体外膜肺氧合在儿童呼吸衰竭中应用的多中心调查

目的 分析中国大陆地区PICU应用体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)技术支持儿童呼吸衰竭的治疗效果.方法 采用问卷调查方法回顾2011年6月至2016年2月中国大陆地区三级儿童专科医院或综合医院PICU应用ECMO支持因重症肺炎、急性呼吸窘迫综合征等导致的呼吸衰竭,且常规呼吸支持方式效果不佳患儿的治疗情况及预后.结果 至2016年2月,共有来自4家医院的21例儿童呼吸衰竭患者接受ECMO治疗,平均年龄29.0(9.0,81.5)个月,平均体重12.0(9.0,20.8)kg.原发病为重症肺炎7例(33%),重症肺炎合并急性呼吸窘迫综合征6例(29%).21例患儿中成功撤离ECMO 12例(57%),出院存活率38%.患儿P/F比值均数为56.0(44.5,69.0)mmHg(1mmHg=0.133kPa).ECMO治疗前OI值31.5(19.2,41.0),ECMO治疗24h后OI值6.2(3.8,14.9);患儿经ECMO治疗24h后血气分析PO2、SaO2均有明显上升,PO2从ECMO前的49.5(40.4,61.9)mmHg升至65.0(42.6,120.5)mmHg,并且存活者上升水平显著高于死亡者[52.0(1.8,89.4) mmHg比8.2(-15.1,33.9) mmHg,P=0.036];SaO2从ECMO前的80%(70.35%,91.75%)升至98%(95.65%,100%),存活者SaO2上升水平显著大于死亡者[23.5%(11.4%,27.1%)比4.3%(2.4%,23.8%),P=0.039].ECMO的使用降低了呼吸机参数及平均气道压.ECMO平均治疗时间149(91.25,242)h,平均费用15.88(12.57,24.08)万元.VV置管模式存活率比VA置管模式高(3/3例 比 5/18例);ECMO前使用呼吸机时间越长,病死率越高,死亡组呼吸机治疗时间明显长于存活组[4.5(2.5,12.0)h比1.6(1.0,2.2)h,P=0.015].ECMO并发症主要为出血,本次调查出血发生率为38%,血流感染发生率为9.5%.结论 ECMO可以明显改善呼吸衰竭患儿的氧合情况.     

儿童暴发性心肌炎清醒体外膜肺氧合治疗三例报道

目的:探讨清醒体外膜肺氧合(ECMO)支持在儿童暴发性心肌炎患者中应用的有效性和可行性。方法:回顾分析2019年3月至2019年9月八一儿童医院PICU收治的3例清醒ECMO支持的暴发性心肌炎患儿资料,分析病例资料、管理及预后,对比治疗前后超声数据,总结呼吸机、ECMO使用时间,介绍清醒ECMO治疗在儿科应用的经验及可行性。结果:3例患儿行清醒ECMO,撤离呼吸机后,其中1例患儿因恶性心律失常再次行机械通气,最终3例患儿心功能恢复,其中1例遗留肾功能不全,3例患儿均存活出院。结论:静脉-动脉ECMO支持的儿童暴发性心肌炎,撤离呼吸机行清醒ECMO支持是可行的,有必要针对儿童清醒ECMO进行进一步研究。     

12例心脏病术后患儿体外膜肺的临床结果及经验

目的回顾性总结分析阜外心血管病医院12例儿童体外膜肺氧合(ECMO)支持治疗的临床结果和经验。方法2004年12月~2005年12月共实施儿童ECMO病例12例,所有患儿均使用Medtronic ECMO系统,管道、氧合器及离心泵内膜采用全肝素涂抹技术,行静脉-动脉ECMO辅助,激活凝血时间维持146~258 s,肝素用量5~20 U/(kg.h)。辅助期间平均流量在40~220 ml/(kg.min)。结果ECMO支持时间55~266 h,平均120 h;9例(75%)顺利撤离ECMO,其中6例康复出院(67%),3例术后死亡,3例不能撤离ECMO而放弃治疗;总出院率为50%(6/12)。存活出院患儿EC-MO前的动脉血乳酸水平明显低于死亡患儿(P=0.022),两组患儿体重也存在统计学差异(P=0.019)。结论ECMO支持在儿童复杂先天性心脏病术后循环呼吸衰竭的治疗中是一种有效的机械辅助方法,同时可以作为心脏移植患儿等待供体期间的过渡桥梁。手术畸形纠治满意、尽早对心肺衰竭的患儿使用ECMO支持、避免重要脏器的不可逆损伤依然是ECMO成功的关键。     

