体外膜肺氧合在小儿心脏术后急性心肺功能衰竭中的应用

Application of ECMO to pediatric cardiac surgical patients with acute cardiopulmonary failure

目的 回顾性总结分析阜外医院45例小儿体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）支持治疗心脏术后急性心肺功能衰竭的临床结果和经验.方法 2004-12～2009-12对45例小儿先天性心脏病术后急性心肺功能衰竭实施ECMO,所有患儿均行静脉-动脉ECMO（V-A ECMO）辅助方式,激活凝血时间（ACT）维持140～200 s,肝素用量4～20 U/（kg＊h）.辅助期间流量40～150 mL/（kg＊min）.结果 22例患儿成功撤离ECMO,撤机率48.9%;20例患者出院,出院率44.4%.2例成功撤离ECMO后死亡,23例不能撤离ECMO,终止治疗,院内死亡.出院患儿ECMO支持时间（64.21±14.36）h（16～268 h）,死亡患儿ECMO支持时间（109.88±21.98）h（25～308 h）,差异有统计学意义（P=0.05）;出院组年龄、体质量与死亡组比较差异有统计学意义（P=0.000）;肾功能不全、感染及氧合器渗漏的患儿死亡率显著上升.至2010-03-31出院患儿通过电话随访到18例,随访率90.0%;1例出院后1 d死亡,1例出院后57 d死亡;余16例患儿存活,生长发育正常,学龄儿童与同龄正常儿童学习成绩比较差异无统计学意义.结论 ECMO支持治疗在小儿先天性心脏病术后急性心肺功能衰竭的治疗中是一种有效的机械辅助方法,手术畸形矫正满意.尽早对心肺衰竭患儿采用ECMO支持治疗,避免重要脏器的不可逆损伤是ECMO成功的关键.低龄、低体重、长时间ECMO支持是死亡的危险因素.

Objective To retrospectively summarize and analyze the files of consecutive 45 pediatric extracorporeal membrane oxygenation （ECMO） performed in Fuwai Hospital. Methods We reviewed the clinical protocols of 45 pediatric ECMO after cardiac surgery from Dec. 2004 to Dec. 2009 in our hospital. All patients accepted veno - artery ECMO and activated clotting time （ACT） was maintained between 140 -200 sec and heparin dose was 4 -20 U/（ kg ·h）. Mean blood flow was 40±150 mL/（ kg·min）during ECMO assistant period. Results The ECMO time of the survivals was （64.21±14.36）h（16 -268 h）,and the ECMO time of the dead was （109.88±21.98）h（25 - 308 h）. ECbIO were weaned off successfully in 22 patients and 20 of them survived and discharged from hospital and 2 of them died of persistent cardiopulmonary failure or post - operation complications. 23 patients did not wean off ECMO. Total survival rate was 44.4% （ 20/45 ） in this cohort study. Mean age and weight in survived patients was significantly higher than that of dead patients. ECMO duration and complications（renal failure, infection, oxygenator plasma leakage） between the survivors and the dead also had significant difference. 18 cases accepted follow up by telephone interview. 2 patients died while other 16 patients survived after the discharge. Conclusion ECMO is an effective mechanical assistant therapy for cardiac and pulmonary failure patients after open heart surgeries with pediatric congenital heart disease. Perfect correction of abnormality, earlier usage of ECMO for these patients and avoiding the vital organs from irreversible injury are still the key of successful ECMO. Younger, low weight and long ECMO duration were the risk factor for the mortality.