右侧颈部置管建立体外膜肺氧合治疗危重症患儿

Application of right jugular vessels to build extracorporeal membrane oxygenation for treating the critically ill children

目的 总结经右侧颈部血管切开置管建立体外膜肺氧合（ECMO）的技术体会.方法 回顾性分析2011年12月至2015年12月复旦大学附属儿科医院因小儿危重症接受ECMO治疗,并经右侧颈部血管置管建立ECMO的患儿资料,包括疾病种类、年龄、体重、置管时间、ECMO运行时间、并发症及预后等.结果 共28例患儿接受ECMO治疗,3例患儿为先天性心脏病手术后经胸置管建立ECMO未纳入.故最终纳入25例患儿,其中男15例、女10例,中位年龄1.8岁（1 d～13岁）,中位体重12.0（2.8～50.0） kg.25例患儿均因一般机械通气不能维持或心力衰竭对常规药物治疗无反应,均为静脉-动脉转流（V-A模式）ECMO支持;均采用全身麻醉下右侧颈内静脉-颈总动脉插管,其中5例患儿术前右侧颈内静脉已置入颈静脉导管,3例患儿术前右侧颈内静脉已置入血透管,1例患儿在心肺复苏的同时置管.25例患儿均成功顺利置入插管建立ECMO,手术时间为（45±26） min,除1例动脉灌注压力过高,重新更换管道后压力恢复正常外,其余均置管一次成功;置管位置恰当,未再调整置管深度;流量满意,达到80 ～ 150 ml/（kg·min）.ECMO中位运行时间为153（14～567）h,成功撤机16例,撤机成功率为64％,出院存活15例,出院存活率为60％.插管相关并发症：置管位置切口渗血6例;插管固定缝线松弛2例,误伤颈外静脉1例,局部缝合后止血.结论 血管插管是进行ECMO的基础,经右侧颈部血管置管建立小儿ECMO相对简单安全.掌握熟练的切开置管技术可确保ECMO的应用.加强局部管道管理,减少并发症.

Objective To summarize the experience in applying a technique of inserting a cannula through right internal jugular vein and common carotid artery to build extracorporeal membrane oxygenation （ECMO） for critically ill children.Method The data of critically ill patients received ECMO support through right internal jugular vein and common carotid artery between December 2011 and December 2015 from Children＇s Hospital of Fudan University were analyzed retrospectively.The data included diagnosis,age,body weight,time of cannula and ECMO running,complication and prognosis.Result In total 28 patients received ECMO support,3 patients of post-cardiac surgery with transthoracic cannula were excluded.Twenty-five patients inserted cannula through neck vessels were enrolled,15 boys and 10 girls,the median age was 1.8 years （range,1 d-13 years）,the median weight was 12.0 （2.8-50.0） kg.All the cannula sites were right internal jugular vein and right common carotid artery,before cannula use 5 patients had been inserted central vein tube and 3 patients with blood filter tube in right internal jugular vein,in one case cannula was applied during cardiopulmonary resuscitation.V-A ECMO had been built for all the cases successfully,the median operation time was （45 ± 26） min.The pump flow was 80-150 ml/（kg · min）,the median duration of ECMO support was 153 （14-567） h.Sixteen （64%） patients weaned off ECMO successfully,15 （60%） survived to hospital discharge.About the complication of cannula,six patients developed cannula site bleeding,and two patients required re-fixation of cannula,one patient＇s external jugular vein had been hurt and sutured for bleeding.Conclusion Application of right jugular vessels to build ECMO is easy and safe for treating the sick children.The skill should be proficient to assure ECMO run and reduce the complications.