体重小于5kg婴儿建立体外膜肺氧合的置管操作经验

Cannulation for extracorporeal membrane oxygenation in infants less than 5 kg

目的总结体重小于5 kg婴儿建立体外膜肺氧合(ECMO)置管过程中的技术要点,以期减少置管并发症发生率.方法以2016年6月至2018年6月广州市妇女儿童医疗中心重症医学科收治的11例体重小于5 kg行ECMO支持的患儿为研究对象.回顾性分析建立ECMO的支持类型、置管方式及相关并发症等.结果11例患儿中男性9例,女性2例;置管时体重1.96~4.60 kg,平均(3.14±0.65)kg;年龄0.1~30.0 d,中位年龄5.6(1.5,8.3)d;原发病为先天性膈疝并重度肺动脉高压(4例)、先天性心脏病围手术期并发症(7例).所有患儿均给予动脉-静脉(V-A)ECMO支持.4例采用颈动脉-静脉置管,动脉端6~8 F、深度2.5~3.5 cm,静脉端8~10 F、深度6.0~7.5 cm,置管操作时间55~100 min,平均(73±20)min.7例进行主动脉-右心房置管,主动脉端6~8 F、深度1.0~2.0 cm,右心房端12~14 F、深度2.8~3.0 cm;排除2例在心脏手术术中置管外,其余5例主动脉-右心房置管操作时间为35~110 min,平均(64±31)min.有3例患儿发生并发症,其中1例操作中发生血管部分撕裂,1例出现置管部位出血,1例置管位置不正确而需调整位置;所有患儿均无操作部位感染病例,无导管相关性血流感染,未见导管脱出.结论在选择合适的管道、细致熟练的操作下,体重小于5 kg婴儿置管建立ECMO的成功率高且并发症较少.

Objective To summarize the experience of cannulation for extracorporeal membrane oxygenation (ECMO) in infants less than 5 kg. Methods Eleven infants with ECMO support who weighed less than 5 kg were admitted to critical care medicine of Guangzhou Women and Children's Medical Center from June 2016 to June 2018 were enrolled. Retrospective analysis of support type, configuration, site of cannula and complication of ECMO was performed. Results The 11 infants consisted of 9 males and 2 females. The weight on ECMO of 1.96-4.60 kg, with an average of (3.14±0.65) kg;age 0.1-30.0 days, with a median of 5.6 (1.5, 8.3) days. Four cases were given ECMO because of congenital diaphragmatic hernia with severe pulmonary hypertension and other 7 cases were cannulated due to complication of congenital cardiac surgery. All infants were received veno-arterial (V-A) ECMO. In 4 cases, the cannulas were placed in the right internal jugular vein for drainage (8-10 French catheter with 6.0-7.5 cm depth) and the right carotid artery for infusion (6-8 French catheter with 2.5-3.5 cm depth);the average time of cannulation in right carotid and jugular vessels was (73±20) minutes (range 55-100 minutes). In other 7 cases, the cannulas were inserted into the right atrium (12-14 French catheter with 2.8-3.0 cm depth) for draining blood and returning it to the ascending aorta (6-8 French catheter with 1.0-2.0 cm depth);the average time of cannulation in central vessels was (64±31) minutes (range 35-110 minutes) with exclusion of 2 cases intraoperative cannulation. There were three infants with complications. One episode was shown in vascular rupture, one in catheter site hemorrhage and one in cannula malposition with later repositioning. There was no case of insertion site infection, cannula-related bloodstream infection and accident detached cannula. Conclusion Cannulation for ECMO can be performed in infants less than 5 kg with a high rate of success and a low rate of complication owing to appropriate catheter and skillful cannulation.