原创： Alpha Jun 阿尔法医学英语 今天
医学的进步是先辈们筚路蓝缕，一点一滴开拓出来，从青霉素到HPV疫苗，从肿瘤化疗到CART细胞治疗。而现代医学的基石是一个个里程碑式的临床试验 （landmark trial）。我们的教科书的根本也是基于这些landmark trials。
让我们来一起阅读医学史上的经典。阅读，不仅仅是学习医学英语最好的方式，也能更好地理解现代医学的精髓。
ECMO for ARDS
台北市长柯文哲从事危重症抢救工作多年，对自己的专业成绩也总是充满自豪。在他的演讲中，“叶克膜”是一个出现频率颇高的关键词。在TED演讲中，他还说到，叶克膜救活了邵晓玲，老百姓甚至把它误当做是台湾医术最高超的“叶医生”。那么，柯文哲津津乐道的叶克膜到底是何方神圣呢？
柳营奇美医院没有叶医师
Screenshot From TEDxTaipei
急性呼吸窘迫综合征（acute respiratory distress syndrome, ARDS）死亡率极高，主要治疗手段是机械通气，深度镇静、肌松及俯卧位通气。
体外膜肺氧合（extracorporeal membrane oxygenation, ECMO）以其快速、高效的体外气-血交换能力，能够部分或全部替代肺功能，虽然尚没有令人信服的证据表明其能够有效降低ARDS病死率，但并未影响其逐渐成为ARDS“终极”治疗手段，并在全球掀起一股ECMO热潮。
最近发表的NEJM这篇文章，不禁有点让人失望:
主要结论
- Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) did not show a 60-day mortality benefit compared toconventional ventilation and ECMO rescue therapy.
- There were more adverse events in the ECMO group with respect to bleeding requiring transfusion and severethrombocytopenia.
Evidence Rating Level: 1 (Excellent)
试验背景
The efficacy of venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS) remains controversial.
试验结果
In an international clinical trial, we randomly assigned patients with very severe ARDS, to receive immediate venovenous ECMO (ECMO group) or continued conventional treatment (control group).
Severe ARDS was indicated by one of three criteria
- a ratio of partial pressure of arterial oxygen (PaO2) to the fraction of inspired oxygen (FiO2) of less than 50 mm Hg for more than 3 hours
- a PaO2:FiO2 of less than 80 mm Hg for more than 6 hours
- an arterial blood pH of less than 7.25 with a partial pressure of arterial carbon dioxide of at least 60 mm Hg for more than 6 hours
Crossover to ECMO was possible for patients in the control group who hadrefractory hypoxemia. The primary end point was mortality at 60 days.
ECMO is designed as a replacement for the heart and lung.
At 60 days, 44 of 124 patients (35%) in the ECMO group and 57 of 125 (46%) in the control group had died (relative risk, 0.76; 95% confidence interval [CI], 0.55 to 1.04; P=0.09).Crossover to ECMO occurred a mean (±SD) of 6.5±9.7 days after randomization in 35 patients (28%) in the control group, with 20 of these patients (57%) dying.
The frequency of complications did not differ significantly between groups, except that there were more bleeding events leading totransfusion in the ECMO group than in the control group (in 46% vs. 28% of patients; absolute risk difference, 18 percentage points; 95% CI, 6 to 30) as well as more cases of severe thrombocytopenia (in 27% vs. 16%; absolute risk difference, 11 percentage points; 95% CI, 0 to 21) and fewer cases of ischemic stroke (in no patients vs. 5%; absolute risk difference, −5 percentage points; 95% CI, −10 to −2).
It was concluded that among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanicalventilation that included ECMO as rescue therapy.
深度解析与批评
Patients with ARDS have high mortality rates given current interventions, which includes low-volume, low-pressure ventilation strategies. Although ECMO has been used in cases of severe ARDS with encouraging results, limited conclusions could not be drawn from these experimental trials. As such, this randomized controlled trial aimed to compare the use of venovenous ECMO to conventionalmechanical ventilation (which included ECMO rescue therapy) in patients with severe ARDS. The results showed no significant mortality benefit in the ECMO group at 60 days. Additionally, the frequency of complications did not differ significantly between the two groups, though increased bleeding and severe thrombocytopenia was observed in the ECMO group.
Common venovenous ECMO configurations
In EOLIA, Femoral–jugular cannulation (figure.a) was conducted.
Figure From Simon J. Finney. European Respiratory Review 2014 23: 379-389
Strengths of this trial include it’s randomized, multi-center design evaluating patients with severe ARDS, where improved treatment would be expected to show substantial differences in outcomes.
The trial does have limitations, of which it was stopped before the maximum calculated sample size was achieved, 28% of the control group received ECMO for refractory hypoxemia which may have diluted the ECMO effect, and patients were included from both specialist and non-specialist ECMO centers which may have led to differing levels of care.
简单地肯定或否定ECMO的“拯救性”地位均不可取，更应该关注的是，在决定使用ECMO之前，我们是否已经在呼吸机参数调整以及辅助治疗措施方面尽到了全力？ECMO强大高效的气血交换能力毋庸置疑，但其巨大的医疗风险、高昂的治疗费用以及不确定的终点疗效同样不容忽视。尤其是在开展ECMO技术热情高涨的今天，是否掌握这门技术似乎已经成为能否跻身“顶级ICU俱乐部”的门槛。其实，缺乏敬畏心的ECMO滥用才是最值得担忧之处。
Key Word:
- Extracorporeal membrane oxygenation (ECMO)
- 体外膜式氧合
- extracorporeal [ˌekstrəkɔ:ˈpɔ:riəl]
- adj. extra + corpus 体外的
- conventional [kənˈvenʃənl]
- adj.传统的，习用的
- controversial [ˌkɒntrəˈvɜ:ʃl]
- adj. 有争议的；引起争议的
- thrombocytopenia
- [θrɒmbəʊsaɪtəʊ'pi:nɪə]
- n. thrombocyte + penia 血小板减少
- -penia suffix 减少
- ventilation [ˌventɪ'leɪʃn]
- n. 通气
- mechanical ventilation
- n. 机械通气
- veno-venous 静脉静脉的
- refractory hypoxemia 难治性低氧血症
- hypoxemia [ˌhaɪpɒk'si:mɪə]
- n. hypo- + oxygen + haima 低氧血症
- crossover [ˈkrɒsəʊvə(r)]
- n. 交叉；天桥
- transfusion [trænsˈfju:ʒn]
- n. trans + fundere 输血；渗透
来听听这一段ECMO的视频吧：
润耳，又能学到专业英语
https://www.youtube.com/watch?v=FiETnE4as5M
回复ECMO获得文献原文哦:D
阅读医学经典系列
慢性肝病之MELD评分
Child-Pugh Score的诞生之路
发了两次NEJM的地中海饮食研究PREDIMED
UKPDS—糖尿病治疗的基石研究
ADVANCE—糖尿病治疗的基石研究
CAST—终结心梗后抗心律失常药物的研究
AFFIRM——房颤的心率控制VS节律控制
点击“阅读原文”一览往期更多经典
AlphaMedEnglish
gif from giphy.com
edited by zyr
这里是靠谱的医学词汇平台，有趣，有料。
你得到的不仅仅是医学词汇！
欢迎投稿：alphamedenglish@126.com
