Temporary ECMO support following lung and heart-lung transplantation.

7 days) failure. Seven (78%) patients in the early group were weaned off ECMO and 5 (56%) survived to hospital discharge. In the late group, none of the patients could be weaned off ECMO, yielding 100% mortality. ECMO support instituted for pulmonary graft failure that occurred within 24 hours of transplantation may improve patient survival.     

Establishing extracorporeal membrane oxygenation in a university clinic: case series

OBJECTIVES: Although extracorporeal membrane oxygenation (ECMO) is well established for respiratory failure in neonates, application in adults is still considered controversial. The survival of patients with acute respiratory distress syndrome and ECMO therapy is 50% to 70%. DESIGN: A retrospective analysis of 10 patients, who were placed on ECMO from September 2004 to December 2005, was performed. SETTING: University clinic. INTERVENTIONS: Venoarterial ECMO was established in 7 patients, venovenous ECMO in 2 patients, and combined venoarterial and venovenous ECMO in 1 patient. MEASUREMENTS AND MAIN RESULTS: Indications were pneumonia, acute respiratory distress syndrome, near drowning, pericardial tamponade with shock lung, right-heart failure after heart transplantation, shock lung after cardiopulmonary resuscitation, and right-heart failure in chronic thromboembolic pulmonary hypertension. Median maintenance of ECMO therapy was 56.5 hours (range, 36-240). The median Murray score was 3.3 for survivors and 4 for nonsurvivors. Overall mortality was 30%; 70% were weaned from ECMO and survived until discharge. Median pre-ECMO risk for fatal outcome according to Hemmila was 0.43 for survivors and 0.92 for nonsurvivors (p < 0.02). In 2 cases, surgical reintervention was necessary because of bleeding in one, and a side switch of the cannulae had to be performed because of femoral venous thrombosis in the other. CONCLUSIONS: ECMO has been shown to be a successful therapy for acute respiratory distress syndrome when conventional strategies have failed. Pre-ECMO risk assessment may be useful in the evaluation of patients.     

Weaning From Venovenous Extracorporeal Membrane Oxygenation Without Anticoagulation: Is it Possible?

A 19-year-old man affected with severe acute respiratory distress syndrome that was unresponsive to medical treatment was successfully weaned without anticoagulation therapy from venovenous extracorporeal membrane oxygenation (ECMO) because of life-threatening bleeding. The patient received venovenous ECMO with double peripheral cannulation. Heparin infusion was discontinued on day 10 for severe bleeding from thoracic and mediastinal drainages until the ECMO was removed. The weaning was performed while keeping the blood flow unchanged, only gas flows were gradually decreased. The patient was discontinued from ECMO and extubated after pulmonary function improved. Based on this single experience, management and weaning without any anticoagulant agent might be possible.     

Improved Outcome of Cardiac Extracorporeal Membrane Oxygenation in Infants and Children Using Magnetic Levitation Centrifugal Pumps

