体外膜氧合治疗儿童急性暴发性心肌炎的临床观察

The application of extracorporeal membrane oxygenation in the treatment of acute fulminant myocarditis in children

目的探讨体外膜氧合(ECMO)在儿童急性暴发性心肌炎中的临床应用。方法回顾性分析2015年7月至2020年2月在本院儿童ICU因急性暴发性心肌炎接受ECMO治疗的重症患儿的临床资料,包括临床表现、心电图、超声心动图、心肌生化标志物、ECMO的应用、治疗效果及预后。结果共4例患儿男1例,女3例;年龄1.8~9岁;体质量10.8~45 kg;ECMO治疗前血管活性药物评分20~70分;入院至ECMO启动时间0~19 h,ECMO运行时间86~222 h;起病至入ICU时间2~4d;住ICU时间15~37 d;住院时间22~45 d。4例患儿均为恶性心律失常,其中心搏骤停3例,难治性休克1例。ECMO均采用静脉-动脉模式,2例为长时间在ECMO辅助下行CPR(120 min、144 min),2例行连续性肾脏替代治疗时间分别为305 h、498 h;4例ECMO治疗后心功能、心肌损伤及心衰标志物、肝肾功能等指标均较前有明显改善。4例均未发生机械相关并发症,机体相关并发症主要为出血3例,感染3例(泌尿道、菌血症、肺炎),多器官功能障碍2例,急性肾损伤Ⅲ期2例,溶血1例。4例均成功脱离ECMO并存活出院,撤机成功率100%,生存出院率100%。随访2月~4年,4例心功能全部正常,儿童脑功能分类量表评分均为1级,正常。结论ECMO能明显提高急性暴发性心肌炎患儿生存率;把握合适的ECMO介入时机是提高院内心搏骤停患儿治疗成功率及改善预后的关键。

Objective To explore the clinical application of extracorporeal membrane oxygenation(ECMO)in the treatment of acute fulminant myocarditis in children.Methods The clinical data of 4 children with acute fulminant myocarditis supported with ECMO from July 2015 to February 2020 were retrospectively analyzed.Clinical manifestation,electrocardiogram,cardiac ultrasound,myocardial biochemical markers,application of ECMO,therapeutic effect and prognosis were collected.Results A total of 4 children(1 male and 3 females,aged 1.8-9 years,weighted 10.8-45 kg)were treated with ECMO.Vasoactive drug score before ECMO treatment was 20-70.The mean time of starting ECMO from hospital admission was 0-19 h and the ECMO running time was 86-222 h.Time from disease onset to intensive care unit(ICU)admission was 2-4 d.The length of ICU stay and hospital stay was 15-37 d and 22-45 d respectively.Malignant arrhythmia was noted in all 4 cases,with 3 cases of cardiac arrest and 1 case of refractory cardiogenic shock.All patients were supported with veno-arterial ECMO,in which there were 2 cases of ECMO-assisted CPR(120 min,144 min)and 2 cases of ECMO combined with continuous renal replacement therapy(305 h,498 h).The cardiac function,biochemical markers of myocardial injury and heart failure,liver and kidney function were significantly improved after ECMO treatment.There were no mechanical complications in 4 cases.The main body related complications were 3 cases of bleeding,3 cases of infection(urinary tract,bacteremia,pneumonia),2 cases of multiple organ dysfunction,2 cases of acute renal injury(stageⅢ)and 1 case of hemolysis.All the 4 patients were successfully weaned from ECMO and discharged alive(weaning rate 100%,survival rate 100%).All of the patients were followed-up for 2 months to 4 years.The cardiac function and pediatric cerebral performance category scale(PCPC)scores of these children were normal.Conclusion ECMO can significantly improve the survival rate of children with acute fulminant myocarditis.Appropriate timing of ECMO intervention is the key to improve the success rate of treatment and the prognosis of children with cardiac arrest in hospital.