静脉-动脉型体外膜肺氧合治疗儿童难治脓毒性休克的临床疗效观察

Clinical observation of venous-arterial extracorporeal membrane oxygenation in the treatment of refractory septic shock in children

目的探讨静脉-动脉型体外膜肺氧合(VA-ECMO)治疗儿童难治性脓毒性休克(refractory septic shock,RSS)的临床疗效。方法回顾性分析2016年1月至2018年12月上海交通大学附属儿童医院重症医学科(PICU)接受VA-ECMO治疗的RSS临床资料,并以同期收治非难治性脓毒性休克(NRSS)的VA-ECMO患儿作为对照。结果RSS-ECMO组患儿8例,NRSS-ECMO组患儿6例,两组性别、年龄、PRISMⅢ评分、合并症差异无统计学意义(均P>0.05)。8例RSS-ECMO患儿ECMO转流中位时间182(141,216)h,5例存活出院;NRSS-ECMO组ECMO转流中位时间336(170,505)h,3例存活出院。ECMO上机前,RSS-ECMO组患儿血乳酸、血管活性药物指数及脑病比率明显高于NRSS-ECMO组(P<0.05或P<0.01)。RSS-ECMO组血管活性药物使用时间以及联合CRRT比率高于NRSS组,但差异无统计学意义(P>0.05)。RSS患儿ECMO支持后,6h有创动脉压明显上升,24h乳酸明显下降、中心静脉氧饱和度升至正常范围。结论儿童难治脓毒性休克合并MODS与非难治脓毒性休克患儿VA-ECMO治疗成功率相似,需进一步开展ECMO与脓毒症血流动力学指标关系探讨。

Objective To investigate the efficacy of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in the treatment of refractory septic shock in children. Methods From January 2016 to December 2018, the clinical data of children with refractory septic shock (RSS) treated by VA-ECMO in Department of Critical Medicine Affiliated Children's Hospital of Shanghai Jiao Tong University were retrospectively analyzed. The patients with refractory septic shock (RSS) treated by VA-ECMO were compared with those with non-refractory septic shock (NRSS). Results There were 8 cases in the RSS-ECMO group and 6 cases in the NRSS-ECMO group. The sex, age, PRISM score, complication showed no significant difference in the two groups. The median time of ECMO in the RSS-ECMO group was 182 (141, 216) h , and 5 patients were survived and were discharged from the hospital. The blood lactic acid and vasoactive drug index in the RSS-ECMO group was significantly higher than that in the NRSS-ECMO group (P<0.05 or P<0.01). The time of vasoactive drugs use and the ratio of combined continuous renal replacement therapy (CRRT) in the RSS-ECMO group were higher than those in the NRSS-ECMO group, but there was no significant difference (P > 0.05). After ECMO establishment, the mean invasive arterial pressure increased significantly at 6 h, and lactic acid decreased significantly at 12 h after ECMO support. SCVO2 returned to normal at 24-h ECMO therapy. Conclusions The success rate of VA-ECMO treatment in children with refractory septic shock complicated with MODS is similar to that of children with non-refractory septic shock. The relationship between ECMO and hemodynamic indexes in sepsis should be further explored.