小儿先天性心脏病术后体外膜肺氧合治疗:单中心经验

Outcome of extracorporeal membrane pulmonary oxygenation after congenital heart diseases in pediatric: experience from single center

目的回顾总结先天性心脏病(congenital heart disease,CHD)术后体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)辅助患儿的临床预后及死亡原因,拟进一步提高ECMO治疗存活率。方法回顾性分析上海儿童医学中心心胸外科2017年1月至2019年12月收治的CHD术后进行VA-ECMO辅助的105例患儿的临床资料,对死亡原因进行分析。结果105例ECMO患儿,平均年龄110(38,341)d,体重5.30(3.75,8.45)kg,先天性心脏病手术风险调整评分3(2~3)分。存活组(n=51)与死亡组(n=54)患儿的性别、年龄、体重、身长、先天性心脏病手术风险调整评分、手术室安装ECMO例数、经心肺复苏后安装ECMO例数及ECMO持续时间比较差异均无统计学意义(P均>0.05);连续性肾脏替代治疗使用率差异有统计学意义[7.8%(4/51)比38.9%(21/54),P<0.001]。ECMO撤离后死亡主要发生在撤离后1周(83.3%,45/54)。ECMO安置以1月龄~1岁患儿最多(52.4%,55/105),2017至2019年存活率从31.6%(6/19)上升至65.0%(13/20)。ECMO安置时3~5 kg患儿最多(39.0%,41/105),2017至2019年存活率从28.6%(4/14)上升至75.0%(9/12)。死亡原因以心力衰竭为主(48.1%,26/54),其次为出血(18.5%,10/54)和肺动脉高压(13.0%,7/54)。结论随着外科手术、体外循环技术的进步以及术后监护能力的提高,近3年我院CHD患儿ECMO后病死率逐年下降,但ECMO期间需要连续性肾脏替代治疗辅助的患儿病死率较高。因此,临床工作中仍需加强ECMO期间各脏器功能的维护。

Objective To review the clinical prognosis and causes of death in children with extracorporeal membrane pulmonary(ECMO)assistance after congenital heart disease(CHD)operation in our center,so as to improve the survival rate of ECMO.Methods All clinical data of 105 children with VA-ECMO assisted after CHD operation who were admitted to the Department of Cardiothoracic Surgery at Shanghai Children′s Medical Center from January 2017 to December 2019 were collected,and the clinical characteristics and causes of death were retrospectively analyzed.Results The age of 105 children with ECMO was 110(38,341)days,the weight was 5.30(3.75,8.45)kg,and the risk adjustment for congenital heart surgery score was 3(2-3)points.There were no statistically significant differences in gender,age,weight,height,risk adjustment for congenital heart surgery score,the number of ECMO installed in the operating room,the number of ECMO installed after cardiopulmonary resuscitation and ECMO duration between the surviving group(n=51)and the death group(n=54)(P>0.05).While there was a significant difference in utilization of continuous renal replacement therapy[7.8%(4/51)vs.38.9%(21/54),P<0.001].The death mainly occurred within one week after evacuating ECMO(83.3%,45/54).ECMO installation was most in children aged 1 month to 1 year old(52.4%,55/105),and the survival rate showed a rise over three years(2017 to 2019),increased from 31.6%(6/19)to 65.0%(13/20).Children with 3 to 5 kg were the most affected(39.0%,41/105)when ECMO was installed,and the survival rate from 2017 to 2019 increased from 28.6%(4/14)to 75.0%(9/12).The main cause of death was heart failure(48.1%,26/54),followed by bleeding(18.5%,10/54)and pulmonary hypertension(13.0%,7/54).Conclusion With the progress of surgical technology and cardiopulmonary bypass,and the improvement of postoperative management,the mortality of children with CHD in our hospital after ECMO has decreased year by year during the last three years.However,the mortality of children requiring continuous renal replacement therapy assistance during ECMO is higher.Therefore,it is still necessary to strengthen the maintenance of each organ function during ECMO.