体外膜肺氧合辅助心肺复苏治疗儿童心搏骤停临床效果分析

［摘要］　目的　分析体外膜肺氧合（ECMO）辅助心肺复苏（CPR）救治儿童心搏骤停（CA）的临床效果。方法　回顾性分析2015年12月至2022年12月在上海市儿童医院儿童重症监护室（PICU）因CA接受ECMO辅助CPR治疗的8例患儿的临床资料，包括原发疾病、CPR前儿童序贯器官衰竭评估（pSOFA）评分和血管活性药物评分（VIS）、CPR至ECMO转流时间间隔、ECMO置管方式、ECMO运行时长、ECMO撤离成功率、出院存活率以及ECMO转流前和转流24 h后实验室检查指标等。结果　8例接受ECMO辅助CPR治疗的CA患儿中，死亡5例，存活3例，ECMO撤离成功率和出院存活率均为37.50%（3/8）。原发疾病7例为暴发性心肌炎，1例为脓毒性休克。3例患儿为右侧颈内静脉/颈动脉切开置管，5例患儿为股静脉/股动脉置管。ECMO运行中位时长为50.50（3.00，210.00）h，CPR至ECMO转流最短时间间隔为18 min，最长为150 min。转流后6例患儿予床旁连续性肾脏替代治疗（CRRT）辅助治疗，4例行左心减压。ECMO相关并发症包括出血8例，弥散性血管内凝血（DIC）6例，溶血3例，血栓1例，肢端缺血1例，神经系统损伤1例。ECMO转流24 h后患儿血肌酐及肝酶学指标均较转流前显著升高（P<0.05）。与死亡组比较，存活组患儿ECMO转流24 h后乳酸（Lac）水平显著下降（P<0.05）。结论　体外心肺复苏（ECPR）患儿的出院存活率仍较低，出凝血事件发生率高，ECMO转流后24 h Lac水平迅速下降可能提示预后良好。     

急性呼吸衰竭ECMO支持患儿病原学及临床因素对结局的影响分析

［摘要］　目的　分析急性呼吸衰竭需体外膜肺氧合（ECMO）支持治疗患儿的病原学及临床因素对结局的影响。方法　收集2019年1月至2023年6月在广西壮族自治区人民医院儿童重症监护室（PICU）住院的因急性呼吸衰竭行ECMO支持治疗的28例患儿的临床资料,分析年龄、性别、原发疾病、病原学、ECMO支持模式、ECMO上机前后的P/F指数及乳酸水平、上机前Murray肺损伤评分、ECMO支持时长、ECMO前后机械通气时长等对ECMO结局的影响。结果　28例接受ECMO治疗的急性呼吸衰竭患儿中存活17例,死亡11例;细菌感染5例,病毒感染9例,细菌及病毒混合感染6例,病原菌阴性者8例。存活组与死亡组患儿在ECMO前P/F指数、乳酸水平、ECMO支持时长、ECMO前后机械通气时长比较差异无统计学意义（P>0.05）,ECMO支持模式差异有统计学意义(P<0.05)。细菌感染组、病毒感染组、细菌+病毒混合感染组及阴性组在ECMO前后P/F指数和乳酸水平、ECMO支持时长、ECMO后机械通气时长及结局方面比较差异无统计学意义（P>0.05）,但在ECMO前Murray肺损伤评分方面差异有统计学意义(P<0.05),以细菌+病毒混合感染组评分最高。结论　病原学情况对肺部Murray肺损伤评分有影响,但对ECMO支持时长、ECMO后机械通气时长及ECMO的结局无明显影响。此外,静脉-动脉体外膜肺氧合（VA-ECMO）与静脉-静脉体外膜肺氧合（VV-ECMO）模式对患儿的生存结局亦有影响。     