Extracorporeal membrane oxygenation (ECMO) has traditionally been and, for the most part, still is being performed using roller pumps. Use of first‐generation centrifugal pumps has yielded controversial outcomes, perhaps due to mechanical properties of the same and the ensuing risk of hemolysis and renal morbidity. Latest‐generation centrifugal pumps, using magnetic levitation (ML), exhibit mechanical properties which may have overcome limitations of first‐generation devices. This retrospective study aimed to assess the safety and efficacy of veno‐arterial (V‐A) ECMO for cardiac indications in neonates, infants, and children, using standard (SP) and latest‐generation ML centrifugal pumps. Between 2002 and 2014, 33 consecutive neonates, infants, and young children were supported using V‐A ECMO for cardiac indications. There were 21 males and 12 females, with median age of 29 days (4 days–5 years) and a median body weight of 3.2 kg (1.9–18 kg). Indication for V‐A ECMO were acute circulatory collapse in ICU or ward after cardiac repair in 16 (49%) patients, failure to wean after repair of complex congenital heart disease in 9 (27%), fulminant myocarditis in 4 (12%), preoperative sepsis in 2 (6%), and refractory tachy‐arrhythmias in 2 (6%). Central cannulation was used in 27 (81%) patients and peripheral in 6. Seven (21%) patients were supported with SP and 26 (79%) with ML centrifugal pumps. Median duration of support was 82 h (range 24–672 h), with 26 (79%) patients weaned from support. Three patients required a second ECMO run but died on support. Seventeen (51%) patients required peritoneal dialysis for acute renal failure. Overall survival to discharge was 39% (13/33 patients). All patients with fulminant myocarditis and with refractory arrhythmias were weaned, and five (83%) survived, whereas no patient supported for sepsis survived. Risk factors for hospital mortality included lower (<2.5 kg) body weight (P = 0.02) and rescue ECMO after cardiac repair (P = 0.03). During a median follow‐up of 34 months (range 4–62 months), there were three (23%) late deaths and two late survivors with neurological sequelae. Weaning rate (5/7 vs. 21/26, P = NS) and prevalence of renal failure requiring dialysis (4/7 vs. 13/26, P = NS) were comparable between SP and ML ECMO groups. Patients supported with ML had a trend toward higher hospital survival (1/7 vs. 12/26, P = 0.07) and significantly higher late survival (0/7 vs. 10/26, P = 0.05). The present experience shows that V‐A ECMO for cardiac indications using centrifugal pumps in infants and children yields outcomes absolutely comparable to international registry (ELSO) data using mostly roller pumps. Although changes in practice may have contributed to these results, use of ML centrifugal pumps appears to further improve end‐organ recovery and hospital and late survival.     

Extracorporeal life support for posttraumatic acute respiratory distress syndrome at a children's medical center

Background: Primary traumatic injury was considered previously a contraindication for institution of extracorporeal life support because of high risk for persistent or new bleeding. Published experience in adults suggests that extracorporeal membrane oxygenation (ECMO) can successfully support trauma victims with pulmonary failure. The authors reviewed their experience with the use of ECMO in pediatric and adult trauma patients with acute respiratory distress syndrome (ARDS) at a children’s medical center.Methods: ECMO Center records from 1991 through 2001 (76 children, 8 adults) were reviewed to identify all patients with a primary or secondary ICD-9 diagnostic code of posttraumatic ARDS in addition to documented trauma.Results: Five children and 3 adults with traumatic injury and ARDS received ECMO support. Seven patients were injured in motor vehicle collisions; one patient suffered a gunshot wound to the chest. Patient ages ranged from 21 months to 29 years (pediatric median, 4 years; range, 21 months to 18 years). Four patients had pre-ECMO laparotomies, including 3 who required splenectomy. Four patients had liver lacerations, 3 had pulmonary contusions, and 1 had a renal contusion. Median ventilation before ECMO was 6 days (range, 2 to 10). Seven of 8 patients were placed on venovenous (VV) ECMO. Seven patients had significant bleeding on ECMO. Patients were treated with blood product replacement, epsilon-aminocaproic acid (EACA), and aprotinin infusions. Surgical intervention was not required for bleeding. Six patients received hemofiltration. Median time on ECMO was 653 hours (range, 190 to 921 hours). Six of 8 patients overall survived (75%). Four of 5 pediatric patients survived.Conclusions: Children and adults with severe posttraumatic ARDS can be treated successfully on VV extracorporeal support. Hemorrhage occurs frequently but is manageable.     

An extracorporeal membrane oxygenation-based approach to cardiogenic shock in an older population

