün takip edildi ve sonrasında hastaneden şifa ile taburcu edildi.
A 28-year-old male patient presented to the emergency department with complaints of chest pain. Myocarditis was suspected, and he underwent diagnostic coronary angiography. The patient, who developed complications during the procedure, was taken to the coronary intensive care unit with orotracheal intubation. On the 3rd day of hospitalization, despite mechanical ventilation and 100% O2 support, spo2: 85%. Diffuse bilateral pulmonary infiltrates were seen on the chest X-ray. Blood gas values on the fifth day of admission were PaO2: 70 mm Hg, PaCO2: 45 mm Hg, and lactate: 4 mmol/L. Mechanical ventilation support was increased. PEEP titration was performed. Prone positioning was applied because adequate oxygenation was not achieved. On the 9th day of admission, the patient, who remained hypoxic despite mechanical ventilation and prone positioning, was connected to VV-ECMO. During 14 days of ECMO support, ECMO blood flow varied between 3.5 and 5 L/min, sweep gas flow between 2 and 6 L/min, and membrane O2 fraction was set at 100%. A lung-protective ventilation strategy was used to restore lung rest during ECMO. Tidal volume (TV) was <4 ml per kilogram of ideal weight, plateau pressure <25 cmH2O, PEEP between 5 and 15 cmH2O, and a low respiratory rate were adjusted. During VV-ECMO, the patient's need for mechanical ventilation gradually decreased. The patient was successfully extubated on the 4th day of ECMO, while awake. Daily active physical and respiratory exercises were performed in bed with the supervision of a physiotherapist. He was weaned from VV-ECMO on the 14th day. He was transferred from the intensive care unit to the cardiology ward on the 18th day. He was followed up in the cardiology department with nasal oxygen support for 5 days, and was subsequently discharged from the hospital in good health.
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