婴儿先天性心脏病手术后获得性声门下狭窄易感因素

目的 探讨婴儿先天性心脏病手术后获得性声门下狭窄（acquired subglottic stenosis,ASGS）的易感因素.方法 回顾性分析广东省人民医院2004年1月至2010年12月收治的通过纤维支气管镜检查诊断为先天性心脏病术后并声门下狭窄,年龄＜1岁婴儿的临床资料.结果 共42例患儿纳入研究,男27例,女15例,年龄2.0（0～11）个月,体质量4（3.0～7.0）kg.Ⅰ度ASGS 7例、Ⅱ度15例、Ⅲ度20例,无Ⅳ度患儿.所有患儿的气道问题都在本院完成从临床观察、保守疗法和（或）气管扩张术的治疗,40例完成随访,均治愈,2例失访,随访时间21（2～84）个月.所有患儿均有接受先天性心脏病外科手术麻醉气管插管的病史.其中0～1个月、2～6个月及7～11个月婴儿在本院小儿心外手术麻醉后的ASGS发生率分别为3.12％ （20/642）、1.25％（18/1445）及0.25％（4/1573）.气管内置管时间为（6.44±0.71）d,在＜1岁心脏手术后患儿中,置管时间≥4d的ASGS的发生率为4.07％ （31/761）,较置管时间24～96 h及＜24 h的1.42％（8/564）及0.13％（3/2335）明显增加,差异有统计学意义（P＜0.05）.合并感染31例,置管＜4 d（11例）和≥4d（31例）患儿的感染发生率分别为27.27％（3/11）及90.32％（28/31）,两组比较,差异有统计学意义有（P＜0.05）;气管插管内径为（4.14±0.35）mm;有反复气管插管史患儿占50.0％（21例）.结论 先天性心脏病心外手术时麻醉气管插管损伤是本组ASGS的最重要的原因,年龄越小发生率越高,年龄、气管内置管时间、管径大小、感染及插管次数可能是ASGS的危险因素.本组患儿预后良好.     

家庭中心护理干预对小儿先天性心脏病术后康复的效果分析

目的分析家庭中心护理干预对小儿先天性心脏病术后康复的效果。方法选取2015年2月~2016年6月收治的先天性心脏病患儿69例的临床资料,将其分为对照组34例、观察组35例,前者行常规护理,后者行家庭中心护理,观察比较两组术后康复效果及并发症情况。结果对照组住院时间较观察组长,其生理机能、精神状态评分较观察组评分低(P0.05);对照组并发症率20.58%高于观察组的8.57%(P0.05)。结论家庭中心护理可有效促进先天心脏病患儿术后恢复,提高生存质量,减少并发症。     

小儿复杂先天性心脏病术后体外膜肺氧合辅助疗效及其影响因素分析

目的通过分析体外膜肺氧合(ECMO)技术在小儿复杂先天性心脏病术后应用前后的临床数据及治疗情况,为进一步提高ECMO辅助病人抢救的成功率提供依据。方法回顾分析2012年1月至2015年6月我中心31例接受ECMO辅助患儿的临床资料。患儿应用ECMO的指征为:术中难以脱离体外循环机和术后出现严重低心排或心跳骤停,经常规治疗仍无效者。结果患儿年龄53天~8.0岁,体重4.3~28.3kg。ECMO辅助时间70~355(146.48±66.82)小时,31例患儿中脱离ECMO辅助22例(71.0%),最终存活15例(48.4%),死亡16例(51.6%)。死亡组患儿应用ECMO辅助前的血管活性药物评分平均为64.69,明显高于存活组的48.03。死亡原因有心功能持续不恢复9例、脑死亡3例、感染2例、肾功能衰竭2例。结论 ECMO适应症的选择和期间的精细管理、降低相关并发症是影响ECMO辅助疗效的影响因素。     

右腋下小切口小儿先天性心脏病手术围术期的护理

目的探讨右腋下小切口小儿先天性心脏病手术围术期较佳的护理方案。方法将64例手术患儿随机分为观察组和对照组,每组各32例,观察组给予健康教育、心理护理和临床护理,对照组给予常规的临床护理。观察两组患儿术后并发症发生率、术后呼吸机辅助时间、胸液引流量及住院时间。结果两组患儿均顺利完成手术,观察组患儿术后疼痛、肺部感染、肺不张等并发症发生率比对照组明显减少（P〈0.05）,术后呼吸机辅助时间、胸液引流量及住院时间比对照组明显减少（P〈0.05）。结论对右腋下小切口小儿先天性心脏病手术患儿及家长,给予健康教育、心理护理和临床护理,可明显提高医疗护理质量,确保手术安全和成功,是围术期较佳的护理方案,具有广阔的应用前景。     

