复杂先天性心脏病患儿术后体外膜氧合支持治疗的研究

Postoperative extracorporeal membrane oxygenation support in children with complex congenital heart disease

目的探讨复杂先天性心脏病患儿施行体外膜氧合(extracorporeal membrane oxygenation,ECMO)辅助支持治疗的情况。方法收集2017年1月至2020年12月于上海儿童医学中心心胸外科进行ECMO辅助支持治疗的133例复杂先天性心脏病患儿的相关资料。其中,男76例,女57例;年龄范围为0~18岁,ECMO辅助支持治疗时的中位年龄为4.2个月;身高为(71.33±28.53)cm,体重为(9.06±11.38)kg。需ECMO辅助支持治疗的复杂先天性心脏病占比为:大动脉转位占17.29%(23/133),右心室双出口占9.77%(13/133),肺动脉闭锁占9.02%(12/133)、瓣膜病变占8.27%(11/133)、主动脉弓中断和主动脉弓缩窄均占7.51%(10/133)。观察患儿的一般资料、诊疗情况及检查指标,分析总结其治疗过程及预后。结果本研究患儿术中体外循环转流时间为(221.00±161.78)min,阻断时间为(100.31±68.09)min,ECMO转流时间为(114.87±84.39)h,ECMO整体撤机率为63.91%(85/133),患儿生存率为49.62%(66/133)。有42例患儿进行体外心肺复苏(extracorporeal cardiopulmonary resuscitation,ECPR),ECPR撤机率为54.76%(23/42),患儿存活率为40.48%(17/42)。48.87%(65/133)的患儿ECMO辅助天数为3~5 d,该辅助天数的患儿存活率达64.62%(42/65),高于ECMO支持辅助天数<3 d和>5 d的患儿存活率,分别为64.62%(42/65)比22.73%(5/22)、64.62%(42/65)比41.30%(19/46),差异具有统计学意义(P<0.05)。患儿安置ECMO后24 h的乳酸值与撤机(P=0.036)以及存活(P=0.051)表现出相关趋势。患儿围辅助时期常见的并发症是颅内出血及消化道出血,新生儿时期为颅内出血发生的危险因素(P=0.018),而消化道出血则与辅助前乳酸的水平相关(P=0.013)。结论ECMO能为复杂先天性心脏病患儿心功能的恢复争取时间,辅助天数为3~5 d时患儿整体预后最佳,辅助支持治疗期间动态监测乳酸值、相关凝血功能以及肾功能指标有助于改善患儿预后。

Objective To explore the role of extracorporeal membrane oxygenation(ECMO)support in children with complicated congenital heart disease(CHD).Methods From January 2017 to December 2020,the relevant clinical were retrospectively reviewed for 133 children(76 boys and 57 girls aged 0-18 years)with complex congenital heart disease receiving ECMO-assisted support.The average age at the time of ECMO-assisted support was 4.2 months,the average height(71.33±28.53)cm and the average weight(9.06±11.38)kg.Complex congenital heart diseases requiring ECMO-assisted support included transposition of great arteries(17.29%,23/133),double outlet right ventricle(9.77%,13/133),pulmonary atresia(9.02%,12/133),valvular disease(8.27%,11/133)and aortic arch interruption&constriction(7.51%,10/133).G eneral profiles,diagnosis,treatment and examinations were recorded and treatment protocols and outcomes analyzed.Results Intraoperative cardiopulmonary bypass time was(221.00±161.78)min,blocking duration(100.31±68.09)min,ECMO bypass time(114.87±84.39)h,overall weaning rate of ECMO 63.91%(85/133)and survival rate of 49.62%(66/133).Forty-two children underwent extracorporeal cardiopulmonary resuscitation(ECPR)with a weaning rate of 54.76%(23/42)and a survival rate of 40.48%(17/42).And 48.87%(65/133)of them had ECMO assistance days of 3 to 5 days and the survival rate with this assistance day was 64.62%(42/65).It was higher than survival rate of those with ECMO support assistance days<3 days and>5 days[64.62%(42/65)vs.22.7(5/22),64.62%(42/65)vs.41.30%(19/46)]and a difference of 3%had statistical significance(P<0.05).Lactate values at 24 h after ECMO showed a relevant trend with weaning(P=0.036)and survival(P=0.051).Common perioperative complications included intracranial hemorrhage and gastrointestinal hemorrhage.Neonatal period was a risk factor for intracranial hemorrhage(P=0.018)while gastrointestinal hemorrhage was associated with lactate level before assistance(P=0.013).Conclusions ECMO may facilitate the recovery of cardiopulmonary function in postoperative children with complicated CHD.Those with a duration of ECMO 3-5 days have the best overall prognosis.Intracranial hemorrhage is likely to occur with ECMO support during neonatal period.And the pre-ECMO level of lactate is correlated with the occurrence of gastrointestinal hemorrhage.