体外膜氧合支持治疗成功小儿重症肺炎合并心肺功能衰竭一例

目的 报道体外膜肺氧合(ECMO)在小儿重症肺炎合并心肺功能衰竭中的临床应用结果及经验.方法 2008年11月28日,我院儿童重病中心收治1例小儿重症肺炎合并心肺功能衰竭、肝功能严重受损及中毒性脑病的7岁男童,在经过以呼吸机为主的常规方法治疗后仍持续低氧血症且病情有进一步加重的情况下实施右侧股动静脉V-A ECMO辅助方式对患儿心肺进行支持治疗.结果 ECMO初始流量为0.8 L/min,氧流量与血流最之比为1:1,FiO_260%.ECMO开始后10 min,从桡动脉采血,PaO_2迅速从40 mm Hg(1 mm Hg=0.133 kPa)升至177 mm Hg,PCO_2 21 mm Hg,Lac开始下降,由3.5 mmol/L降至2.8 mmol/L.ECMO治疗后4 h,PaO_2202 mm Hg,PCO_244 mm Hg,Lac1.5 mmol/L,将ECMO流最调至0.6 L/min,FiO_2 60%,PaO_2持续维持在150～200 mm Hg.使用ECMO期间,患儿血压稳定,心功能明显好转,心率减慢,肝脏回缩,肝功能好转,瞳孔等大等圆,对光反射灵敏,胸部X线片示肺部炎症逐渐吸收.使用ECMO后第4天,将流量降到0.4 L/min[20 ml/(kg·min)],FiO_2下调到40%,动脉血气分析示:PaO_2 190 mm Hg,PCO_2 36 mm Hg,SaO_2 100%,Lac0.9 mmol/L,于治疗后96 h停止ECMO.ECMO停止后36 h,顺利拔出气管插管,术后2周痊愈出院.ECMO并发症:主要有出血和渗血;血小板有所下降,从230×10~9/L降至130×10~9/L,仍在正常范围.结论 ECMO是疗效肯定、有前景的心肺支持治疗方法,可用于儿科重病患者.

Extracorporeal membrane oxygenation for severe acute respiratory and heart failure in a child with severe pneumonia

Objective To report clinical application of Extracorporeal membrane oxygenation for severe acute respiratory and heart failure in a child with severe pneumonia. Method A seven-year old male patient with severe pneumonia complicated with heart and lung function failure was admitted to PICU in 28th of December,2008. Veno-artery access was set up via euthyphoria cannulation in operative incision. Blood was drained from the right atrium through a cannula introduced via femoral veins, and returned via femoral artery. The inter-surface of the ECMO equipment system was completely coated with heparin-coating technique. Anticoagulation was maintained with heparin to keep the activated clotting time (ACT) between 150 and 200 seconds and heparin usage dose was 10 U/(kg·h), mean blood flow was 1/2-2/3 of 80-120 ml/(kg·min) during ECMO assistant period. During ECMO, ventilator settings were gradually reduced to allow lung rest, i.e. peak inspiratory pressure less than 25 cm H_2O (1 cm H_2O=0.098 kPa), end expiratory pressure 8-10 cm H_2O, rate 10-15 breaths per minute and FiO_2 30%-40%. Results In management of ECMO, the incipient blood flow was set at 0.8 L/min, the radio of oxygen and blood flow was 1 : 1, FiO_2 60%. After ten minutes of ECMO working, the blood oxygen saturaton of radial artery increased from 40 mm Hg (1 mm Hg =0.133 kPa) to 177 mm Hg, Lac decreased from 3.5 mmol/L to 2.8 mmol/L. Four hours later, blood gas analysis of radial artery showed PaO_2 202 mm Hg, PCO_2 44 mm Hg, Lac 1.5 mmol/L, blood flow was set at 0.6 L/min, FiO_2 60%, PaO_2 kept above 150 mm Hg. 96 hours after ECMO surporting,the blood flow was set at 0.4 L/min [20 ml/(kg·min)], the results of blood gas analysis of radial artery was PaO_2 190 mm Hg , PaCO_2 36 mm Hg, SaO_2 100% ,Lac 0.9 mmol/L, then the child weaned off successfully from ECMO. Two days later, the child was successfully extubated. After two weeks treatment,the patient was discharged. The main complication associated with extracorporeal membrane oxygenation were bleeding. Conclusion ECMO is an effective mechanical assistant therapy method for severe pulmonary and cardiac failure in a child.