左心减压用于扩张型心肌病和心肌炎患儿静脉-动脉体外膜氧合治疗调查:一项体外生命支持组织注册数据回顾性研究

目的了解心肌炎和扩张型心肌病(dilated cardiomyopathy,DCM)患儿静脉-动脉体外膜氧合(extracorporeal membrane oxygenation,ECMO)时左心减压(left heart decompression,LHD)与存活情况的关系。次要结果是研究LHD和心肌炎患儿存活情况的关系,并与DCM患儿进行比较。设计对一多中心注册数据库进行回顾性研究。场所国际ECMO中心向体外生命支持组织报告的数据。对象诊断为心肌炎或DCM且行ECMO治疗的≤18岁儿童。干预措施无。测量方法与主要结果共确认1438次儿童ECMO运行。37%患儿罹患心肌炎(n=532),其余则为DCM。出院存活率63%。     

中国儿童重症监护病房体外膜肺氧合技术应用现状调查

目的：了解中国PICU体外膜肺氧合( ECMO)技术开展及ECMO疗效情况。方法采用问卷调查方式,2015年3月至2015年8月对全国三级甲等医院PICU进行调查。结果共调查了38家儿童医院或综合医院的PICU,其中儿童医院28家,综合医院10家。10家医院的PICU拥有12台ECMO设备;能开展ECMO技术的单位6家,准备开展ECMO技术的单位14家;接受过ECMO培训的医院8家。共有63例患儿在 PICU 内接受非开胸 ECMO 治疗,成功撤离 ECMO 者49例,有效率77.8％;36例存活,存活率57.1％。儿童患者(大于28 d)51例,其中呼吸系统疾病21例,心脏疾病28例,心肺衰竭2例;存活出院31例,存活率60.8％。新生儿患者12例,呼吸系统疾病10例,心脏疾病2例,存活出院5例,存活率41.7％。结论国内儿科领域ECMO技术尚处于起步阶段,且发展不均衡,整体上存活率低于国际水平,今后需要进一步增加ECMO技术在儿科领域应用的临床实践,提高国内危重患儿的救治水平。     

体外膜肺氧合在儿科心肺功能衰竭救治中的临床应用

目的探讨体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)技术在儿科心肺功能衰竭救治中的应用。方法回顾性分析2012年6月至2014年10月接受ECMO支持的心肺功能衰竭重症患儿的临床资料。结果共24例心肺功能衰竭患儿接受ECMO支持,男18例,女6例;年龄1 d~7岁;体质量3~20 kg;共有15例成功脱离ECMO,总撤概率62.5%;存活10例(42.7%),死亡14例,其中9例因无法撤离ECMO死亡,3例撤离ECMO后死于并发症,2例撤离ECMO家属放弃治疗死亡;11例(45.8%)患儿在ECMO支持期间出现并发症。结论对于难治性呼吸循环衰竭重症患儿ECMO技术可以提供有效的心肺支持。     

