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.

The survey of multi-center experience on rescue use of extracorporeal membrane oxygenation in pediatric patient with respiratory failure

Objective To review multi-center experience on rescue use of extracorporeal membrane oxygenation(ECMO) in pediatric patients with respiratory failure and to investigate its short-term outcome in China.Methods The survey was conducted in 4 tertiary hospitals in China mainland.All children<18 years old who had been supported with non-open chest ECMO to rescue respiratory failure in PICU were reviewed.Results Twenty-one patients with ECMO support were diagnosed respiratory failure.Male was 14,female was 7.Twelve patients successfully weaned off ECMO, 8 patients survived to discharge and 13 died.The largest part of protopathy was severe pneumonia(33%)and acute respiratory distress syndrome(29%).Their mean age was 29.0(9.0,81.5)months, mean weight was 12.0(9.0,20.8)kg,and mean OI index was 31.5(19.2,41.0).The average length of ECMO run was 149.0(91.2,242.0)hours.The blood gas analysis showed that PO2 increased from 49.5(40.4,61.9)mmHg(1mmHg=0.133kPa) at the beginning to 65.0(42.6,120.5)mmHg at 24h after ECMO treatment,and the increase of PO2 was higher in the survival compared with the nonsurvival[52.0(1.8,89.4) mmHg vs.8.2(-15.1,33.9) mmHg,P=0.036].The SO2 increased from 80.0%(70.4%,91.8%)at ECMO initiation to 98.0%(95.6%,100%)at 24h after ECMO treatment,and increase of SO2 was higher in survival group compared to that of nonsurvival group[23.5%(11.4%,27.1%) vs.4.3%(2.4%,23.8%),P=0.039].VV mode had higher survival rate than VA mode(3/3 vs.5/18).The longer the use of ventilator before ECMO,the mortality rate increased as well.The mechanical ventilation time before ECMO was significantly longer in nonsurvival group than that in the survival group[4.5(2.5,12.0)h vs.1.6(1.0,2.2)h,P=0.015].The most common complications during ECMO run were bleeding and disfunction of oxygenator.Conclusion ECMO is an effective support treatment for the pediatric patients with respiratory failure,which significantly improves oxygenation.