BACKGROUND: We investigated the efficacy of an integrated system of advanced supportive care based on extracorporeal membrane oxygenation (ECMO) in older patients with an estimated mortality of more than 90% to establish whether its use is justifiable. METHODS: Treatment was provided by cardiac surgeons and critical care physicians and included the following key elements: (1) ECMO, (2) early application of continuous venovenous hemofiltration, (3) inhaled nitric oxide, (4) maintenance of perfusion pressure with norepinephrine, (5) maintenance of pulmonary blood flow by ventricular filling with intravenous colloids, (6) avoidance of early postoperative anticoagulation, (7) frequent use of transesophageal echocardiography, and (8) low tidal volume ventilation. Demographic features, intraoperative details, postoperative course, ECMO weaning rate, morbidity, survival to hospital discharge, and the quality of life of survivors were recorded. RESULTS: Seventeen consecutive patients (median age, 69 years) with refractory cardiogenic shock were studied. The median duration of ECMO was 86 hours (20 to 201 hours). Eleven patients (65%) were successfully weaned from ECMO. Seven patients (41%) survived to discharge. The major causes of morbidity were bleeding and leg ischemia. All patients who survived to discharge were alive and well at follow-up (median, 21 months) and reported a satisfactory quality of life. CONCLUSIONS: An ECMO-based approach can be used with acceptable results in the treatment of refractory cardiogenic shock, even in older patients.     

The effect of extracorporeal membrane oxygenation on the survival of neonates with high-risk congenital diaphragmatic hernia: 45 cases from a single institution

At The Children's Hospital, Boston (TCH), in the 3 years before extracorporeal membrane oxygenation (ECMO) was available, infants with high-risk congenital diaphragmatic hernia (CDH) had a 47% survival rate. In February 1984, ECMO was introduced and offered to all high-risk CDH infants with a 100% predicted mortality. Since February 1984, 45 infants with high-risk CDH presented to TCH. Twenty-six (58%) were supported with ECMO; 19 (42%) never met the criteria for 100% predicted mortality and were supported with conventional mechanical ventilation (CMV). Overall survival was 49%. Nine (35%) of the 26 ECMO patients survived. Thirteen (68%) of the 19 CMV patients survived. Although there was no change in survival, there was a change in the cause of death. Deaths in the ECMO group were either early (n = 8, secondary to a complication of ECMO or lack of pulmonary improvement) or late (n = 9). The late deaths were infants who were successfully weaned from ECMO, never weaned from CMV, and who died secondary to complications of chronic lung disease.     

体外膜式氧合支持治疗100例回顾性分析

目的 回顾性分析100例心肺功能衰竭患者应用体外膜式氧合(ECMO)支持治疗的临床经验.方法 2004年12月至2008年9月,对100例心肺功能衰竭患者行ECMO支持治疗.其中男性67例,女性33例;年龄5 d～76岁,平均(28±26)岁;体质量3.8～100.0 kg,平均(42±30)kg.采用全肝素涂抹技术的氧合器和离心泵ECMO系统,婴幼儿采用右心房-升主动脉插管,成人应用右心房-股动脉插管或股-动静脉插管,辅助期间流量40～220 ml·kg-1·min-1.结果 辅助时间12～504 h,平均(119±80)h.61例(61.0%)顺利撤离ECMO装置,ECMO平均时间(108±59)h;其中康复出院55例(90.2%),6例患者撤机后院内死亡.39例患者不能脱机或放弃治疗,ECMO平均时间(136±102)h.总出院率55.0%.存活患者ECMO前平均动脉压高于死亡患者(P=0.038);死亡患者ECMO前血乳酸水平高于存活患者(P=0.005).结论 ECMO支持是一种有效的循环呼吸衰竭辅助支持治疗方法,尽早对心肺衰竭患者使用ECMO支持治疗,避免重要脏器不可逆损伤,对提高治疗效果有积极的帮助.     

Pediatric extracorporeal membrane oxygenation in posttraumatic respiratory failure

