体外膜氧合救治儿童爆发性心肌炎的临床疗效观察

Clinical features and outcomes of pediatric acute fulminant myocarditis requiring extracorporeal membrane oxygenation

目的探讨体外膜氧合(ECMO)救治儿童急性爆发性心肌炎(AFM)的临床疗效。方法回顾性总结2015年12月至2018年12月上海交通大学附属儿童医院接受ECMO治疗AFM患儿的临床资料,根据ECMO撤机后48 h是否存活分为ECMO撤机成功组(9例)与ECMO撤机失败组(3例)。分析影响ECMO撤机成功的相关因素,总结撤机成功患儿ECMO救治前后临床与生化指标的变化趋势。计量资料采用中位数(四分位数间距)表示,两组间比较采用非参数秩和检验。结果12例AFM患儿接受ECMO救治,男4例,女8例;中位体重20(17,36)kg,中位年龄66(48,103)个月。ECMO撤机成功9例(75.0%),出院存活8例(66.7%),住院死亡4例(33.3%)。ECMO治疗前中位病程3.0(2.2,4.0)d,ECMO中位支持时间120(68,152)h。撤机失败组ECMO建立前最高血乳酸(LA)水平、血管活性药物评分(VIS)、心电图QRS波时限均显著高于撤机成功组(均P<0.05)。撤机成功组患儿ECMO支持后平均有创动脉压、中心静脉氧饱和度、血LA、心肌损伤标志物(肌酸激酶MB同工酶、心肌钙蛋白Ⅰ、心肌脂肪酸结合蛋白)以及左室射血分数明显改善,与ECMO建立时比较差异有统计学意义(均P<0.05)。结论AFM患儿ECMO撤机成功因素与ECMO建立前血LA水平、VIS、心电图QRS波时限有关。

Objective To observe the clinical features and effects of extracorporeal membrane oxygenation(ECMO)in critically ill children with acute fulminant myocarditis(AFM).Methods A retrospective analysis was performed in pediatric patients with AFM requiring ECMO,from December 2015 to December 2018,who were admitted to the Pediatric Intensive Care Unit(PICU)in Shanghai Children′s Hospital.According to whether patient was alive at least 48 hours after weaning,the children were divided into successful weaning group(9 cases)and unsucessful weaning group(3 cases).The factors related to successful ECMO weaning were explored.The changes of clinical and biochemical parameters before and after ECMO treatment in successful weaning group were analyzed.Continuous variables were presented as median(inter quartile range)for abnormal distribution data,and Mann-Whitney U test was used to compare the data.Results A total of 12 pediatric patients including 4 males and 8 females were enrolled in this study.The median body weight was 20(17,36)kg,and the median age was 66(48,103)months.Nine cases were successfully weaned from ECMO,and 8 cases survived to discharge,and 4 cases died in the hospital.The median interval between symptoms onset and ECMO establishment was 3.0(2.2,4.0)days,the median duration of ECMO support was 120(68,152)hours.In the unsuccessful weaning group,patients displayed higher levels of initiallactic acid(LA),higher vasoactive-inotropic score(VIS),and longer QRS duration before ECMO establishment when compared with those in the successful weaning group(all P<0.05).After ECMO establishment,mean arterial pressure(MAP),systemic central venous oxygen saturation,LA,myocardial injury markers and left ventricular ejection fraction were all significantly improved in the successful weaning group(all P<0.05).Conclusion In pediatric AFM patients,serum LA level,VIS and QRS duration before ECMO establishment are associated with successful ECMO weaning.