利用体外膜肺氧合救治儿童大咯血1例并文献复习

A child with massive hemoptysis successfully rescued by extracorporeal membrane oxygenation and literature review

目的总结体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)治疗儿童咯血的适应证及抗凝管理策略。方法分析郑州大学附属儿童医院/河南省儿童医院采取ECMO治疗并获成功的1例大咯血患儿临床资料。以“massive hemoptysis;extracorporeal membrane oxygenation”或“hemoptysis;ECMO”为检索词,检索PubMed、SCI、Embase数据库相关文献;以“大咯血,体外膜肺氧合”为检索词,检索万方数据库及中国知网、中国生物医学文献服务系统相关文献;检索时间截止至2021年6月;排除成人病例及重复文献后进行文献复习。结果共检索到6篇文献13例患儿,结合本文报道1例共14例患儿纳入本研究。14例患儿中,男6例,女8例,年龄35 d~15岁,平均年龄8.9岁。病因:脓毒血症2例,自身免疫性疾病8例,真菌感染1例,血管畸形2例,肺含铁血黄素沉积症1例。14例均因大咯血、呼吸衰竭行ECMO治疗,平均上机时间6.4 d,1例因心脏骤停采取动脉-静脉(V-A)模式,13例采取静脉-静脉(V-V)模式。在抗凝管理方面,13例应用肝素抗凝,1例未提及是否抗凝。止血药物应用:1例应用氨甲环酸,11例未用止血药物,2例未提及是否应用止血药。14例中,4例行手术治疗(肺叶切除术2例,血管内支架置入及病变血管栓塞治疗1例,血管栓塞治疗1例),10例未行手术治疗。14例ECMO运行期间未见出血增加。结论儿童大咯血少见,ECMO为威胁生命的大咯血患儿提供了新的可能的救治手段。全身肝素化下运行ECMO未增加出血风险。

Objective To summarize the indications and anticoagulation managements of extracorporeal membrane oxygenation(ECMO)for hemoptysis patients.Methods A successful case of ECMO in the treatment of massive hemoptysis at our hospital was analyzed and the relevant literature retrieved for reviewing.The databases of PubMed,Science Citation Index and Embase were searched with the keywords of“massive hemoptysis;extracorporeal membrane oxygenation”or“hemoptysis;ECMO”in Wanfang,CNKI and Biomedical Literature Service System.The searching time was up to June 2021.Adult cases and duplicate literature were excluded and the search results summarized.Results A total of 6 literatures and 13 children were retrieved along with 1 child at our department.A total of 14 children were analyzed.There were 6 boys and 8 girls with an average age of 8.9(5/52-15)years.The etiologies were sepsis(n=2),autoimmune disease(n=8),fungal infection(n=1),vascular malformation(n=2)and pulmonary hemosiderosis(n=1).All 14 children received ECMO treatment due to massive hemoptysis and respiratory failure with an average on-machine time of 6.4 days.One child underwent arterial-venous(V-A)mode due to cardiac arrest while the remainders venous-venous(V-V)mode.Heparin anticoagulation was confirmed(n=13)and unknown(n=1).Hemostatic agent of tranexamic acid was used(n=1),not used(n=11)and unknown(n=2).Four cases were operated,including lobectomy(n=2),endovascular stenting plus vascular embolization(n=1)and vascular embolization(n=1).The remainders were not operated.No massive bleeding occurred during ECMO.Conclusion Massive hemoptysis is rare in children.For children with life-threatening massive hemoptysis,ECMO provides a new possible rescue method.Furthermore,ECMO under systemic heparinization poses no elevated risk of bleeding.