Can the outcome of pediatric extracorporeal membrane oxygenation after cardiac surgery be predicted?
Can the outcome of pediatric extracorporeal membrane oxygenation after cardiac surgery be predicted?
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发表时间：
2006-02
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通讯作者：
G. Baslaim;J. Bashore;F. Al-Malki;A. Jamjoom
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作者：
G. Baslaim;J. Bashore;F. Al-Malki;A. Jamjoom
本研究的目的是评估临床和生化变量是否可用于预测心脏手术后接受体外膜肺氧合（ECMO）治疗的儿童的结局，并确定何时停止ECMO支持。方法回顾性分析2000年10月至2004年5月在我院行体外膜肺氧合（ECMO）治疗的26例心脏术后患儿的临床资料。结果患者平均年龄为16.4个月（范围，2周至144个月），平均体重为6.3 kg（范围，2.2-26 kg）。在26例需要ECMO支持的患儿中，23例接受了双心室修复术，3例接受了单心室手术。单心室修复组和动脉干修复组在ECMO支持下均未存活。12例患者（46%）在ECMO支持下存活并出院。4例患者在心肺复苏（CPR）时间（范围= 30-55 min）平均45 min（平均）后需要ECMO支持，2/4存活出院。所有存活至出院的患者均未显示神经功能缺损或弥散性血管内凝血（DIC）的证据，而5例患者死于卒中，8例死于DIC（p = 0.021和0.002）。8例发生肾衰竭（1例存活，7例死亡，p = 0.022）。17名患者（65%）需要再次探查纵隔出血。ECMO的时间长度，虽然在非幸存者中更长，但在幸存者（74.5小时）和非幸存者（118.2小时）组之间没有显著差异（p = 0.41）。计算ECMO启动时的正性肌力评分和ECMO 72小时内的血清乳酸，两组之间的差异与生存率无显著相关性（分别为p = 0.29和0.22）。结论ECMO支持期间发生肾功能衰竭、脑卒中和DIC的患者死亡率高。单心室生理和动脉干修复的患者从ECMO支持中获益较少，死亡风险增加。最初72小时内乳酸水平升高、ECMO开始时的高正性肌力评分和ECMO支持持续时间长（超过3天）都是可用于确定何时停止ECMO支持的潜在变量。
PURPOSE The purpose of this study is to assess whether clinical and biochemical variables may be used to predict outcome in children treated with extracorporeal membrane oxygenation (ECMO) after cardiac surgery and to determine when to discontinue ECMO support. METHODS We retrospectively reviewed the medical records of 26 children treated with ECMO after cardiac surgery at our institution from October 2000 to May 2004. RESULTS Patients mean age was 16.4 months (range, two weeks to 144 months) and mean weight was 6.3 kg (range, 2.2-26 kg). Of the 26 children requiring ECMO support, 23 underwent biventricular repair, and 3 had single ventricle procedure. None of the single ventricle repair or the truncus arteriosus repair group survived the ECMO support. Twelve patients (46%) survived the ECMO support and were discharged from hospital. Four patients needed ECMO support after 45 min (mean) of cardiopulmonary resuscitation (CPR) time (range = 30-55 min) with 2/4 survived to discharge. All patients who survived to discharge showed no evidence of neurological deficit or disseminated intravascular coagulopathy (DIC) whereas 5 patients died following stroke, and 8 following DIC, respectively (p = 0.021 and 0.002). Renal failure developed in 8 cases (1 survivor and 7 nonsurvivors, p = 0.022). Seventeen patients (65%) required re-exploration of the mediastinum for bleeding. Length of time on ECMO, although it was longer among the nonsurvivors, was not significantly different between the survivor (74.5 hours) and nonsurvivor (118.2 hours) groups (p = 0.41). Inotrope score at ECMO initiation and serum lactate within 72 hours of ECMO were calculated and the difference between the two groups was not significantly related to survival (p = 0.29 and 0.22 respectively). CONCLUSION Our findings suggest patients who develop renal failure, stroke and DIC during ECMO support have a high mortality. Patients with single ventricle physiology, and repaired truncus arteriosus may benefit less from ECMO support and have an increased risk of death. Elevated levels of lactate during the first 72 hours, high inotrope score at the initiation of ECMO and long ECMO support duration (more than 3 days) are all potential variables that can be used in determining when to discontinue ECMO support.