中华儿科杂志
中華兒科雜誌
중화인과잡지
Chinese Journal of Pediatrics
2008年
1期
26-29
,共4页
林茹%谈林华%张泽伟%孙眉月%杜立中
林茹%談林華%張澤偉%孫眉月%杜立中
림여%담림화%장택위%손미월%두립중
体外膜氧合作用%婴儿,新生%心排血量,低%手术并发症
體外膜氧閤作用%嬰兒,新生%心排血量,低%手術併髮癥
체외막양합작용%영인,신생%심배혈량,저%수술병발증
Extracorporeal membrane oxygenation%Infant,newborn%Cardiac output low%Postoperative complications
目的 总结ECMO救治新生儿心脏术后严重低心排的成功经验.方法 2007年7月18日我们对一例患先天性大动脉转位(TGA)合并房间隔缺损(ASD)、动脉导管未闭(PDA)2.8 kg出生6 d的新生儿,进行了大动脉调转术(arteries switch)、ASD修补、PDA结扎术,畸形矫正后出现严重低心排综合征,低血压[＜39/30 mm Hg(1 mm Hg=0.133 kPa)]、高乳酸血症(Lac 8.8 mmol/L)、高左房压(LAP＞20 mm Hg)、血性痰、少尿[＜1 ml/(kg·h)],由于转流时间较长(263 min)且难以脱离体外循环,常规治疗无效后接V-A ECMO进行心肺辅助.结果 经87h ECMO辅助后,左心功能明显恢复,患儿顺利脱离ECMO,ECMO第1天LVEF 20%,第2天34%,第3天43%;ECMO第1天CKMB 41 μ/L,第2天恢复正常.脱离ECMO后,在较高浓度血管活性药支持下[肾上腺素0.2 μg/(kg·min),多巴胺/多巴酚丁胺8 μg/(kg·min),米力农0.56 μg/(kg·min)],循环基本稳定.ECMO撤离后第4天,关闭胸部切口.ECMO撤离后第22天,撤离呼吸机,术后30 d撤离血管活性药.术后58 d康复出院.出院时心肺、肝肾功能正常,神志清醒,四肢肌张力和运动正常.整个病程中多次头颅超声检查均未发现脑出血、梗死等病灶.ECMO并发症:(1)肺出血;(2)伤口出血和心包填塞;(3)溶血;(4)高胆红素血症.结论 ECMO对抢救新生儿心脏术后严重心功能不全有良好的疗效.
目的 總結ECMO救治新生兒心髒術後嚴重低心排的成功經驗.方法 2007年7月18日我們對一例患先天性大動脈轉位(TGA)閤併房間隔缺損(ASD)、動脈導管未閉(PDA)2.8 kg齣生6 d的新生兒,進行瞭大動脈調轉術(arteries switch)、ASD脩補、PDA結扎術,畸形矯正後齣現嚴重低心排綜閤徵,低血壓[＜39/30 mm Hg(1 mm Hg=0.133 kPa)]、高乳痠血癥(Lac 8.8 mmol/L)、高左房壓(LAP＞20 mm Hg)、血性痰、少尿[＜1 ml/(kg·h)],由于轉流時間較長(263 min)且難以脫離體外循環,常規治療無效後接V-A ECMO進行心肺輔助.結果 經87h ECMO輔助後,左心功能明顯恢複,患兒順利脫離ECMO,ECMO第1天LVEF 20%,第2天34%,第3天43%;ECMO第1天CKMB 41 μ/L,第2天恢複正常.脫離ECMO後,在較高濃度血管活性藥支持下[腎上腺素0.2 μg/(kg·min),多巴胺/多巴酚丁胺8 μg/(kg·min),米力農0.56 μg/(kg·min)],循環基本穩定.ECMO撤離後第4天,關閉胸部切口.ECMO撤離後第22天,撤離呼吸機,術後30 d撤離血管活性藥.術後58 d康複齣院.齣院時心肺、肝腎功能正常,神誌清醒,四肢肌張力和運動正常.整箇病程中多次頭顱超聲檢查均未髮現腦齣血、梗死等病竈.ECMO併髮癥:(1)肺齣血;(2)傷口齣血和心包填塞;(3)溶血;(4)高膽紅素血癥.結論 ECMO對搶救新生兒心髒術後嚴重心功能不全有良好的療效.
