重症超声在儿童体外膜肺氧合管理中的应用价值

体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)可对心肺功能进行替代,是一种严重呼吸和(或)循环衰竭的挽救性治疗措施。在儿童ECMO治疗的各个环节如ECMO启动、穿刺和置管、运行过程中的管理,ECMO并发症的及时发现和处理,以及ECMO撤机等,可应用床旁超声对患儿的心肺、...     

儿童脓毒症休克与体外膜肺氧合治疗

儿童难治性脓毒症休克可很快进展为多器官功能衰竭,病死率高。体外膜肺氧合(extracorporeal membrane oxygenation, ECMO)技术作为液体复苏无效和血管活性药物抵抗的难治性脓毒症休克的挽救性治疗正越来越受到重视和应用。但目前对于难治性脓毒症休克时ECMO救治的确切疗效、应用时机以及模式、置管方式等方面仍不明确。该文就ECMO治疗此类患儿的应用原理、发展历史、争议焦点和ECMO运行期间应关注问题进行探讨,以期更为合理、规范地应用ECMO技术治疗难治性脓毒症休克患儿,提高生存率。     

儿童体外膜肺氧合抗凝研究进展

体外膜肺氧合(ECMO)作为心肺衰竭的支持技术,在儿童中的应用越来越广泛,但出血及血栓仍是目前ECMO运行过程中最常见和最严重的并发症。肝素是目前儿童ECMO运行中最主要的抗凝药物。临床常监测激活凝血时间、活化部分凝血活酶时间及抗Ⅹa活性来指导肝素用量,但肝素最佳用量和最合适的监测方法仍不明确。本文就儿童ECMO运行过...     

儿童体外膜肺氧合呼吸支持技术

重症呼吸系统疾病是体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)最主要的一组治疗群体.ECMO通过体外氧合器使患者不依赖肺就能获得足够的血气交换,满足生命代谢需要.ECMO呼吸支持应用的基本指征是患者经ECMO以外所有治疗无效,且病情具有潜在可恢复性.除抗凝禁忌及技术可及性外,ECMO对年龄及病种没有特殊要求.ECMO呼吸支持治疗首选VV模式,对伴有循环障碍者可选VA模式.ECMO可以帮助患者度过疾病危重期,为治疗及病情恢复提供时间和空间.ECMO的治疗结局受到原发病可逆性及不同病种等多种因素影响.     

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...     

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。     

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.     

体外膜肺氧合期间儿童脑功能监测与预后评估

近年来,体外膜肺氧合(extracorporeal membrane oxygenation, ECMO)患儿脑部并发症相关报道增多,除出血、梗死、癫痫发作和脑灌注不足等常见并发症,还有其他尚不明确但相关的损伤和临床表现,并在短期内影响ECMO患儿的预后乃至决定ECMO治疗是否成功,因此脑功能监测显得尤为重要,已成为ECMO患者管理的要素之一。此外,人们逐渐认识到,神经系统并发症可能不只发生在早期阶段,ECMO患儿也易并发长期神经认知功能不良事件,如学习、工作障碍。但目前在ECMO患儿脑功能监测方面还未形成统一的临床管理策略和方案,尤其患儿出院后的神经认知功能和神经心理随访,需要更系统更科学的管理流程。     

An overview of extracorporeal membrane oxygenation therapy

A brief overview of extracorporeal membrane oxygenation and its use in infants and children is presented. The history, selection, operative procedure, daily management and complications are discussed. The international results are shown.     

ECMO患者心肌顿抑的诊治

体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)是一种心肺支持技术,以血泵产生负压,从静脉引血,血液经膜式氧合器氧合后,重新灌入体内,用于较长时间的持续心肺替代支持,临床上主要用于呼吸功能衰竭和(或)心脏功能衰竭经传统治疗无效的患者.近些年,国内ECMO技术在临床应用逐渐增多,而有效防治ECMO并发症是决定该技术是否成功的重要因素.本文主要针对ECMO运转中的心肌顿抑的诊治进行讨论.     

Dexamethasone therapy in neonates treated with extracorporeal membrane oxygenation

OBJECTIVE: To test the hypothesis that infants who received dexamethasone would have a shorter length of time on extracorporeal membrane oxygenation (ECMO).Study design Infants placed on ECMO for respiratory failure were randomly assigned to receive either dexamethasone for 3 days or placebo. Chest radiographs were scored through the use of a validated standard scoring system to assess lung injury. RESULTS: Thirty infants received dexamethasone and 29 received placebo. The median (25th%, 75th%) duration of time on ECMO was 143.5 (100, 313) hours in the dexamethasone group and 160 (111, 303) hours in the placebo group (not significant). Survival was 80% in the dexamethasone group and 83% in the placebo group. Radiographic lung injury scores (mean+/-SEM) were significantly improved in the dexamethasone group (10.5+/-0.6) versus placebo (12.3+/-0.5) on day 3 of ECMO (P=.013). Hypertension developed in 27 of the 30 infants receiving dexamethasone and 13 of the 29 infants in the placebo group during ECMO (P<.01). CONCLUSIONS: Dexamethasone given during the first 3 days of ECMO results in significant improvement in lung injury scores by day 3 of ECMO but does not significantly decrease the duration of ECMO or improve survival. The preponderance of evidence would not support the use of dexamethasone in this setting.     