动态监测血乳酸与小儿危重病例评分的相关性

目的 探讨动态监测PICU患儿血乳酸与小儿危重病例评分(PCIS)的相关性.方法 对77例入住南通大学附属常州儿童医院儿科重症监护病房的患儿立即进行PCIS,根据评分结果分为极危重组(23例)、危重组(32例)、非危重组(22例).并检测患儿动脉血乳酸水平,每6 h监测1次,并测出乳酸峰值.比较各组间乳酸监测指标(入PICU乳酸水平、乳酸峰值)和PCIS,进行相关性分析,探讨其与患儿预后的相关性.结果 极危重组血乳酸水平:入PICU时乳酸[(5.28±3.69) mmol·L-1]、乳酸峰值[(8.54±4.32) mmol·L-1]明显高于危重组和非危重组(F=3.98,3.12,Pa<0.01),而PCIS[(65.79±2.34) 分]明显低于其他2组(F=4.23,P<0.01);死亡组 PCIS[(62.35±4.22) 分]低于存活组[(89.21±5.36) 分](t=3.15,P<0.01),而血乳酸水平[(5.31±4.05) mmol·L-1]高于存活组[(3.22±2.13) mmol·L-1](t=2.32,P<0.05);PCIS与血乳酸水平呈负相关(r=-0.889,P<0.01).结论 血乳酸升高的PICU危重患儿病情更重、预后更差,PCIS评分可有效评估患儿的病情和预后,并与乳酸水平存在显著负相关.动态监测血乳酸水平是反映危重病患儿病情严重程度和预测患儿转归的较好指标.     

体外膜肺氧合治疗儿童重度急性呼吸窘迫综合征一例

目的 探讨体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)在儿童重度急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)中的应用.方法 回顾性分析2016年2月浙江大学医学院附属儿童医院PICU收治的1例行ECMO治疗的儿童重度ARDS患儿的临床资料.结果 患儿,男,1岁9个月.ECMO前机械通气时间5d,高频呼吸机MAP 26cmH2O(1cmH2=0.098kPa),FiO2 100%应用下SpO2 86%,血气分析pH 7.040,PCO2 128mmHg(1mmHg=0.133kPa),PaO2/FiO2 58mmHg.ECMO建立后,患儿低氧血症及高碳酸血症迅速纠正,呼吸机参数明显下调.ECMO期间经液体平衡、抗凝、并发症控制、营养及呼吸道等多方面综合管理,患儿肺部渗出减少,ECMO参数下调,于18d后成功撤离ECMO,住院时间81d,出院随访至今无脏器功能不全存在.结论 ECMO的合理应用及管理能有效改善重度ARDS患儿的预后.     

体外二氧化碳清除技术治疗儿童急性呼吸窘迫综合征的初步探讨

目的近年来体外二氧化碳清除技术(ECCO2R)越来越多地应用于救治危重急性呼吸衰竭患者, 但在儿童应用非常少。我院PICU采用持续肾替代治疗(CRRT)平台开展ECCO2R, 为1例高碳酸血症的急性呼吸窘迫综合征(ARDS)患儿成功提供部分呼吸支持, 为儿童ARDS采用ECCO2R治疗提供临床参考。方法我院PICU收治的1例腺病毒肺炎、重度ARDS患儿, 在体外膜肺氧合(ECMO)撤机后出现高碳酸血症, 采用CRRT平台开展ECCO2R进行部分呼吸支持, 取得良好效果。结果患儿, 男, 1岁4个月, 因腺病毒肺炎、重度ARDS, 行机械通气和静脉-动脉ECMO治疗, ECMO治疗25 d, 撤离ECMO后出现严重的高碳酸血症。在CRRT平台上, 采用血液净化系统体外循环串联膜肺, 开展二氧化碳清除治疗。治疗1 h后, pH值升高11.2%(从7.222升至7.303), PCO2下降29.1%(从72.6 mmHg降至51.5 mmHg, 1 mmHg=0.133 kPa);治疗6 h, 高频震荡通气模式下平均气道压下降5 cmH2O(从20 cmH2O降至15 cmH2O, 1 cm...     