The leading cause of death in the pediatric population in the United States is trauma. A retrospective review of patients treated with extracorporeal membrane oxygenation (ECMO) for traumatic respiratory failure was performed. Eight children were treated at the Ochsner Medical Foundation and additional data on six children were available from the National Registry. Six children developed respiratory failure as a result of blunt trauma and eight as a result of near drowning. Standard venoarterial ECMO was used with a circuit very similar to that used in neonatal ECMO. Vascular access was via the common carotid artery and the internal jugular vein. Ventilatory support was weaned to minimal settings during ECMO. Central hyperalimentation and systemic antibiotics were used in all of the cases. Four of six children survived in the blunt trauma group; three of eight children survived in the near drowning group. Although significant conclusions cannot be drawn from a small group of patients the average pre-ECMO PO2 for survivors was 87 mm Hg, whereas for nonsurvivors the average PO2 was only 46 mm Hg. Ventilatory support for both groups was not remarkably different, and the average PCO2 was lower in the nonsurvivor group. The cause of death in this group of patients is usually multisystem organ failure. In the four patients treated at Ochsner who did not survive, all had positive blood cultures and presumed systemic sepsis. ECMO has been demonstrated to be very successful in neonatal respiratory failure. Predicting mortality and morbidity in pediatric respiratory failure has been more difficult.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extracorporeal membrane oxygenation for the circulatory support of children after repair of congenital heart disease

We have treated 39 infants and children with congenital heart disease with extracorporeal membrane oxygenation during the past 5 years. Thirty-six were treated for low cardiac output or pulmonary vasoreactive crisis after repair of congenital heart defects. Twenty-two (61%) survived. Most patients were cannulated from the neck via the right internal jugular vein and the right common carotid artery. Six patients were cannulated from the chest, including three who had separate drainage of the left side of the heart with a left atrial cannula. Two of these patients survived and were the only survivors of the nine patients cannulated in the operating room because they could not be weaned from cardiopulmonary bypass after open cardiac operations. We also reviewed 312 patients (the predictor study series) having open cardiac operations before the availability of extracorporeal membrane oxygenation; 27 of these patients died. Data were collected at 1 and 8 hours postoperatively to determine if any parameters might predict early mortality. With these parameters used as criteria, patients who went on extracorporeal membrane oxygenation were as sick as those who died before extracorporeal membrane oxygenation was available. The most common complication was bleeding related to heparinization. The mean transfusion requirement in survivors was 1.50 +/- 1.13 ml/kg/hr, 5.63 +/- 7.0 ml/kg/hr in the nonsurvivors, and 7.46 +/- 8.29 ml/kg/hr in those cannulated in the operating room because they could not be weaned from bypass. Four children had intracranial hemorrhage, and two of them died. There was one late death. Nine of the 22 survivors are entirely normal. All survivors who do not have Down's syndrome are considered to have normal central nervous system function. We conclude that extracorporeal membrane oxygenation can improve survival in patients with both pulmonary artery hypertension and low cardiac output after operations for congenital heart disease.     

Continuous renal replacement therapy combined with extracorporeal membrane oxygenation in advanced cardiac failure patients

Acute renal failure during extracorporeal membrane oxygenation (ECMO) support is associated with extremely high mortality. This report describes treatment of myocardial dysfunction in one 48-year-old and one 11-year-old patient. Venoarterial ECMO was required to support myocardial dysfunction. Continuous venovenous hemodialysis was performed for acute renal failure with pulmonary edema and oliguria. Both patients survived following treatment with venoarterial ECMO combined with continuous venovenous hemodialysis.     

体外膜肺氧合在临床肺移植中的应用

目的 总结体外膜肺氧合(ECMO)技术在临床肺移植中应用的经验.方法 45例肺移植受者,年龄(50.5±8.6)岁(16～74)岁.原发病为肺纤维化合并肺动脉高压32例,慢性阻塞性肺病4例,矽肺2例,肺结核2例,弥漫性细支气管炎1例,支气管扩张2例,以及原发性肺动脉高压2例.其中3例受者在术前经股动、静脉切开置ECMO管道,分别维持13、19和6d后,在ECMO支持下接受了肺移植手术;40例受者在术中应用了ECMO辅助;2例未在体外循环下接受肺移植的受者,因原发性移植物功能丧失(PGD)于术后行ECMO辅助支持.结果 40例术中应用ECMO者,37例于术毕顺利撤除ECMO,术中辅助流量为(2.8±0.6)L/min,辅助持续时间为(7.7±0.9)h,存活31例;3例术后继续使用ECMO,直至血流动力学稳定,其中2例分别于术后36 h和7d时顺利撤除,另1例术后使用ECMO维持5d后出现急性肾功能衰竭,术后2周时死于多器官功能衰竭.2例术中无体外循环辅助受者和其余3例术中辅助受者因术后发生PGD或急性心力衰竭,而初次或再次使用ECMO,辅助流量分别为(2.5±0.3)L/min和(2.6±0.4)L/min,辅助持续时间分别为(53.5±21.9)h和(88.7±45.9)h,其中3例治愈出院,2例因多器官功能衰竭而死亡.所有受者均未发生明确与ECMO相关的并发症.结论 ECMO是肺移植围手术期支持的重要辅助工具,对于降低等待肺移植过程中的死亡率、稳定术中血流动力学、改善术后严重呼吸功能障碍以及原发性移植物功能不良,可以提供良好的辅助功能.     

