危重症儿童体外膜肺氧合置管体会

Extracorporeal membrane oxygenation catheterization in critically ill children

目的总结儿童体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)置管的方法技术体会。方法回顾性分析2016年10月至2018年10月中国医科大学附属盛京医院因小儿危重症接受ECMO治疗的患儿资料,包括患儿年龄、体重、诊断疾病、ECMO模式、置管方法、ECMO运行时间、并发症及预后等。结果共15例患儿接受ECMO治疗,其中男5例,女10例,中位年龄(范围)4.9(1.0~11.0)岁,中位体重21.5(范围)(8.5~49.0)kg。暴发性心肌炎5例,重症肺炎7例,感染性休克3例,静脉-动脉转流(VA模式)8例,静脉-静脉转流(VV模式)7例。15例患儿均采取经皮置管,有2例患儿经皮穿刺置管困难,采取切开插管技术获得成功,无因置管困难而未采取ECMO的病例。置管位置恰当,15例均未再调整管的深度并且流量满意。ECMO运行时间96.8(1.0~366.0)h。成功撤机8例,撤机成功率53%,转院1例,出院存活8例,存活率60%。置管相关并发症:置管位置切口渗血2例,1例经局部压迫止血,1例局部缝合后止血。股动脉血栓1例,经皮左下肢股动脉造影及腔内成形术好转。颈动脉血栓1例,肝素抗栓治疗动态复查中。左下肢神经损伤1例,经口服B族维生素及低频电刺激治疗后好转。结论ECMO置管是ECMO运行的基础,根据患儿的具体情况选择合适的置管方法。经皮置管建立小儿ECMO相对安全简单,是首选的置管方法,如穿刺失败或需实施心外按压时应迅速采取外科方式—半开放置管或切开置管。掌握熟练的切开置管技术可确保儿童ECMO的临床应用。

Objective To summarize the technical experience of extracorporeal membrane oxygenation(ECMO)catheterization in children. Methods Data of patients that received ECMO treatment in the pediatric intensive care unit between October 2016 and October 2018 were analyzed retrospectively.The age, weight, diagnosis, complications and the final outcomes of the patients, as well as the working mode, catheterization mode and duration of ECMO were collected. Results A total of 15 children were treated with ECMO, including 5 males and 10 females.The median age(range) was 4.9 (1.0-11.0)years and the median weight(range) was 21.5(8.5-49.0)kg.There were 5 cases of fulminant myocarditis, 7 cases of severe pneumonia, 3 cases of septic shock, 8 cases of venous-arterial bypass(VA mode), and 7 cases of venous-venous bypass(VV mode). All the 15 patients underwent percutaneous catheterization.Two patients that experienced difficulty in percutaneous catheterization turned to open catheterization.None abandoned ECMO due to the difficulty in catheterization.The position and depth of the catheter, and the flow rate required no further adjustment.The mean ECMO duration was 96.8(1-366)h.Weaning was successful in 8 cases(53%). One case was transferred and 8 cases were dismissed, and the survival rate was 60%.There were 2 cases of bleeding at the site of catheter entrance, one treated with local compression and the other with suture.There was 1 case of femoral artery thrombosis that was relieved by percutaneous femoral artery angiography and intracavitary formation.Another case developed carotid artery thrombosis and had been undergoing antithrombotic therapy and following-up.One case had nerve injury in the left lower extremity that was relieved by oral vitamin Bs and low frequency electrical stimulation. Conclusion Catheterization is the basis of ECMO execution.Catheterization method should be individualized.Percutaneous catheterization is the choice of thumb due to its safety and simplicity.In case of failure, or during the extra-cardiac compression, the surgical method should be taken quickly, and the catheter should be placed in an open or partly-open manner.Proficient catheterization technique ensures the smooth application of ECMO in children.