目的 总结人工膜肺氧合(extracorporeal membrane oxygenation,ECMO)治疗暴发性心肌炎患儿的成功经验.方法应用ECMO联合药物治疗救治1例11岁急性重症暴发性心肌炎男性患儿.患儿同时合并心源性休克、急性心力衰竭、Ⅲ度房室传导阻滞、束支传导阻滞、多源性室性心律、阵发性多源性室性心动过速、广泛性ST-T弓背向上抬高.心脏超声:右房扩大4.4mm,右室略大2.3mm,三尖瓣重度反流,左心收缩功能不全,室壁运动不协调.心肌酶谱:肌酸激酶2 161 U/L,肌酸激酶同工酶109 U/L,α-羟丁酸脱氢酶612 U/L,乳酸脱氢酶696 U/L,肌钙蛋白22.1μg/L,血乳酸4.0 mmol/L.先予患儿吸氧,静脉使用多巴酚丁胺、多巴胺、米力农、呋塞米、大剂量甲泼尼龙、静脉丙种球蛋白、大剂量维生素C及磷酸肌酸,患儿病情仍不稳定,且进行性加重,故建立ECMO体外辅助装置.辅助过程中继续上述药物治疗,严密监测神志、体温、心率(律)、呼吸、血压、血氧饱和度、尿量、动脉血气、血电解质、血乳酸、血糖、肝肾功能、血常规、活化凝血时间及下肢血运情况,根据结果调整药物.结果ECMO系统成功建立并持续应用7d,患儿心功能明显改善,恶性心律失常消失,未出现出血、栓塞、感染等并发症.ECMO应用过程中患儿曾出现3次心搏停止,1次心室扑动,1次心室颤动,经电除颤和抗心律失常药物联合应用均成功复律.患儿共住院20 d.出院前复查心肌酶谱正常.心电图:窦性心律,电轴右偏,完全性右束支传导阻滞,Ⅰ度房室传导阻滞.心脏超声:心脏各室腔大小正常,心肌收缩功能正常,室间隔增厚(0.9 cm).出院2周后随访,心电图:窦性心律,电轴右偏,完全性右束支传导阻滞.心脏超声:心脏各室腔大小正常,心肌收缩功能正常,室间隔增厚(0.9 cm).出院2个月后随访,心电图与出院2周相同；心脏超声:室间隔厚度0.7cm,余正常.患儿出院至今无自觉症状,活动无明显受限.结论ECMO是救治急性重症暴发性心肌炎的有效治疗手段,适时应用是成功关键.
目的 總結人工膜肺氧閤(extracorporeal membrane oxygenation,ECMO)治療暴髮性心肌炎患兒的成功經驗.方法應用ECMO聯閤藥物治療救治1例11歲急性重癥暴髮性心肌炎男性患兒.患兒同時閤併心源性休剋、急性心力衰竭、Ⅲ度房室傳導阻滯、束支傳導阻滯、多源性室性心律、陣髮性多源性室性心動過速、廣汎性ST-T弓揹嚮上抬高.心髒超聲:右房擴大4.4mm,右室略大2.3mm,三尖瓣重度反流,左心收縮功能不全,室壁運動不協調.心肌酶譜:肌痠激酶2 161 U/L,肌痠激酶同工酶109 U/L,α-羥丁痠脫氫酶612 U/L,乳痠脫氫酶696 U/L,肌鈣蛋白22.1μg/L,血乳痠4.0 mmol/L.先予患兒吸氧,靜脈使用多巴酚丁胺、多巴胺、米力農、呋塞米、大劑量甲潑尼龍、靜脈丙種毬蛋白、大劑量維生素C及燐痠肌痠,患兒病情仍不穩定,且進行性加重,故建立ECMO體外輔助裝置.輔助過程中繼續上述藥物治療,嚴密鑑測神誌、體溫、心率(律)、呼吸、血壓、血氧飽和度、尿量、動脈血氣、血電解質、血乳痠、血糖、肝腎功能、血常規、活化凝血時間及下肢血運情況,根據結果調整藥物.結果ECMO繫統成功建立併持續應用7d,患兒心功能明顯改善,噁性心律失常消失,未齣現齣血、栓塞、感染等併髮癥.ECMO應用過程中患兒曾齣現3次心搏停止,1次心室撲動,1次心室顫動,經電除顫和抗心律失常藥物聯閤應用均成功複律.患兒共住院20 d.齣院前複查心肌酶譜正常.心電圖:竇性心律,電軸右偏,完全性右束支傳導阻滯,Ⅰ度房室傳導阻滯.心髒超聲:心髒各室腔大小正常,心肌收縮功能正常,室間隔增厚(0.9 cm).齣院2週後隨訪,心電圖:竇性心律,電軸右偏,完全性右束支傳導阻滯.心髒超聲:心髒各室腔大小正常,心肌收縮功能正常,室間隔增厚(0.9 cm).齣院2箇月後隨訪,心電圖與齣院2週相同；心髒超聲:室間隔厚度0.7cm,餘正常.患兒齣院至今無自覺癥狀,活動無明顯受限.結論ECMO是救治急性重癥暴髮性心肌炎的有效治療手段,適時應用是成功關鍵.
