连续性肾替代治疗联合体外膜肺氧合救治儿童心肺衰竭的疗效观察

Continuous renal replacement therapy combined with extracorporeal membrane oxygenation for pediatric cardiopulmonary failure

目的 探索体外膜肺氧合（ECMO）联合连续性肾替代治疗（CRRT）抢救儿童心肺功能衰竭的疗效.方法 回顾性总结2015年12月至2017年11月,上海交通大学附属儿童医院14例心肺功能衰竭合并急性肾损伤（AKI）或液体超载患儿接受ECMO联合CRRT患儿（ECMO＋CRRT组）的资料,并以同期未联合使用CRRT的ECMO治疗11例患儿（ECMO组）作为对照,比较两组病情、并发症及治疗结局,两组间比较采用t检验或非参数秩和检验.结果 25例ECMO治疗患儿,男15例、女10例,年龄9（1-117）月龄,体重10（2-42）kg.ECMO支持平均治疗时间199.2 h.14例ECMO＋CRRT组患儿中CRRT连接于ECMO管路中12例,独立运行2例,CRRT持续时间平均78.6 h.ECMO＋CRRT组血肌酐高于ECMO组[53（22-126）比29（12-92）μmol/L,Z=-2.208,P=0.043].ECMO＋CRRT组患儿ECMO支持时间较ECMO组长,但差异无统计学意义[（257±203）比（122±83）h,t=-2.062,P=0.051],治疗期间ECMO＋CRRT组血小板降低发生率高于ECMO组（10/14比3/11,χ^2=4.812,P=0.028）.ECMO＋CRRT组撤机成功和出院存活分别为9例和8例,ECMO组撤机成功8例,出院存活8例,组间比较差异均无统计学意义（χ^2=0.203、0.659,P=0.652、0.417）.结论 儿童心肺衰竭ECMO治疗期间,联合使用CRRT治疗AKI和液体超载是安全有效的方法.

Objective To explore the effectiveness and safety of continuous renal replacement therapy （CRRT） combined with extracorporeal membrane oxygenation （ECMO） on rescuing pediatric patients with cardiopulmonary failure.Methods The medical records of patients treated with ECMO admitted to pediatric intensive care unit （PICU） in Shanghai Children＇s Hospital from December 2015 to November 2017 were retrospectively extracted.There were 14 patients treated with ECMO combined with CRRT （ECMO＋ CRRT group） due to acute kidney injury （AKI） or fluid overload,while 11 cases treated with ECMO only.The demographics and clinical characteristics of patients,the indications,details and complications of ECMO and CRRT support,and the survival rates were analyzed.Results A total of 25 cases including 15 boys and 10 girls with cardiopulmonary failure treated with ECMO were enrolled in this study,whose median age and body weight were 9 （1-117） months and 10 （2-42） kg.The median duration of ECMO support was 199.2 h,and the median duration of CRRT was 78.6 h.Among the 14 cases in ECMO ＋ CRRT group,12 cases were treated with CRRT connected to ECMO pipeline,and 2 other cases were treated with independently operated CRRT.The serum level of creatinine was significantly higher in ECMO ＋ CRRT group than that in ECMO group （53 （22-126） vs.29 （12-92） μmol/L,Z=-2.208,P=0.043）.There was no significant difference in running time between ECMO＋CRRT group and ECMO group （（257±203） vs.（122±83） h,t=-2.062,P=0.051）.And the incidence of thrombocytopenia was higher in ECMO＋CRRT group than that in ECMO group （10/14 vs.3/11,χ^2=4.812,P=0.028）.There were no differences in the successful weaning rate and discharge survival rate between ECMO ＋ CRRT and ECMO group （9 vs.8,x^2=0.203,P=0.652 and 8 vs.8,χ^2=0.659,P=0.417,respectively）.Conclusion The combination of CRRT and ECMO is an effective and safe treatment to alleviate fluid overload and improve kidney function in pediatric patients with cardiopulmonary failure.