婴儿心脏手术体外循环与体外膜肺氧合切换的探讨

Setup of extracorporeal membrane oxygenation from cardiopulmonary bypass in infants undergoing cardiac surgery

目的探讨先天性心脏病患儿手术后体外循环(extracorporeal circulation,ECC)停机困难转为体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)辅助治疗的优化方案的效果。方法回顾性分析阜外华中心血管病医院2020年1月至2021年12月收治的12例复杂先天性心脏病患儿临床资料,其中男8例,女4例;中位年龄3.1个月,年龄范围在1~8个月;身高为(65.43±8.56)cm,体重为(3.24±0.35)kg。患儿均ECC心脏手术后停机困难,切换为ECMO继续辅助治疗,运用ECC内血液动态预充至ECMO系统,切换完成后在ECMO系统中行超滤治疗,观察系统切换及超滤过程中的血流动力学及血气等指标变化。两组比较采用独立样本t检验。结果患儿术中ECC转流时间为(245.00±12.08)min,阻断时间为(105.23±13.06)min,ECMO准备时间为(8.34±1.16)min,系统切换时间为(5.12±1.46)min,置换期间动脉压维持在(35.23±5.34)mmHg(1 mmHg=0.133 kPa)。与置换前相比,置换后超滤前红细胞比容、血红蛋白、胶体渗透压均有所降低,分别为(26.6±0.2)%、(93±2)g/L、(23.4±0.5)mmHg比(23.6±0.4)%、(85±4)g/L、(21.3±0.6)mmHg,差异有统计学意义(P<0.05);与置换后超滤前相比,超滤后红细胞比容、血红蛋白、胶体渗透压包被蛋白均有所升高,(23.6±0.4)%、(85±4)g/L、(21.3±0.6)mmHg比(30.5±0.6)%、(102±6)g/L、(26.4±0.3)mmHg,pH值、血乳酸、碱剩余均有所降低,分别为(7.37±0.03)、(6.3±0.6)mmol/L、(-2.06±0.16)mmol/L比(7.32±0.04)、(3.9±0.4)mmol/L、(-3.47±0.26)mmol/L,差异有统计学意义(P<0.05)。结论婴儿心脏手术ECC切换ECMO过程中,运用ECC中的血液动态预充ECMO系统结合改良超滤技术的优化处理方案方便快捷、安全有效。

Objective To explore the effectiveness of an optimized protocol for converting postoperative difficulty in extracorporeal circulation(ECC)into extracorporeal membrane oxygenation(ECMO)as an adjuvant therapy in children with congenital heart disease(CHD).Methods From January 2020 to December 2021,retrospective analysis was performed for 12 children with complex CHD.There were 8 boys and 4 girls with a median age of 3.1(1-8)months.Body height was(65.43±8.56)cm and body weight(3.24±0.35)kg.After ECC cardiac procedures,all of them had difficulty weaning off the machine and switched into ECMO for auxiliary treatment,using dynamic pre-charging of blood within ECC.After switching,ultrafiltration was performed in ECMO system.The changes of hemodynamics and blood gas parameters were observed during system switching and ultrafiltration.Two groups were compared by independent sample t-test.Results Intraoperative ECC time was(245.00±12.08)min,blocking time(105.23±13.06)min,ECMO preparation time(8.34±1.16)min and system switching time(5.12±1.46)min.During replacement,arterial pressure was maintained at(35.23±5.34)mmHg(1 mmHg=0.133 kPa).As compared with pre-replacement,hematocrit,hemoglobin and colloid osmotic pressure pre-hemoconcentration decreased from(26.6±0.2)%,(93±2)g/L,(23.4±0.5)mmHg to(23.6±0.4)%,(85±4)g/L and(21.3±0.6)mmHg.There were statistically significant differences(P<0.05).Before and after hemoconcentration,hematocrit,hemoglobin and colloidal osmotic pressure spiked by(23.6±0.4)%,(85±4)g/L,(21.3±0.6)mmHg to(30.5±0.6)%,(102±6)g/L and(26.4±0.3)mmHg.And pH value,blood lactate and alkaline surplus declined from(7.37±0.03),(6.3±0.6)mmol/L,(-2.06±0.16)mmol/L to(7.32±0.04),(3.9±0.4)mmol/L and(-3.47±0.26)mmol/L.The differences were statistically significant(P<0.05).Conclusions While switching from ECC into ECMO during infantile cardiac surgery,an optimized protocol of combining blood dynamic pre-filling ECMO system in ECC with modified hemoconcentration technology is convenient,fast,safe and effective.