CAJ | 학술논문

目的总结小儿先天性心脏病术后严重心力衰竭和暴发型心肌炎应用体外膜肺氧合(ECMO)支持治疗的经验.方法 8例中术后不能脱离CPB 7例、暴发型心肌炎1例.均使用离心泵,全部静脉-动脉模式;采用中心插管、右房-升主动脉7例,周围大血管插管、股静脉-股动脉模式1例.辅助65～498 h,辅助流量80～120ml·min-1·kg-1.结果死亡5例;出院3例,生存率38%.并发症包括出血5例、血栓形成2例、溶血1例、DIC 1例、肝衰竭1例、营养不良2例、机械故障2例.结论先心病术后无残余解削畸形,而出现严重心衰病例,往往因合并左、右心室并伴肺功能不全,宜及时施行ECMO支持治疗,而取代肺脏气体交换功能,减少呼吸器使用中的高浓度氧气和气道压的肺损伤,降低总体病死率;注意及时补充新鲜血小板、血浆等血制品;合理应用血管活性药物和肝素,根椐出血部位及量采用针对性措施,维持内环境稳定;加用超滤,减少机体特别是出血的并发症.应选用长期使用的肝素涂层膜肺,监测膜前后压力,注意血浆渗漏,减少机械并发症.
목적 총결소인선천성심장병술후엄중심력쇠갈화폭발형심기염응용체외막폐양합(ECMO)지지치료적경험.방법 8례중술후불능탈리CPB 7례、폭발형심기염1례.균사용리심빙,전부정맥-동맥모식;채용중심삽관、우방-승주동맥7례,주위대혈관삽관、고정맥-고동맥모식1례.보조65～498 h,보조류량80～120ml·min-1·kg-1.결과 사망5례;출원3례,생존솔38%.병발증포괄출혈5례、혈전형성2례、용혈1례、DIC 1례、간쇠갈1례、영양불량2례、궤계고장2례.결론 선심병술후무잔여해삭기형,이출현엄중심쇠병례,왕왕인합병좌、우심실병반폐공능불전,의급시시행ECMO지지치료,이취대폐장기체교환공능,감소호흡기사용중적고농도양기화기도압적폐손상,강저총체병사솔;주의급시보충신선혈소판、혈장등혈제품;합리응용혈관활성약물화간소,근거출혈부위급량채용침대성조시,유지내배경은정;가용초려,감소궤체특별시출혈적병발증.응선용장기사용적간소도층막폐,감측막전후압력,주의혈장삼루,감소궤계병발증.
Objective The use of extracorporeal membrane oxygenation (ECMO) as a treatment for the failure of cardiopulmonary function after cardiac surgery is increasing and has been reported to be 3% to 5% in the cases with congenital heart disease. We reviewed our experience with ECMO in children who received heart surgery for congenital heart disease and complicated with severe heart failure postoperatively. Methods Eight patients received ECMO, seven was due to the failure to wean from bypass and one had fulminant myocarditis. Import membrane oxygenator,veno-arterial mode ECMO and right atriumascending aortic cannulation were used in 7 cases and peripheral cannulation via femoral veno-artery route was used in 1 case.Supportive intervention persisted from 65 to 498 hours, with flow rate maintained at 80 to 120 ml per minute per kilogram body weight. Results Five patients died, with a mortality of 62.5%, and 3 cases discharged, with a survival rate of 38%. Bleeding occurred in 5 cases, thrombosis occurred in 2 cases, hemolysis was identified in 1 case and DIC was observed in 1 case.One case had liver failure and 2 cases had malnutrition. Oxygenator plasma leakage occurred in 2 cases. Mean arterial blood pressure increased significantly after the establishment of ECMO as compared with that before the procedure [( 60.2 ± 7.8 )mmHg vs. (48. 1 ± 5.2 ) mmHg, P≤0.05]. The arterial concentration of lactate decreased significantly, from (5. 1 ± 0. 8 )mmol per liter before ECMO to ( 3.6 ±0. 5 )mmol per liter after ECMO, P ＜0.05. Conclusion For patients who survived the congenital heart surgery and no residual anatomic deformity, ECMO can be used as early as possible as a treatment for severe heart failure which resulted from coexistent of left and right ventricular and pulmonary insufficiency. An overall mortality may be decreased by ECMO technique as it plays a substitution role for gas exchange in the lung. As a result, the concentration of oxygen and the airway pressure used during ventilation, and the resultant lung injury can be reduced. Appropriate strategies involve transfusion of fresh platelet and packed red blood cells, replacement of frozen plasma and blood products, as well as rational use of vasoactive drugs and heparin, and maintaining a stable internal environment. Following strategies are also recommended: using continuous arterio-venous hemofiltration and durable heparin-coated membrne oxygenator, reducing hemorrhagic complications, monitoring pressure on both side of the film, identifying plasma leakage carefully and reducing the mechanical complications.