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体外膜肺氧合抢救一例急性暴发型心肌炎

临床资料 男性患儿, 11 岁, 因“发热4 d, 腹痛1 d”入院。患儿4 d 前无明显诱因发热伴咽痛, 最高体温39 ℃, 就诊当地医院, 考虑“上呼吸道感染”, 输注头孢呋辛及对症处理, 效果欠佳, 转诊我院急诊。查体: 心率102 次/min, 呼吸34 次/min, 血压60 /32 mm Hg( 1 mmHg = 0. 133 kPa) , 体温38 ℃。K+ 5.4 mmoL/L, Na+ 126 mmoL/L, Cl - 95 mmoL/L,WBC 11. 5 ×109 /L, RBC 4. 76 ×1012 /L, Hb 120 g/L。心肌酶谱: CK 2098 U/L, CKMB 82 U/L, TNT 32. 1 U/L。ECG 提示:不规则多源性室性心律, Ⅲ度房室传导阻滞, 广泛导联ST-T损伤型改变。临床诊断: ①急性暴发型心肌炎; ②心源性休克; ③Ⅲ度房室传导阻滞。

Application of The Femoral Vesseles Catheterization in Extracorporeal Membrane Oxygenation for Salvage Treatment （Report of 47 Cases）

目的　分析股动静脉插管在体外膜肺氧合（extracorporeal membrane oxygenation，ECMO）抢救治疗中的临床应用。方法　回顾性分析笔者所在医院2002 年6 月至2010年7 月期间因重症心肺功能衰竭而施行股动静脉插管并进行静脉-动脉转流体外膜肺氧合（VA-ECMO）抢救的47例患者的临床资料。结果　本组47例患者均顺利施行ECMO支持，37例患者经过治疗后治愈出院，10例死亡。插管并发症有出血、肢体缺血等，均经相应处理后治愈。结论　ECMO对急性心肺衰竭是理想的支持方法，股动静脉为急救插管的首选通道。

Organ Procurement Process for Organ Donation after Cardiac Death

Objective　To summarize and further investigate the initial experience of organ procurement process for organ donation after cardiac death （DCD）. Methods　The clinical data，the selected standard，and the organ procurement process of 28 cases of DCD from July 2009 to January 2012 in the liver transplantation center of Guangzhou General Hospital were reviewed and analyzed. Results　Twenty-eight cases of DCD all had donated organs successfully. Among these cases，there were 3 cases （10.7%） of the Maastricht Ⅲ， and one case （3.6%） of the Maastricht Ⅳ，and 24 cases （85.7%） of the organ donation after brain death plus cardiac death （DBCD）．Three cases of the Maastricht Ⅲ were practiced the organ procurement process of DCD．One case of the Maastricht Ⅳ was practiced the organ procurement process of DBCD without the extracorporeal membrane oxygenation （ECMO）．Twenty-four cases of DBCD were practiced the organ procurement process of DBCD with the ECMO．The donator warm ischemic time was zero min in DBCD，18 min in Maastricht Ⅳ，and mean 25 min （22-28 min） in MaastrichtⅢ．All the donated organs included 28 livers，40 kidneys，and 2 hearts．And all these organs had been practiced the liver transplantation，the kidney transplantation，and the heart transplantation. Conclusions　The organ procurement process for organ DCD includes the DCD process and the DBCD process in China，and the later includes the organ procurement process with the ECMO and without the ECMO．The ECMO could well control the warm ischemia for protecting the donors just without ethics dispute. So，the using of the ECMO for the organ DCD of citizen in China has a very important contribution．

Airway Reconstruction supported by Extracorporeal Membrane Oxygenation

Objective To explore the feasibility and safety of extracorporeal membrane oxygenation (ECMO) to support the airway reconstruction for the patients with airway obstruction or stenosis who cannot be ventilated routinely. Methods There were 3 patients received trachea reconstruction procedures assisted by ECMO. Among the patients, 2 cases with tracheal neoplasms underwent fibrobrochoscopy treatments, another one with endotracheal stenosis and fistula received tracheoplasty and semi-tracheostomy. Results ECMO can provide enough oxygenation for the patients with airway obstruction or stenosis and more time for advanced therapies. All three patients recovered after interventional surgeries, in whom one case died due to multiple organ failure caused by esophageal carcinoma metastasis after 3 months, and the others survived with dyspnea classification of 2-3 grade. Conclusion ECMO can be a safe and effective approch for the patients who cannot be ventilated conventionally in airway reconstruction.

The progress of extracorporeal cardiopulmonary resuscitation

Although the survival rate reported in each center is different, according to the present studies, compared to conventional cardiopulmonary resuscitation (CCPR), extracorporeal cardiopulmonary resuscitation (ECPR) can improve the survival rate of cardiac arrest patient, no matter out-of-hospital or in-hospital. The obvious advantage of ECPR is that it can reduce the nervous system complications in the cardiac arrest patients and improve survival rate to hospital discharge. However, ECPR is expensive and without the uniformed indications for implantation. The prognosis for patients with ECPR support is also variant due to the different etiology. If we want to achieve better result, the ECPR technology itself needs to be further improved.