先天性心脏病对儿童心理行为的影响

目的 研究先天性心脏病对儿童心理行为的影响,并对照研究介入治疗与外科手术对先天性心脏病患儿术后心理行为的影响. 方法 采用徐韬园1992年修订的Achenbach儿童行为量表对232例先天性心脏病患儿进行心理行为检测. 结果 先天性心脏病儿童心理行为异常检出率显著高于对照组.先天性心脏病各组患儿心理行为总粗分显著高于对照组(P＜0.01),先天性心脏病患儿心理行为粗分均值亦高于对照组(P＜0.01或P＜0.05).男孩主要表现在抑郁、交往不良、体诉(各种躯体不适的反应)、社会退缩、违纪及攻击方面,女孩主要表现在抑郁、社会退缩、体诉、违纪方面.术后测试,男、女两治疗组心理行为总粗分分别显著低于治疗前(P＜0.01).介入组男孩术后总粗分及攻击行为粗分分别低于外科组,差异具有统计学意义(P＜0.05),介入组女孩术后心理行为总粗分及抑郁、社会退缩和违纪行为粗分分别低于外科组,差异具有统计学意义(P＜0.05).心理行为因子异常检出率与病程呈正相关,病程越长检出率越高. 结论 先天性心脏病患儿存在着明显的心理行为问题,应引起重视.早期治疗以及采用介入治疗方式可较明显改善先天性心脏病患儿的心理行为状况.     

先天性心脏病患儿术后神经智力发育随访测试

目的:了解先天性心脏病患儿术后神经智力发育状况及影响神经智力发育的围术期危险因素。方法:对89例先天性心脏病术后门诊复查患儿及90例相同年龄段无心脏疾病正常儿童进行神经智力发育评估。将先天性心脏病患儿分为简单先天性心脏病组(RACHS-1评分≤2级)和复杂先天性心脏病组(RACHS-1评分≥3级),分组进行儿心量表各项目评估分析,并与正常儿童进行对比;分析患儿围术期参数与神经智力发育的相关性。结果:正常儿童神经智力发育情况优于整体先天性心脏病组患儿(P0.05)。简单先天性心脏病组患儿发育商优于复杂先天性心脏病组患儿(P0.05),与正常儿童发育商分布类似(P=0.420)。复杂先天性心脏病组患儿发育商值处于中等程度以下的比例高于简单先天性心脏病组患儿(P=0.032)和正常儿童(P0.001)。多元回归分析提示,先天性心脏病患儿接受手术治疗时低月龄与神经智力发育落后相关性显著(P0.05)。术前血浆尿素氮(BUN)降低、肌酐(Cr)升高以及术中体外循环(CPB)时间延长与神经智力发育落后存在相关性(P0.05)。结论:复杂先天性心脏病组患儿存在明显神经智力发育落后。手术治疗时月龄、术前BUN值、术前Cr值以及术中CPB时间与先天性心脏病患儿远期神经智力发育具有相关性。     

舒适护理在小儿先天性心脏病手术中的应用

目的探讨小儿先天性心脏病患者进行舒适护理的意义。方法选取2014年11月~2015年10月我院收治的先天性心脏病患儿54例为研究对象,根据其住院顺序分为观察组和对照组,各27例。对照组只进行常规护理,观察组在常规护理的基础上加入舒适护理。比较两组患儿在术后1年的恢复情况,包括术后并发症、住院时间。结果观察组并发症情况优于对照组,差异有统计学意义(P0.05);观察组的住院时间为(5.27±1.75)天,低于对照组的(7.05±2.01)天,差异有统计学意义(P0.05)。结论对先天性心脏病手术患儿采用舒适护理干预,能减少并发症及住院时间,值得临床推广。     

体外膜肺氧合在心血管急危重症的临床应用

目的总结体外膜肺氧合(ECMO)在心血管急危重症临床应用的经验,评价其疗效。方法纳入2019年3月至2019年9月兰州大学第一医院收治并行ECMO辅助治疗的患者24例。其中,经皮冠状动脉介入治疗(PCI)组12例均在手术室建立ECMO,心原性休克组12例均在冠心病重症监护室(CCU)建立ECMO。回顾性分析24例患者的临床资料。结果 PCI组12例均在导管室手术完成后顺利撤离ECMO(脱机率12/12),12例均存活出院(生存率12/12);ECMO辅助时间1.3～4(2.6±1.5)h,辅助流量1.7～2.8(2.1±0.4)L/min;2例联合应用主动脉内球囊反搏(IABP)治疗。PCI组完全再血管化达11例(11/12),1例因右冠状动脉慢性完全闭塞反复尝试后未开通。PCI组患者术后第7天左心室射血分数(LVEF)较术前差异无统计学意义(P0.05)。心原性休克组12例患者中10例顺利脱离ECMO(脱机率10/12),8例存活出院(存活率8/12),2例成功撤除ECMO后死亡(下消化道出血1例,无法脱离IABP 1例);ECMO辅助时间73～223(139.2±46.6)h;术后第7天LVEF较术前明显增加(P0.05)。24例患者均无机械故障及氧合器故障,无脱管,无下肢缺血坏死,无心脏压塞;共发生出血并发症11例。结论 ECMO是急危重症冠心病行PCI的重要的保驾护航手段之一,可以使得心原性休克患者获益,提高心原性休克生存率。高效的ECMO团队、ECMO时机的把握、精细化个体化管理、有效控制和预防并发症是ECMO救治成功的关键因素。     

