1例儿童暴发型心肌炎伴心源性休克的体外膜氧合治疗

Extracorporeal membranous oxygenation for cardiogenic shock due to pediatric fulminant myoearditis

目的探讨体外膜氧合（EcM0）技术辅助治疗1例儿童重症暴发型心肌炎的临床疗效及安全性评价。方法回顾分析2015—08广东省人民医院儿科重症监护病房（PICU）应用VA—ECMO辅助成功抢救1例暴发型心肌炎伴难治性休克的6岁男童的临床资料，收集ECMO支持前、辅助期间、应用后的生命体征、血清高敏肌钙蛋白T（TnT—HS）和脑利钠肽前体（proBNP）浓度、心脏超声左室射血分数（LVEF）和短轴缩短率（Fs）变化、血管活性药物使用及并发症，结合文献进行报道。结果ECMO辅助支持86h，入院LVEF和Fs分别为41％和20％，辅助前24％和11％，运行期间每天评估LVEF和Fs，依次为34％和23％、41％和23％、49％和27％，脱机前为58％和29％。辅助后血清TnT—HS、proBNP浓度呈逐日下降趋势，脱机时短暂回升，生命体征逐渐稳定，收缩压、舒张压均有升高，运行期间逐渐下调并可停用血管活性药物。并发症为颈内动静脉插管处渗血、急性溶血性贫血、血小板减少、右上肢皮下出血、股静脉插管处血肿。共住院3周，康复出院。结论尽早应用ECMO辅助重症暴发型心肌炎的治疗可取得较好疗效，适时脱机以缩短辅助支持时间，可减少严重并发症出现，保障患者安全。

Objective To summarize the effectiveness of acute fulminant myocarditis patient with cardiogenic shock supported by extracoI3poreal membrane oxygenation （ECMO） and evaluate its safety. Methods The clinical data of a 6-year old boy suffered from acute fulminant myocarditis with refractory cardiogenic shock rescued with venoarterial ECMO （VA-ECMO） mode successfully at the de- partment of pediatric intensive care unit of Guangdong General Hospital in August 2015 were retrospectively summarized. The pre-ECMO, post-ECMO vital signs, inotropies, vasopressors, TNT-HS and ProBNP blood levels and degrees and the ECMO-related complications were analyzed and the literature was reviewed. Results The length of ECMO support was 86 hours. Left ventricular ejection fraction （LVEF） and fractional shortening （FS） assessed by Doppler echocardiography on admission were 41% and 20%, 24% and 11% at initial ECMO support, then improved to 34% and 23%, 41% and 23%, 49% and 27% during the 3 consecutive days of ECMO respectively, 58% and 29% at the time of EC-MO termination. TNT-HS and ProBNP blood levels showed a downward tendency after ECMO but exhibited a short rebound in termination of ECMO, the vital signs were stable, the systolic and diastolic blood pressure were increased gradually, and the dosage of inotropics and vasoactive agents were tapered gradually until discontinued. Major complications during ECMO included the insertion site errhysis of internal jugular arteriovenous catheterization, acute hemolytic anemia, thrombocytopenia, subcutaneous hemorrhage of the right upper limb, local hematoma occurred at the insertion site of femoral vein. The patient recovered with normal cardiac function. The length of stay was 3 weeks. Conclusion ECMO is a life-saving treatment strategy and can be successfully used for children with severe fulminant myocarditis. Shortening the duration of ECMO support can reduce the potentially serious complications and ensure the safety of patient.