体外膜氧合技术在儿童先天性心脏病术后的临床应用

The application of extracorporeal membrane oxygenation in children with congenital heart disease after surgical procedures

目的总结体外膜氧合(ECMO)技术在儿童先天性心脏病术后的临床应用经验。方法回顾性分析2016年11月至2020年11月在上海市儿童医院心胸外科先天性心脏术后实施ECMO支持的11例患儿临床资料,包含患儿的一般资料、临床诊断、实验室指标、ECMO持续时间、ECMO支持过程中并发症及住院时间等。根据患儿出院结局分为存活组与死亡组。结果 11例患儿中成功脱机9例,脱机率81.8%,存活6例,存活率54.6%。11例患儿ECMO辅助时间为4~192(89.00±58.27)h,住院时间为10~49(30.09±12.75)d。存活组在ECMO撤离时血乳酸(Lac)水平有明显下降[2.00(0.88,2.43)比4.20(2.15,10.20),P=0.044],但两组正性肌力评分、体外循环时间、主动脉阻断时间和ECMO支持时间比较无显著性差异(P>0.05)。且在ECMO支持前两组的Lac和正性肌力评分均无显著性差异(P>0.05)。存活组ECMO撤离时的Lac及正性肌力药物评分均较ECMO前显著降低[2.00(0.88,2.43)mmol/L比9.05(1.75,16.00)mmol/L,P=0.043;7.50(4.50,14.50)分比24.00(22.25,35.00)分,P=0.028]。死亡组ECMO撤离时正性肌力药物评分较ECMO前显著性降低[13.00(5.00,15.00)比30.00(25.00,34.50),P=0.043],ECMO撤离时Lac较ECMO前无显著性差异(P>0.05)。结论 ECMO技术应用于先天性心脏病患儿术后救治是一种有效的心肺支持措施,提高ECMO期间抗凝管理以及及时连续肾脏替代治疗(CRRT)或腹膜透析治疗,可提高患儿的撤机率及存活率。

Objective To summarize the clinical application experience of extracorporeal membrane oxygenation(ECMO) technology in children with congenital heart disease after surgical procedures. Methods A retrospective analysis of 11 children with congenital heart disease after surgical procedures, supporting with ECMO in Shanghai Children’s Hospital from November 2016 to November 2020 was conducted. The general information, clinical diagnosis, laboratory results, duration of ECMO support, various complications and hospital length of stay were collected. The children were divided in two groups including the survival group and death group. Results Nine cases successfully weaned from ECMO, in which six cases survived,the weaning rate was81.8% and the survival rate was 54.6%. The duration of ECMO support was from 4 to 192(89.00 ± 58.27) hours and the hospital length of stay was from 10 to 49(30.09±12.74) days. The level of blood lactic acid(Lac) of the survival group was significantly lower than that in the death group [2.00(0.88, 2.43) vs. 4.20(2.15, 10.20), P=0.044] at the time of weaning from ECMO support, but there were no significant differences in the vasoactiveinotropic score, the cardiopulmonary bypass time, the aortic cross-clamping time and the duration of ECMO support(P>0.05). And the levels of blood Lac and the vasoactive-inotropic score were not significantly different before the use of ECMO between these two groups. In the survival group, the level of blood Lac and vasoactive-inotropic score significantly decreased at the time of weaning after ECMO treatment [2.00(0.88,2.43) mmol/L vs. 9.05(1.75, 16.00) mmol/L, P=0.043;7.50(4.50, 14.50) vs. 24.00(22.25, 35.00), P=0.028].In the death group, the vasoactive-inotropic score significantly reduced at the time of weaning from ECMO treatment [13.00(5.00, 15.00) vs. 30.00(25.00, 34.50), P=0.043], but the level of blood Lac had no obvious changes(P>0.05). Conclusion ECMO management is an effective supportive measure in children with congenital heart disease after surgical procedures. It is necessary to manage the use of anticoagulants and implement prompt continuous renal replacement therapy(CRRT) and peritoneal dialysis treatment for the improvement of the weaning rates and the survival rates in children with congenital heart disease after surgical procedures.