목적 총결인공막폐양합(extracorporeal membrane oxygenation,ECMO)치료폭발성심기염환인적성공경험.방법응용ECMO연합약물치료구치1례11세급성중증폭발성심기염남성환인.환인동시합병심원성휴극、급성심력쇠갈、Ⅲ도방실전도조체、속지전도조체、다원성실성심률、진발성다원성실성심동과속、엄범성ST-T궁배향상태고.심장초성:우방확대4.4mm,우실략대2.3mm,삼첨판중도반류,좌심수축공능불전,실벽운동불협조.심기매보:기산격매2 161 U/L,기산격매동공매109 U/L,α-간정산탈경매612 U/L,유산탈경매696 U/L,기개단백22.1μg/L,혈유산4.0 mmol/L.선여환인흡양,정맥사용다파분정알、다파알、미력농、부새미、대제량갑발니룡、정맥병충구단백、대제량유생소C급린산기산,환인병정잉불은정,차진행성가중,고건립ECMO체외보조장치.보조과정중계속상술약물치료,엄밀감측신지、체온、심솔(률)、호흡、혈압、혈양포화도、뇨량、동맥혈기、혈전해질、혈유산、혈당、간신공능、혈상규、활화응혈시간급하지혈운정황,근거결과조정약물.결과ECMO계통성공건립병지속응용7d,환인심공능명현개선,악성심률실상소실,미출현출혈、전새、감염등병발증.ECMO응용과정중환인증출현3차심박정지,1차심실복동,1차심실전동,경전제전화항심률실상약물연합응용균성공복률.환인공주원20 d.출원전복사심기매보정상.심전도:두성심률,전축우편,완전성우속지전도조체,Ⅰ도방실전도조체.심장초성:심장각실강대소정상,심기수축공능정상,실간격증후(0.9 cm).출원2주후수방,심전도:두성심률,전축우편,완전성우속지전도조체.심장초성:심장각실강대소정상,심기수축공능정상,실간격증후(0.9 cm).출원2개월후수방,심전도여출원2주상동；심장초성:실간격후도0.7cm,여정상.환인출원지금무자각증상,활동무명현수한.결론ECMO시구치급성중증폭발성심기염적유효치료수단,괄시응용시성공관건.
Objective To report the clinical experience of extracorporeal membrane oxygenation (ECMO)in the emergency management of fulminant myocarditis.Methods The patient,an 11 year-old boy,had fever for 4 day and abdominal pain,vomiting for 1 day and anuria for 12 hours.Electrocardiogram showed Ⅲ atrial-ventricular block,multifocal ventricular rhythm,bundle branch block,convulsivum multifocal ventricular tachycardia,extensive low voltage,ST-T elevation at lead Ⅰ,AVR,V1,V2,V3;and there were ST-T intrusion,T wave inversion at lead Ⅱ,Ⅲ,AVR,AVF,V4～5.Blood creatine kinase was 2 161 U/L,reatine kinase isoenzyme 109 U/L,α-hydroxybutyrate dehydrogenase 612 U/L,lactate dehydrogenase 696 U/L,troponin Ⅰ 22.1 U/L.Echocardiogram showed right atrium 4.4 mm,right ventricular 2.3 mm,severe tricuspid valve regurgitation,left ejection fraction 33％,left ventricular fractional shortening 15％,ventricular wall motion dyssynchrony.Blood lactate was 4.0 mmol/L.The patient's condition was still unstable after using dobutamin,dopamine,milrinone,furosemide,large dose methylprednisolone,intravenous human immunoglobin,phosphocreatine and so on.ECMO was used for cardio-pulmonary support.It is necessary to monitoring the consciousness,temperature,heart rate,respiration,blood pression,SaO2,urinary volume,ariterial blood gas,blood electrolytes,blood lactate,blood glucose,liver function,renal function,blood routine,activated clotting time(ACT),lower extremity blood supply and so on.ACT was maintained at 160～200 s.Heparin was used persistently[5～10 U/(kg·min)].Results ECMO system had been successfully used for 7 days.The cardiac function of the patient was improved significantly.There was no complication,such as hemorrhage,infection,and embolism.Heart arrest in the patient occurred three times,ventricular fibrillation and ventricular flutter occurred one time respectively during ECMO.The rhythm was recovered by electric defibrillation and antiarrhythmic drugs.On day 20,the patient was discharged.At the time of hospital discharge,the patient demonstrated good activity,with normal myocardial enzymes.The echocardiogram showed the size of the cardiac chambers and the contractile function of the myocardia were normal.Electrocardiogram showed Ⅰ degree atrial-ventricular block,complete right bundle branch block.Two weeks later,the electrocardiogram demonstrated complete right bundle branch block.Echocardiogram showed septal thickening(0.9 cm).Two months later,the electrocardiogram was just as that of two weeks before.Echocardiogram showed septal thickening(0.7 cm).The children had no symptom after he was discharged and acted without limitation.Conclusion ECMO is a kind of effective treatment for fulminant myocarditis.The key to desirable therapeutic effect is the timing of its application.