Three layer functional model and energy exchange concept of aging process

Relying on a certain degree of abstraction, we can propose that no particular distinction exists between animate or living matter and inanimate matter. While focusing attention on some specifics, the dividing line between the two can be drawn. The most apparent distinction is in the level of structural and functional organization with the dissimilar streams of ‘energy flow’ between the observed entity and the surrounding environment. In essence, living matter is created from inanimate matter which is organized to contain internal intense energy processes and maintain lower intensity energy exchange processes with the environment. Taking internal and external energy processes into account, we contend in this paper that living matter can be referred to as matter of dissipative structure, with this structure assumed to be a common quality of all living creatures and living matter in general. Interruption of internal energy conversion processes and terminating the controlled energy exchange with the environment leads to degeneration of dissipative structure and reduction of the same to inanimate matter, (gas, liquid and/or solid inanimate substances), and ultimately what can be called ‘death.’ This concept of what we call dissipative nature can be extended from living organisms to social groups of animals, to mankind. An analogy based on the organization of matter provides a basis for a functional model of living entities. The models relies on the parallels among the three central structures of any cell (nucleus, cytoplasm and outer membrane) and the human body (central organs, body fluids along with the connective tissues, and external skin integument). This three-part structural organization may be observed almost universally in nature. It can be observed from the atomic structure to the planetary and intergalactic organizations. This similarity is corroborated by the membrane theory applied to living organisms. According to the energy nature of living matter and the proposed functional model, the decreased integrity of a human body's external envelope membrane is a first cause of the structural degradation and aging of the entire organism. The aging process than progresses externally to internally, as in single cell organisms, suggesting that much of the efforts towards the restoration and maintenance of the mechanisms responsible for structural development should be focused accordingly, on the membrane, i.e., the skin. Numerous reports indicate that all parts of the human body, like: bones, blood with blood vessels, muscles, skin, and so on, have some ability for restoration. Therefore, actual revival of not only aging tissue of the human body's membrane, but the entire human body enclosed within, with all internal organs, might be expected. We assess several aging theories within the context of our model and provide suggestions on how to activate the body's own anti-aging mechanisms and increase longevity. This paper presents some analogies and some distinctions that exist between the living dissipative structure matter and inanimate matter, discusses the aging process and proposes certain aging reversal solutions.     

Unusual responses of nocturnal pineal melatonin synthesis and secretion to swimming: Attempts to define mechanisms

Abstract: The effect of swimming at night on rat pineal melatonin synthesis was compared with that of light exposure at night. Rats were forced to swim at 0030 hr (lights out at 2000 hr) and sacrificed by decapitation 15 and 30 min later, immediately after swimming. Other groups of animals were exposed to white light (650μW/cm²) for 15 and 30 min at same time. Swimming caused a rapid and highly significant drop in the melatonin content in the pineal gland; however, the activity of N-acetyltransferase (NAT), the supposed rate limiting enzyme in the melatonin production, was not changed. Despite the drop in pineal melatonin levels, serum concentrations of the indole remained elevated in the rats that swam. In contrast, melatonin levels in the pineal and serum of light exposed rats fell precipitously, accompanied by a significant suppression of NAT activity. Since we anticipated that the strenuous exercise associated with swimming may induce release of artrial natriuretic peptide (ANP) from the heart, which in turn could cause the release of pineal melatonin, in a second study we injected physiological saline intravenously to stretch the cardiac muscle and release ANP. Three milliliters of normal saline was injected during the day into the jugular vein of anesthetized rats that were pretreated with isoproterenol to stimulate pineal melatonin production. Animals were killed 15 min after the saline injection, and pineal NAT activity and pineal melatonin levels were measured. The saline injections caused no alteration in the elevated levels of either NAT or melatonin. These data suggest that the disparity in pineal NAT activity (which was high) and pineal melatonin (which was low), in animals swum at night, may not be caused by ANP which is released during strenuous exercise such as swimming.     