Nitrogen balance during extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) has been used as a support system for neonates with pulmonary failure since 1975. During ECMO, thermal regulation, pulmonary gas exchange, and cardiac output can be partially or nearly completely provided by the circuit. The presumed resultant decrease in energy requirement has prompted the question of whether infants are in a catabolic or anabolic state of metabolism while on ECMO. Directly measuring the metabolic rate in babies on ECMO is difficult. However, studying the nitrogen balance in these infants may suggest an answer. Nitrogen balance was studied in 21 neonates spanning a single ECMO team's experience at two institutions. Children were studied at the Ochsner Clinic from 1986 to 1990 and at the University of Chicago Wyler Children's Hospital from 1990 to the present. The infants received total parenteral nutrition (TPN) as their only nutritional source during the entire ECMO course. During this time, 24-h urine collections were analyzed for urea nitrogen (UUN). The daily nitrogen balance was calculated by subtracting nitrogen output (estimated as the UUN) from nitrogen input (the measured amino acid content of the intravenous feeding). Fecal losses were not included in the nitrogen output since the infants were not enterally fed and rarely had stools while on ECMO. The kilojoules (1 kilocalorie = 4.2 kilojoules) and protein provided by the parenteral nutrition varied. Nitrogen intake exceeded nitrogen output by ECMO day 2 (the initial nitrogen balance determination). Infants receiving as little as 0.4 g/kg protein and 168 kJ/kg daily remained in positive nitrogen balance. Correspondence to: R. Arensmann     

体外膜肺技术在9例危重症患儿中的应用

目的 探讨心肺功能衰竭患儿体外膜肺(ECMO)支持治疗的临床经验。方法 回顾性分析2008年12月至2012年5月收住复旦大学附属儿科医院重症监护病房及心脏监护病房的9例危重症患儿接受ECMO治疗的情况及转归。结果 9例患儿均采用颈内动、静脉置管,V-A ECMO模式,体外肝素抗凝,活化凝血时间(ACT)维持在180～220 s;体外辅助血流量为50~100 mL·kg-1·min-1。治疗期间进行心肺功能、血液指标和影像学等监测。9例患儿ECMO使用时间为5~280 h,中位数112 h。经治疗后8例病情好转,撤离ECMO治疗,其中7例痊愈出院,1例撤离ECMO治疗后3 d自动出院。1例因室间隔缺损修补术后合并严重脓毒症、脓毒症休克和心肺功能衰竭,ECMO治疗1周,撤机后死亡。发生各类并发症共14例次,其中机械系统并发症6例次,包括氧合器漏液3例次,管路血栓2例次,水箱加温器故障1例次;机体并发症7例次,其中6例发生贫血,1例右上肢功能障碍;意外事件1例,患儿在ECMO运行过程中因右腋下动脉置管意外滑脱而形成血肿。未发生颅内并发症、出血和感染等。结论 ECMO能有效对危重症患儿行心肺功能支持,使用安全。建立一支专业的技术团队能促进ECMO的更好开展。     

Neonatal pertussis requiring extracorporeal membrane oxygenation

Despite widespread immunization against Bordetella pertussis, whooping cough remains potentially fatal in susceptible populations such as neonates. A case of neonatal pertussis with severe pulmonary hypertension (PH) requiring extracorporal membrane oxygenation (ECMO) is described. PH associated with pertussis severe enough to require ECMO is frequently irreversible and associated with a poor prognosis. Accepted: 20 December 1999     

体外膜肺氧合相关并发症及其防治

体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)并发症包括技术相关并发症和机体相关并发症,前者主要包括氧合器功能障碍、插管相关性并发症及ECMO支持过程中出现溶血、氧合器或管路内血栓形成等,后者主要有出血和栓塞、感染、肾功能障碍、神经系统损伤等,其中以出血为临床最常见.严格选择ECMO适应证和方案、培训和协调团队协作、密切监测和早期识别相关并发症,对降低病死率和改善预后十分重要.现将ECMO治疗的相关并发症及其防治进行介绍.     

体外膜肺在儿科临床应用研究进展

体外膜肺是一种体外生命支持技术,用于心肺功能衰竭的患者心肺替代治疗,为多种危重疾病的评估、诊治、康复争取到宝贵时间.本文就体外膜肺的相关知识、在儿科领域的临床应用、在临床应用过程中可能出现的并发症及其防治等方面的研究进展作一介绍,以期加深对体外膜肺的认识,为进一步在临床应用体外膜肺拓宽视野.     

Left ventricular performance in neonates on extracorporeal membrane oxygenation

Summary The evaluation of left ventricular systolic performance in infants undergoing extracorporeal membrane oxygenation (ECMO) using traditional ejection-phase indices is hampered by significant alterations in preload and afterload. Therefore, a load-independent index, which relates heart-rate-corrected mean velocity of circumferential fiber shortening (VCFc) to afterload, measured as end-systolic wall stress (ESS), was used to assess left ventricular function in 18 term neonates undergoing ECMO. The mean age at the onset of ECMO was 75.5 h and the duration of therapy was 171±106 h. Left ventricular performance was highest before the onset of ECMO (VCFc=1.65±0.49 circ/s) and decreased toward normal during (1.38±0.33 circ/s) and following ECMO (1.29±0.16 circ/s). Initially, nine of 17 (53%) patients had enhanced performance for the degree of afterload but in only 16 of 48 (33%) studies during ECMO and none following ECMO was VCFc elevated beyond the normal range predicted for ESS. These changes in left ventricular performance may be the result of variations in exogenous, as well as endogenous, catecholamines rather than intrinsic alterations in myocardial contractility. It is concluded that the VCFc/ESS relation permits a meaningful assessment of ventricular performance in critically ill neonates undergoing ECMO.