体外膜肺氧合在儿科危重病急救中的应用

Emergency use of extracorporeal membrane oxygenation in pediatric critically ill patients

目的总结体外膜肺氧合（extracorporealmembraneoxygenation，ECMO）在儿科危重病急救中应用的管理经验。方法回顾性分析2007年7月至2011年5月，浙江大学医学院附属儿童医院应用ECMO抢救12例多种原因所致严重心肺功能衰竭患儿的临床情况。结果12例，男7例，女5例；年龄6d-11岁；体重2．8-35（17．21±11．64）k，其中4例小于60d。肺部感染并发急性呼吸窘迫（AcuteRespiratoryDistressSyndrome，ARDS）致呼吸衰竭2例，心脏术后低心排不能脱离体外循环直接转ECMO4例，暴发性心肌炎3例，右心室心肌病反复心跳骤停4次l例，完全性大动脉转位术前严重低氧血症1例，过敏性休克并发大量肺出血，严重低氧血症1例。12例中有3例为心肺复苏胸外按压（cardiopulmonaryresuscitation，CPR）同时建立ECMO（E-CPR）。平均ECMO支持时间为151．75（15-572）h，12例中7例脱离ECMO，脱机率58．33％，存活出院6例，存活率50．00％，死亡6例。机械并发症：膜肺渗漏更换有2例，溶血更换系统3例，膜肺氧合不佳更换2例，膜肺血栓形成1例；机体并发症：伤口出血6例、二次开胸止血2例、急性肾衰2例、感染3例，高胆红素血症2例、下肢缺血1例、高血糖3例、弥漫性血管内凝血1例。随访半年至4年半，1例因下肢缺血运动障碍，出院后1年行肢体矫形术，功能得到基本恢复；其余5例生活质量、社会功能良好，无任何智力、神经系统障碍。结论ECMO可以有效地为可逆性严重心肺衰竭患儿提供呼吸循环支持治疗。

Objective The history of clinical application of extracorporeal membrane oxygenation （ECMO） has been more than 30 years. But in China, there were only a few ECMO centers with limited successful cases reported by the end of twentieth century. The high morbidities and mortalities in current pediatric ECMO practice are noted in China. Therefore, it is necessary to review the experience on rescue use of ECMO in critically ill pediatric patients. Method A retrospective analysis was done for patients who had been receiving ECMO treatment to rescue refractory cardiorespiratory failure from different causes in a hospital between July 2007 and May 2011. Result A total of 12 patients were treated with ECMO; 7 of them were male and 5 female, they aged 6 days to 11 years, weighed 2. 8-35 （ 17.21± 11.64） kg. The underlying causes of cardiorespiratory failure were as follows： two cases with acute respiratory distress syndrome （ARDS） leading to respiratory failure, 4 with failure of weaning from cardiopulmonary bypass, 3 with fulminant myocarditis, 1 with fight ventficular cardiomyopathy leading to repeated cardiac arrest, 1 with preoperative severe bypoxemia, and 1 with anaphylactic shock complicated with massive pulmonary hemorrhage and severe hypoxemia. Of the 12 cases, 3 were established ECMO （E-CPR） while underwent chest compression cardiopulmonary resuscitation （CPR）. The mean ECMO support time was 151.75 （15 - 572） h. Seven patients （58.33%） were weaned from ECMO, 6 patients （50.00%） were successfully discharged. Six cases had bleeding from sutures, 2 cases with severe bleeding underwent thoracotomy hemostasis, 2 presented with acute renal failure. Infection was documented in 3 cases, hyperbilirubinemia in 2 cases, lower limb ischemia in 1 case, hyperglycemia in 3 cases, disseminated intravascular coagulation in1 case, membrane lung leakage in 2 cases, systemic hemolysis in 3 eases, oxygenator failure in 2 cases and oxygenator thrombosis in one case. During the Mlow-up between 6 months and 4. 5 years, 5 patients survived with good quality of life, without any documented central nervous system disorders. One case survived with the right lower extremity disorder from ischemic damage. His motor function has been improved following orthopedic operation at one year after discharge. Conclusion ECMO is a justifiable alternative treatment for reversible severe cardiopulmonary failure in critically ill children.