Melatonin and photoperiodic time measurement: Seasonal breeding in the sheep

Abstract: Well-established circadian physiology supports the view that photoperiodic time measurement utilizes the coincidence between the presence of light and a photosensitive phase of a 'biological clock' to alter reproductive status—the so-called external coincidence model of seasonal breeding. In this review, we examine the mechanism whereby photoperiod interacts with presumed suprachiasmatic nuclei activity to allow endogenous melatonin to normally synchronize reproductive activity to the optimal time of year. The Romney Marsh sheep is particularly explored as an experimental model. It is suggested that the on/off activity of seasonal reproduction may be a robust mechanism able to be predictably manipulated by the judicious use of the light/dark cycle and exogenous melatonin, but firmly based on circadian principles.     

The immunoneuroendocrine role of melatonin

Abstract: A tight, physiological link between the pineal gland and the immune system is emerging from a series of experimental studies. This link might reflect the evolutionary connection between self-recognition and reproduction. Pinealectomy or other experimental methods which inhibit melatonin synthesis and secretion induce a state of immunodepression which is counteracted by melatonin. In general, melatonin seems to have an immunoenhancing effect that is particularly apparent in immunodepressive states. The negative effect of acute stress or immunosuppressive pharmacological treatments on various immune parameters are counteracted by melatonin. It seems important to note that one of the main targets of melatonin is the thymus, i.e., the central organ of the immune system. The clinical use of melatonin as an immunotherapeutic agent seems promising in primary and secondary immunodeficiencies as well as in cancer immunotherapy. The immunoenhancing action of melatonin seems to be mediated by T-helper cell-derived opioid peptides as well as by lymphokines and, perhaps, by pituitary hormones. Melatonin-induced-immuno-opioids (MHO) and lymphokines imply the presence of specific binding sites or melatonin receptors on cells of the immune system. On the other hand, lymphokines such as -γ-interferon and interleukin-2 as well as thymic hormones can modulate the synthesis of melatonin in the pineal gland. The pineal gland might thus be viewed as the crux of a sophisticated immunoneuroendocrine network which functions as an unconscious, diffuse sensory organ.     

Serological survey of HIV and syphilis in pregnant women in Madagascar

Objectives Peripartal transmission of human immunodeficiency virus (HIV) and Treponema pallidum, the causative agent of syphilis, leads to severe consequences for newborns. Preventive measures require awareness of the maternal infection. Although HIV and syphilis testing in Madagascar could be theoretically carried out within the framework of the national pregnancy follow‐up scheme, the required test kits are rarely available at peripheral health centres. In this study, we screened blood samples of pregnant Madagascan women for HIV and syphilis seroprevalence to estimate the demand for systemic screening in pregnancy. Methods Retrospective anonymous serological analysis for HIV and syphilis was performed in plasma samples from 1232 pregnant women that were taken between May and July 2010 in Ambositra, Ifanadiana, Manakara, Mananjary, Moramanga and Tsiroanomandidy (Madagascar) during pregnancy follow‐up. Screening was based on Treponema pallidum haemagglutination tests for syphilis and rapid tests for HIV, with confirmation of positive screening results on line assays. Results Out of 1232 pregnant women, none were seropositive for HIV and 37 (3%) were seropositive for Treponema pallidum. Conclusions Our findings are in line with previous studies that describe considerable syphilis prevalence in the rural Madagascan population. The results suggest a need for screening to prevent peripartal Treponema pallidum transmission, while HIV is still rare. If they are known, Treponema pallidum infections can be easily, safely and inexpensively treated even in pregnancy to reduce the risk of transmission.     

Response of rat pineal melatonin to calcium, magnesium, and lithium is circadian stage dependent

Abstract: Herein we documented the response of pineal melatonin production to electrolytes known to be effective on pineal function in view of a possible circadian stage dependence. We studied the release of melatonin by perifused rat pineal glands at 2 different circadian stages corresponding to the middle of the light and dark periods, i.e., respectively, 7 and 19 HALO (Hours After Light Onset, L:D = 12:12). The initial efflux rates were, as expected, much higher in the perifusates of glands removed from rats sacrificed during the dark phase than of those removed during the light phase. After 3 hr of perifusion, melatonin release reached similar levels which were found constant up to the 8th hr of perifusion, whatever the circadian stage. Perifusion of the glands with physiological concentrations for the rat of calcium (5.2 mmol/1) and magnesium (1.34 mmol/1) resulted in a stimulatory effect on the pineal glands removed from rats sacrificed in the middle of the dark period (19 HALO), whereas no effects were observed on the pineal glands removed from rats sacrificed during the light (7 HALO). Lithium (0.28 and 0.55 mmol/1) was ineffective on melatonin release in pineal glands removed 7 and 19 HALO. Our results show differences in the initial efflux rates of melatonin and in the response of perifused pineal glands to calcium and magnesium according to the circadian stage.