목적 총결ECMO구치신생인심장술후엄중저심배적성공경험.방법 2007년7월18일아문대일례환선천성대동맥전위(TGA)합병방간격결손(ASD)、동맥도관미폐(PDA)2.8 kg출생6 d적신생인,진행료대동맥조전술(arteries switch)、ASD수보、PDA결찰술,기형교정후출현엄중저심배종합정,저혈압[＜39/30 mm Hg(1 mm Hg=0.133 kPa)]、고유산혈증(Lac 8.8 mmol/L)、고좌방압(LAP＞20 mm Hg)、혈성담、소뇨[＜1 ml/(kg·h)],유우전류시간교장(263 min)차난이탈리체외순배,상규치료무효후접V-A ECMO진행심폐보조.결과 경87h ECMO보조후,좌심공능명현회복,환인순리탈리ECMO,ECMO제1천LVEF 20%,제2천34%,제3천43%;ECMO제1천CKMB 41 μ/L,제2천회복정상.탈리ECMO후,재교고농도혈관활성약지지하[신상선소0.2 μg/(kg·min),다파알/다파분정알8 μg/(kg·min),미력농0.56 μg/(kg·min)],순배기본은정.ECMO철리후제4천,관폐흉부절구.ECMO철리후제22천,철리호흡궤,술후30 d철리혈관활성약.술후58 d강복출원.출원시심폐、간신공능정상,신지청성,사지기장력화운동정상.정개병정중다차두로초성검사균미발현뇌출혈、경사등병조.ECMO병발증:(1)폐출혈;(2)상구출혈화심포전새;(3)용혈;(4)고담홍소혈증.결론 ECMO대창구신생인심장술후엄중심공능불전유량호적료효.
Objective To summarize the experience of extracorporeal membrane oxygenation (ECMO)to rescue a neonate with severe low cardiac output syndrome following open heart surgery.Methods The patient was a male,2 d,2.8 kg,G3P2 full-term neonate with gestational age 40 weeks,born by Cesarean-section with Apgar score of 10 at 1 min.He was admitted due to severe dyspnea with oxygen desaturation and heart murmur on the second day after birth.Physical examination showed clear consciousness,cyanosis,dyspnea,RR 70 bpm and a grade Ⅱ/6 heart murmur.Bp was 56/45 mm Hg (1 mm Hg=0.133 kPa)and SpO2 around 65%.Blood WBC 13.1×109/L,N 46.1%,Hb 238 g/L,Plt 283×109/L.CRP＜1 mg/L.Echoeardiographic findings:TGA+ASD+PDA with left ventricular ejection fraction(LVEF)of 60%.After supportive care and prostaglandin E1(5 ng/kg/min)treatment,his condition became stable with SpO2 85-90%.On the 6th day of life,the baby underwent an arterial switch procedure+ASD closing and PDA ligation.The time of aorta clamp was 72 mins.The cool 4:1 blood cardioplegia was given for 2 times during aortal clamp.Ultrafiltration was used.The internal and external volumes were almost equal and the electrolytes and blood gas and hematocrit(36%)were normal during extracorporeal bypass.Due to a failure(severe low cardiac output)to wean from cardiopulmonary bypass (263min)with acidosis(lactate 8.8 mmol/L),low blood pressure(＜39/30 mm Hg),increased LAP cardio-pulmonary support.ECMO setup:Medtronic pediatric ECMO package(CB2503R1),carmeda membrane oxygenator and centrifugal pump(bio-console 560)were chosen.Direct cannulation of the ascending aorta(Edward FEM008A)and fight atrium(TF018090)was performed using techniques that were standard for cardiopulmanory bypass.The ECMO system was primed with 400 ml blood,5%CaCl21g,5%sodium bicarbonate 1.5 g,20%mannitol 2 g,albumin 10 g,and heparin 5 mg.The blood was recirculated until the temperature was 37℃and blood gases and the electrolytes were in normal range.The patient was weaned from bypass and connected to V-A ECMO.Management of ECMO:the blood flow was set at 150-200 ml/kg/min.Venous saturation(SvO2)was maintained at the desired level(75%)by increasing and decreasing extracorporeal blood flow.Systemic blood pressure was maintained at 76/55-80/59 mm Hg by adiusting blood volume.Hemoglobin was maintained between 120-130 g/L.Platelet count was maintained at ＞75.000/mm3 and ACT was maintained at 120-190 s.The mechanical ventilation was reduced to lung rest settings(FiO2 35%,RR 10 bpm,PIP 16 am H2O,PEEP 5 cm H2O)to prevent alveolar collapse.Inotropic drug dosages were kept at a low level.Results The patient was successfully weaned from ECMO following 87 hours treatment.LVEF on day 1.2 and 3 following ECMO were 20%,34%and 43%respectively.The circulation was stable after weaning from ECMO with Bp 75/55 mm Hg,HR 160 bpm andPaO2 104 mm Hg.PaCO,45 mm Hg,lactate 3.8 mmoL/L,Hct 35%,K+3.8 mmol/L,Ca++ 1.31 mmol/L. The serum lactate was normal after 24 h off-ECMO.On day 22 off-ECMO.the baby was successfully extubated and weaned from conventional ventilator.On day 58.the patient was discharged.Serial ultrasound imaging studies revealed no cerebral infarction or intracranial hemorrhage during and after ECMO.At the time of hospital discharge.the patient demonstrated clear consciousness with good activity,normal function of heart.lung.liver and kidney.However,more subtle morbidities,such as behavior problems,learning disabilities should be observed ria long term follow-up.The main ECMO complications were pulmonary hemorrhage,bleeding on the sternal wound,tamponade,hemolysis and hyperbilirubinemia.Conclusion ECMO is an effective option of cardio-pulmonary support for neonate with low cardiac output syndrome following open heart surgery.