左心发育不良综合征I期重建术后体外膜肺的应用

目的尽管体外膜肺(ECMO)是心脏术后难治性心衰患儿可接受的治疗策略,但在左心发育不良综合征I期重建术后的作用及其可变性,尚存争议。本研究目的是评价I期重建术后非选择ECMO治疗的预后。设计病例回顾地点儿童重症监护室研究对象1998年1月~2005年5月I期重建术后采用ECMO治疗的婴儿。干预无测量和主要结果研究期间共完成左心发育不良I期重建手术382例,36例术后需ECMO治疗。ECMO指征包括无法停用体外循环14例,心脏停搏22例。14例(38·8%)存活出院。死亡患儿体外循环时间较长[(150·1±70·0)minvs(103·9±30·0)min,P=0·01]。9/14(64%)存活婴儿术后ECMO时间>24h,而5/22(22%)存活婴儿ECMO时间<24h(P=0·02)。所有5例诊断为急性分流血栓症的婴儿早期均存活。生存者ECMO平均时间(50·1±12·5)h,死亡者(125·2±25·0)h(P=0·01)。7/14早期存活者的平均随访时间为20个月(2~78个月)。结论根据我们的经验,ECMO治疗可挽救I期重建术后1/3濒死患儿的生命。尤其适用于潜在可逆性疾病,如急性分流血栓症和短暂心室功能障碍。     

Favorable Outcome of Pediatric Fulminant Myocarditis Supported by Extracorporeal Membranous Oxygenation

Myocarditis among pediatric patients varies in severity from mild disease to a fulminant course with overwhelming refractory shock and a high risk of death. Because the disease is potentially reversible, it is reasonable to deploy extracorporeal membranous oxygenation (ECMO) to bridge patients until recovery or transplantation. This study aimed to review the course and outcome of children with acute fulminant myocarditis diagnosed by clinical and echocardiographic data only who were managed by ECMO because of refractory circulatory collapse. A chart review of a single center identified 12 children hospitalized over an 8-year period who met the study criteria. Data were collected on demographics, diagnosis, disease course, and outcome. The patients ranged in age from 20 days to 8 years (25.5 ± 29.6 months). Echocardiography showed a severe global biventricular decrease in myocardial function, with a shortening fraction of 12% or less. Ten children (83.3%) were weaned off extracorporeal support after 100–408 h (mean, 209.9 ± 82.4 h) and discharged home. Two patients died: one due to multiorgan failure and one due to sustained refractory heart failure. During a long-term follow-up period, all survivors showed normal function in daily activities and normal myocardial function. The study showed that ECMO can be safely and successfully used for children with acute fulminant myocarditis diagnosed solely on clinical and radiographic grounds who need mechanical support. These patients usually have a favorable outcome, regaining normal or near normal heart function without a need for heart transplantation.     

儿童暴发性心肌炎的早期诊断及治疗进展

暴发性心肌炎是一种以急性血流动力学障碍为主要表现的心肌炎,临床表现多样且病死率极高。暴发性心肌炎早期诊断需依靠血清学指标、心电图、超声心动图等进行综合分析,心脏磁共振成像检查在心肌炎诊断中也具有很好的应用价值。传统的暴发性心肌炎治疗,包括对症支持、抗病毒及免疫疗法等,但对危重患儿往往难以奏效。体外膜肺氧合技术(ECMO)的开展,大大提高了儿童暴发性心肌炎的抢救成功率,成为救治儿童暴发性心肌炎的可靠手段。文章综述目前儿童暴发性心肌炎的诊断及最新治疗进展。     

体外膜肺氧合在儿童暴发性心肌炎中的应用

暴发性心肌炎是一种以急性血流动力学障碍为主要表现的急危重症,起病急、进展快,病死率高。该病目前无特效药物治疗,一般采用对症及支持疗法。近年来,体外膜肺氧合(ECMO)可为暴发性心肌炎患儿提供有效的生命支持,为心脏功能恢复赢得时间,提高该病的抢救成功率。该文就目前ECMO在儿童暴发性心肌炎中的应用和进展做一简单综述。     

Clinical application of extracorporeal membrane oxygenation in children with refractory cardiopulmonary failure

Background

This study aimed to discribe the experience in supporting children with refractory cardiopulmonary failure with extracorporeal membrane oxygenation (ECMO).

Methods

We retrospectively reviewed 12 children with refractory cardiopulmonary failure supported with ECMO from February 2009 to August 2015 in the Pediatric Intensive Care Unit (PICU), Children’s Hospital, Zhejiang University School of Medicine.