The use of venovenous extracorporeal membrane oxygenation in sheep receiving severe smoke inhalation injury

Smoke inhalation injury now represents the most frequent cause of death in burn patients, and accounts for 20-80 per cent of overall mortality. We have studied the use of extracorporeal membrane oxygenation (ECMO) to support sheep which have received lethal pulmonary smoke damage. The animals (n = 19) received inhalation injury induced by insufflation with smoke derived from burning cotton delivered with a bee smoker. The treatment group, those placed on ECMO at the time of injury (n=6), were systemically heparinized and placed on a venovenous perfusion circuit consisting of a roller pump, membrane oxygenator and heat exchanger. Blood flow rate in the circuit approximated 20-25 per cent of cardiac output. The animals remained on partial venovenous bypass until the termination of the experiment 96 h after injury. All animals in the treatment group survived. The control sheep (n = 7) received inhalation injury alone and had a 100 per cent mortality (P = 0.0015 ECMO vs. control). Ventilatory management of treatment and control groups followed an identical protocol. We have also studied a third group (n = 6) composed of animals receiving inhalation injury with systemic heparinization but not ECMO. This group had a 66 per cent mortality at 96 h. These studies suggest that partial venovenous ECMO may be a valuable form of adjunctive treatment in severe inhalation injury.     

Selective use of extracorporeal membrane oxygenation in the management of congenital diaphragmatic hernia

Extracorporeal membrane oxygenation (ECMO) provides lung rest for moribund infants with congenital diaphragmatic hernia (CDH) after deterioration from a "honeymoon" period. This suggests that unstable pulmonary hypertension determines demise more than pulmonary hypoplasia. We avoided treating overwhelming pulmonary hypoplasia by using ECMO only if the premoribund condition had been marked by evidence of adequate lung parenchyma as a best preductal PO2 greater than 100 torr and PCO2 less than 50 torr with maximal therapy. Twenty-six CDH infants with respiratory distress within 4 hours survived operation. Five were not ECMO candidates, with best PO2 33 +/- 9, PCO2 157 +/- 30 torr, and died. Seven honeymoon infants, with best PO2 325 +/- 80, PCO2 27 +/- 5, survived without ECMO. Fourteen additional infants had honeymoon 26 +/- 13 hours with PO2 256 +/- 48, PCO2 30 +/- 8 followed by a-AdO2 gradients 600 torr x 16 +/- 4.5 hours despite maximal therapy. All 14 were treated with ECMO for 48 to 210 hours. Arterial blood gas values at initiation were PO2 34 +/- 6, PCO2 59 +/- 19, and pH 7.22 +/- 0.2. Right-to-left shunting due to pulmonary hypertension was documented by oximetry and two-dimensional echo/Doppler examination. Twelve of 14 (86%) ECMO-treated infants survived with normal arterial blood gas values on room air, no right-to-left shunting, and no gross neurologic sequellae to date. Two of 14 died.Improvement on ECMO was marked by positive hyperoxia response and decreased right-to-left shunting.(ABSTRACT TRUNCATED AT 250 WORDS)     

Venovenous Extracorporeal Membrane Oxygenation With Prophylactic Subcutaneous Anticoagulation Only: An Observational Study in More Than 60 Patients