房间隔缺损修补术后体外膜肺联合体位疗法的观察及护理一例

Extracorporeal membrane oxygenation combined with hypothermia therapy for children patients with refractory cardiac arrest after congenital heart disease surgery: A randomized controlled trial

Objective To explore the value of extracorporeal membrane oxygenation(ECMO) combined with hypothermia therapy for children patients with refractory cardiac arrest after congenital heart disease surgery. Methods From January 2013 to June 2016, we conducted a prospective study of 23 children (18 males, 5 females at age of 7±11 months) who underwent ECMO for refractory cardiac arrest after congenital heart disease surgery. All patients were randomly divided into two groups: a standard group (11 patients) and a hypothermia group (12 patients). The patients of the standard group received standard therapy (the core body temperature maintaining at 37.0℃) and the hypothermia group received hypothermia therapy (the core body temperature maintaining at 33.0℃). The hospital discharge rate, the rate of weaning from ECMO and the morbidity were compared between the two groups. Results Eleven of 23 patients (47.8%) were weaned from ECMO successfully and 7 of 23 patients (30.4%) discharged from hospital. The hospital discharge rate between the hypothermia group (n=6, 50.0%) and the standard group (n=1, 9.1%) had no statistical difference (χ2=4.537, P=0.069). The rate of weaning from ECMO of the hypothermia group (n=9, 75.0%) was higher than that of the standard group (n=2, 18.2%, χ2=7.425, P=0.006). The morbidity between the two groups had no statistical difference. Conclusion Extracorporeal cardiopulmonary resuscitation can improve the survival rate of the children who suffered from refractory cardiac arrest after congenital heart disease surgery. There is no evidence that ECMO combined with hyperthermia therapy is better than the only ECMO in improving the discharge rate. But ECMO combined with hypothermia therapy has higher rate of weaning from ECMO than that of the only ECMO.

单心室心脏分期术后机械循环支持的临床经验

目的 探讨单心室心脏分期手术后循环衰竭行机械辅助的临床结果及治疗意义。 方法 2008 年 1 月至 2017 年 6 月上海儿童医学中心 89 例患者心脏术后行机械辅助，其中单心室心脏手术后行机械辅助 4 例（4.5%）。3 例为 Glenn 术后，1 例为 B-T 分流术后。辅助方式均为正中经胸的静脉-动脉体外膜肺氧合（V-A ECMO）技术。3 例 ECMO 插管方式为右心房单根静脉回流， 1 例 Glenn 术后加用上腔静脉插管增加静脉引流量。单心室转流期间 ECMO 按常规管理。分析单心室术后需要机械辅助支持的原因、辅助方式、插管特点及临床结果。 结果 4 例单心室机械辅助病例，3 例 ECMO 撤机成功，1 例因持续性肺动脉高压放弃治疗。辅助时间为 104（55～504）h。治疗中 1 例，1 例长期随访中，出院 2 例，其中 1 例出院后 2 周在当地死亡，死亡原因不明。 结论 单心室术后的辅助循环脱机成功率较低。应根据患儿临床情况尽早启用，以提高存活率。非搏动性血流与搏动性血流的机械辅助效果尚待临床验证。针对 Fontan 循环衰竭患儿的长期心室辅助装置辅助是机械辅助领域最具挑战性的热点。

如何治疗主动脉瓣狭窄合并体外膜肺氧合支持下的心源性休克

背景：患者，男，77 岁。因活动后呼吸困难及劳累性胸痛入院，完善相关检查后发现存在重度主动脉瓣狭窄及严重冠状动脉狭窄，随后行经导管冠状动脉介入治疗至右冠狭窄处植入支架。术后，患者突发心源性休克和心脏骤停，复苏后依赖于静脉-动脉体外膜肺氧合支持。检查：心电图，经胸廓的超声心动图，冠状动脉造影，计算机断层血管摄影。诊断：严重主动脉瓣狭窄合并心源性休克。治疗：为稳定患者血流动力学状态，早日拔除体外膜肺，患者被转运至导管室实施急诊经导管主动脉瓣置换术。

右心辅助在心脏移植术后急性右心衰竭中的临床应用

目的 探讨右心辅助方式治疗合并重度肺动脉高压患者心脏移植术后急性右心衰竭的初步经验。 方法 回顾性分析 2017 年 4～8 月我院行右心辅助 4 例患者的临床资料，其中男 3 例、女 1 例，平均年龄（46.2±1.8）岁。术前行右心导管监测肺动脉阻力为（7.80±0.67）Wood 单位，肺动脉收缩压（69.75±3.47）mm Hg。在心脏复跳后体外循环并行循环时行肺动脉和股静脉插管，建立右心室辅助并撤离体外循环。辅助至右心功能恢复满意，逐步减低流量，撤除右心辅助。 结果 4 例患者全部成功撤除右心辅助并存活。平均供心冷缺血时间为（235.0±18.8）min，体外循环时间为（272.0±41.1）min，并行辅助循环时间为（166.0±32.7）min，平均右心辅助时间为（157.7±27.5）h，全血激活凝固时间（ACT）监测波动于 120～150 s 之间。期间无再次开胸止血事件，无辅助机械障碍发生，无管道内凝血事件发生。 结论 右心辅助比体外膜肺氧合具有机械故障少，辅助时间长，抗凝要求低，出血少，血细胞、血小板和凝血因子破坏少的优点，而且经济效益可观，更加接近生理循环，不会增加左心后负荷。