Results

Seven of the 12 patients were weaned successfully from ECMO and dischaged from the hospital, with a survival rate of 58.3% (7/12). Among them, five patients had acute fulminant myocarditis (AFM). Complications during ECMO included hemorrhage, hemolysis, thrombosis, acute kidney injury, and secondary hematogenous infection. During 1-24 month follow-up, the seven surviving patients recovered with normal cardiopulmonary function.

Conclusions

ECMO is useful for supporting children with refractory cardiopulmonary failure, especially for treatment of AFM.

     

ECMO Support in a Child with Acute Fulminant Myocarditis

An 11-yr-old boy with acute fulminant myocarditis was treated with routine medical therapy (antibiotics, inotropic and vasosactive agents, etc.) for 5 days, but exacerbated. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated 39 h after admission to the intensive care unit (ICU). Twenty-four hrs after ECMO, urine volume and blood pressure (BP) improved significantly. After treatment with ECMO for 140 h, the patient’s ejection fraction (EF) increased to 45%, BP because normal and urine volume maintained at about 100 ml/h. So, the patient was weaned from the ECMO. The patient was discharged from the hospital on 23rd day post admission, when EF improved to 72% and with normal chest radiograph, echocardiography results and hemodynamics.     

无创正压通气在重症支气管哮喘治疗中的应用

目的 观察在常规治疗的基础上加用无创正压通气(NIPPV)对儿童重症支气管哮喘(哮喘)的治疗作用.方法 选取急性发作期重症哮喘患儿40例.随机分为NIPPV组20例和对照组20例.NIPPV组在解痉平喘、抗感染、祛痰、纠正酸碱和水电解质平衡等综合治疗基础上,于发病24 h内予NIPPV治疗;对照组除上述基础治疗外予鼻导管吸氧.监测2组治疗前及治疗4 h、8 h、12 h 及24 h心率、动脉血pH、动脉血氧分压 [pa(O2)]、动脉血二氧化碳分压[pa(CO2)]、血氧饱和度(SpO2)水平.结果 治疗后对照组和NIPPV组心率、动脉血pH值、pa(O2)、pa(CO2)及SpO2水平均较治疗前明显改善,并且随治疗时间的延长而改善有所增加,差异均有统计学意义(Pa<0.01).治疗后,NIPPV组较对照组改善更明显,NIPPV组在治疗4 h、8 h的心率[(119±10)次·min-1、(97±12)次·min-1]、动脉血pH(7.28±0.06、7.34±0.04)、pa(O2)[(67±6) mmHg、(81±5) mmHg](1 mmHg=0.133 kPa)、pa(CO2)[(40±9) mmHg、(31±9) mmHg]、SpO2[(96.23±1.83)%、(98.04±1.32)%]较对照组心率[(125±11)次·min-1、(104±10)次·min-1]、动脉血pH(7.22±0.08、7.29±0.07)、pa(O2)[62±6) mmHg、(76±4) mmHg]、pa(CO2)[(46±9) mmHg、(37±7) mmHg]及SpO2 [(95.05±1.69)%、(97.01±1.41)%]均明显改善,差异均有统计学意义(Pa<0.05).48 h后NIPPV组患儿全部脱机成功,且无严重并发症发生.结论 早期应用NIPPV配合常规药物治疗有助于减缓重症哮喘的病情恶化,可提高急性发作的治疗效果,是抢救重症哮喘的一种安全有效的方法.     

Entry criteria for extracorporeal membrane oxygenation In neonates with congenital diaphragmatic hernia treated with high-frequency oscillatory ventilation