Extracorporeal lung support and therapeutic anticoagulation are dogmatically linked for most clinicians in fear of clotting of the extracorporeal circuit. In the last decade, however, we have learned that bleeding complications in the course of extracorporeal membrane oxygenation (ECMO) therapy are common and not occasionally limiting or fatal. Even though international guidelines lowered the PTT‐target values, ECMO therapy without anticoagulation has only been reported sporadically in case reports heretofore. This monocentric, observational study was designed to evaluate a protocol for venovenous ECMO therapy without additional anticoagulation. Patients without former thrombotic events solely received thrombosis prophylaxis with 40 mg subcutaneous enoxaparin per day like every critical care patient. After approval by the local ethics committee (Albert‐Ludwigs‐University Freiburg ethics committee, EK 513/14) all consecutive patients treated with venovenous ECMO therapy since introduction of the protocol have been identified. Digital charts of the patients have been evaluated with special regard to bleeding and thrombotic or embolic events or breakdown of the extracorporeal circuit. Sixty‐one patients received venovenous ECMO therapy with prophylactic subcutaneous enoxaparin only. Median duration of ECMO therapy was 7 days (2–32). Overall 560 ECMO days have been observed. No system exchange because of thrombotic occlusion was necessary within the permitted 5 days run time of the centrifugal pump. Overall we identified thrombotic complications in four patients. In three of them centrifugal pump after a runtime of more than 5 days unexpectedly stopped completely because of thrombotic occlusion. In all cases pump exchange was performed promptly and patients did not incur hypoxic deficit. One other patient received substitution of blood products and coagulation factor concentrates because of severe bleeding and sustained myocardial infarction the day after. Only 18% of patients presented with essential clinical bleeding after 7 days of therapy. No fatal bleeding event and no intracranial hemorrhage was observed. Patients required only a third of blood product transfusion compared to published data. Venovenous ECMO therapy with prophylactic anticoagulation only was feasible in this study. It was not associated with an increased rate of system exchanges compared to regimes with therapeutic anticoagulation in registry data. It provides the potential to relevantly decrease the incidence of severe bleeding events and blood transfusion requirements. The apodictic adherence to anticoagulation in therapeutic dosage should be critically scrutinized in every patient.     

Expanded application of extracorporeal membrane oxygenation in a pediatric surgery practice

OBJECTIVE: To examine the breadth of application and resulting outcomes in a university-based extracorporeal membrane oxygenation (ECMO) program directed by pediatric surgeons. SUMMARY BACKGROUND DATA: Several randomized control trials have supported the use of ECMO in neonates with respiratory failure. No comparable data exist for older children and young adults who may be afflicted with a variety of uncommon conditions. The indications for ECMO in these patients remain controversial. METHODS: Patient data were recorded prospectively and reported to the Extracorporeal Life Support Organization. These data were analyzed by indications and outcomes on all patients treated since the inception of the program. RESULTS: Two hundred sixteen patients were treated with 225 courses of ECMO. Neonates (188 [87%]) outnumbered 28 older patients (aged 6 weeks to 22 years). Overall, 174 patients survived (81%). Sixty-four of 65 (98.5%) neonates with meconium aspiration syndrome survived. ECMO support after heart (3), lung (2), heart-lung (1), and liver (1) transplant yielded a 57% survival to discharge. ECMO also resulted in survival of patients with uncommon conditions, including severe asthma (1), hydrocarbon aspiration (1/2), congestive heart failure due to a cerebral arteriovenous malformation (1), tracheal occlusion incurred during endoscopic stent manipulation (2), meningitis (1), and viral pneumonia (3/5). CONCLUSIONS: ECMO can potentially eliminate mortality for meconium aspiration syndrome. Survival for other causes of respiratory failure in neonates and older children, while not as dramatic, still surpasses that anticipated with conventional therapy. Moreover, survival of transplant patients has been comparable to that achieved in other children.     

Effect of pulmonary support using extracorporeal membrane oxygenation for adult liver transplant recipients with respiratory failure

BackgroundAdult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation.MethodsFrom January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT.ResultsA venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO.ConclusionsECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.     