Although respiratory management with high-frequency oscillatory ventilation (HFOV) has generally been used for neonates with congenital diaphragmatic hernia (CDH), entry criteria for extracorporeal membrane oxygenation (ECMO) based on data from patients who underwent HFOV have not yet been reported. To establish entry criteria for ECMO in such patients, we retrospectively studied 36 neonates with CDH treated by HFOV in our institutions between 1986 and 1994. From the admission records, preductal and postductal arterial blood gas data and HFOV ventilation conditions for 72 h after admission were extracted. Oxygenation index (01) and alveolar-arterial oxygen gradient (A-aD02) time interval combinations were calculated. Patients were divided into two groups: candidates for ECMO (n = 22) who underwent ECMO (n = 18) or died without ECMO (n = 4); and non-candidates (n = 14), who survived without ECMO. Blood gas data in patients placed on ECMO were comparable to those in patients who died without ECMO: mean pre- and postductal OI for 4 h > 30, postductal A-aD02 ≥620 mmHg for 4 h, postductal A-aD02 ≥580 mmHg for 8 h, and postductal A-aD02 ?550 mmHg for 12 h showed better sensitivity with a specificity of more than 90% compared to entry criteria that had previously been used in our institutions: a postductal OI >40 for 4 h and postductal A-aDO₂ ≥610 mmHg for 8 h. In addition, a combination of preand postductal OI >30 for 4 h indicated a sensitivity of 95.5% and a specificity of 92.9%.     

Circulating cardiac troponins levels and cardiac dysfunction in children with acute and fulminant viral myocarditis

Objectives: To study the correlation between cardiac Troponins blood levels and degrees of cardiac dysfunction in children with acute and fulminant viral myocarditis and to study their prognostic role in predicting the outcomes and risk of having dilated cardiomyopathy. Methodology: Troponin I & T blood levels were measured in 65 children with acute or fulminant viral myocarditis. The cardiac functions of RV & LV were assessed by Doppler echocardiography. Results: The levels of cTnI & CTnT were significantly higher in patients with fulminant myocarditis than in controls and children with acute myocarditis (p < 0.05 & <0.001* respectively). The cardiac functions were significantly impaired in fulminant myocarditis than in acute myocarditis (p < 0.001*). There were negative correlations between the cardiac troponins levels and the cardiac functions measured by echocardiography in children with acute and fulminant myocarditis. There were 3 deaths (7.5%), and 10 (25%) children developed dilated cardiomyopathy in acute myocarditis while there were eight deaths (32%) and one patient (4%) who developed dilated cardiomyopathy in fulminant myocarditis group. Conclusion: Cardiac troponins levels can predict the severity of myocarditis and the prognosis on the short‐term level. Fulminant myocarditis was associated with higher levels of both cTn I & cTn T than acute myocarditis. Despite that fulminant myocarditis has a more aggressive course, the risk of developing cardiomyopathy was less than in acute myocarditis.     

Severe heart failure and the need for mechanical circulatory support and heart transplantation in pediatric patients with myocarditis: Results from the prospective multicenter registry “MYKKE”

Myocarditis represents an important cause for acute heart failure. MYKKE, a prospective multicenter registry of pediatric patients with myocarditis, aims to gain knowledge on courses, diagnostics, and therapy of pediatric myocarditis. The role of mechanical circulatory support (MCS) in children with severe heart failure and myocarditis is unclear. The aim of this study was to determine characteristics and outcome of patients with severe heart failure requiring MCS and/or heart transplantation. The MYKKE cohort between September 2013 and 2016 was analyzed. A total of 195 patients were prospectively enrolled by 17 German hospitals. Twenty‐eight patients (14%) received MCS (median 1.5 years), more frequently in the youngest age group (0‐2 years) than in the older groups (P < 0.001; 2‐12 and 13‐18 years). In the MCS group, 50% received a VAD, 36% ECMO, and 14% both, with a survival rate of 79%. The weaning rate was 43% (12/28). Nine (32%) patients were transplanted, one had ongoing support, and six (21%) died. Histology was positive for myocarditis in 63% of the MCS group. Patients within the whole cohort with age <2 years and/or ejection fraction <30% had a significantly worse survival with high risk for MCS, transplantation, and death (P < 0.001). Myocarditis represents a life‐threatening disease with an overall mortality of 4.6% in this cohort. The fulminant form more often affected the youngest, leading to significantly higher rate of MCS, transplantation, and mortality. MCS represents an important and life‐saving therapeutic option in children with myocarditis with a weaning rate of 43%.