Extracorporeal membrane oxygenation for cardiac failure after congenital heart operation.

Despite continuing improvement in myocardial protection and surgical technique, the repair of complex congenital heart lesions can result in cardiopulmonary compromise refractory to conventional therapy. In a 29-month period, 24 patients (aged 14 hours to 6 years) were treated with extracorporeal membrane oxygenation (ECMO) 28 times for profound cardiopulmonary failure. Four patients required ECMO after each of two cardiopulmonary bypass procedures. Seventeen patients required ECMO to be initiated in the operating room: 12 (71%) were weaned successfully from ECMO, and 8 (47%) survived. Seven patients had ECMO initiated in the intensive care unit: 6 (86%) were weaned, and 5 (71%) survived. Serial echocardiograms demonstrated substantial recovery of cardiac function in 18 of 21 instances (86%) of ventricular failure from myocardial dysfunction. Overall, 18 of 24 patients (75%) were successfully weaned from ECMO including all 4 who underwent 2 ECMO treatments. We conclude that ECMO can successfully salvage children who have serious cardiopulmonary failure immediately after a congenital heart operation and that long-term survival is possible after two ECMO treatments.     

Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in children

Size limitations and technical barriers prohibit the use of many conventional mechanical circulatory support systems for postcardiotomy ventricular dysfunction in pediatric populations. Extracorporeal membrane oxygenation (ECMO), frequently used to treat neonatal respiratory failure, can provide cardiac support and is effective treatment of postoperative myocardial failure in children. From 1981 to 1987, 10 patients aged 2 days to 5 years were maintained on ECMO for 15 to 144 hours (mean duration, 92 +/- 16 hours) after cardiotomy. Operative procedures included repair of tetralogy of Fallot (2 patients), closure of a ventricular septal defect (2), the Senning procedure for transposition of the great arteries (1 patient), repair of interrupted aortic arch with closure of a ventricular septal defect (1), repair of a partial atrioventricular septal defect (2), closure of a ventricular septal defect with excision of an anomalous muscle bundle (1), and the Fontan procedure (1). Venoarterial ECMO was established in all 10 children. Six patients underwent transthoracic right atrium-ascending aorta cannulation, 3 had right internal jugular vein-right common carotid artery cannulation through a cervical incision, and 1 had right internal jugular vein-left axillary artery cannulation. Eight of the 10 patients were successfully weaned from ECMO, and 7 are long-term survivors. There were 3 deaths; 1 was caused by cardiac and acute renal failure complicated by sepsis two days after decannulation, another occurred 19 days after atrioventricular septal defect repair, and 1 was caused by massive pulmonary hemorrhage. Major hemorrhage developed in 3 patients while on ECMO; 2 required premature decannulation for mediastinal bleeding from operative sites and ultimately survived, and 1 died of respiratory failure as a result of endobronchial bleeding. We conclude that the use of ECMO in pediatric populations for transient postoperative ventricular dysfunction improves survival with limited overall morbidity.     

序贯式双肺移植九例报告

目的探讨9例序贯式双肺移植的手术指征和安全性。方法自2003年1月至2005年6月，共进行了9例序贯式双肺移植。2例受者在第1侧肺植入后恢复通气和灌注，再作第2侧肺的切除和植入；6例在第1侧肺植入后使用体外膜氧合（ECMO），再完成第2侧肺的切除和植入；1例在体外循环（CPB）下完成，同时使用一氧化氮（NO）吸入。结果前2例患者术中出现严重的移植肺水肿，术后仅生存12和36h。使用ECMO的6例患者均安全渡过手术关，术后移植肺氧合良好，拔除口插管时间为36～72h，平均为48h，其中4例患者顺利恢复出院，最长已生存16个月，1例术后1个月死于肺部感染大咯血，1例术后3周死于肾功能衰竭。使用CPB的1例患者术中死于大量渗血和严重的酸中毒。结论序贯式双肺移植手术指征较广，但手术风险大；使用ECMO可显著提高手术的安全性。