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1、中华小儿外科杂志 2016 年 6 月第 37 卷第 6 期 Chin J Pediatr Surg.Junc 2016, Vol. 37,No. 6#体外膜肺氧合专题小儿右侧颈动、静脉体外膜肺氧合致颅脑损伤多因素分析应力阳熊启星叶莉芬范勇杨丽君张晨美舒强杜立中林茹 310052杭州，浙江大学医学院附属儿童医院心脏外科 通信作者：熊启星Email: xiongqx 163. comDOI： 10. 3760/cma j. issn. 0253-3006 2016. 06 002【摘要】 目的 f解小儿右颈动静脉体外膜肺氧合(extracorporeal membrane oxygenation
2、, ECMO)致颅脑损伤的高风险因素.方法 回顾性分析自2009年7月至2015年11月19例严重心 肺衰竭患儿行右颈总动脉和右颈内静脉插管，并结扎相应远端血管转ECMO的临床资料。本组男 12例女7例;年龄1 d13岁新生儿2例;体重3. 761.0 kg,平均(22.7 15.2)kg.本组行ECMO 前低鴻注13例(6& 4%),伴有高乳酸血症10例(52.6%),少尿10例(52.6%),心肺复苏胸外按压同 时ECMO(&CPR；7例(36.8%).低氧和/或酸中毒16例(84.2%).采用静脉动脉转流ECMO(VA- ECMO)18例，静脉-静脉转流ECMO(W-ECMO)!例。结果
3、 能在1 h内建立有效循环并在随后24 h内获得明显组织堰注改善17例，不能改善2例。ECMO支持时间65572 h,平均(172.0 141. 0) h。19例中脱机14例(73.7%),存活13例(6& 4%),死亡6例(31.6%)。发生颅脑损伤4例 (21. 0%,颅脑损伤组)，其中心搏骤停3例(院外心搏骤停史1例.E-CPR 2例)，插管困难且不能在24 h获得内环境和组织灌注改善2例,ECMO前长时间严重低氧血症1例，最终死亡2例(50. 0%)。行 E-CPR 7例的存活率为力.4%7),病死率为28.6%7)；颅脑损伤发生率为28.6%(2/7),明显高 于总体平均水平。本组2
4、例新生儿，存活1例为新生儿隔疝，1例为胎粪吸人综合征死于严重溶血、 肝衰竭，这2例均无颅脑损伤。存活13例出院后随访时间1个月6年不等，无颅脑损伤后遗症12 例，能正常生活学习，有明显颅脑损伤后遗症1例(7.7%)。存活13例中有10例在ECMO撤离后行 颈部血管趙声检杳,均桿示右颈总动脉尺颈内静脉结扎远端血管充盈血流iF常;7例行脑NIRI检 査,2例行脑部CT检査,发现颅内岀血2例。新生儿中存活1例脑干听觉诱发电位测定提示双耳正 常。结论ECMO能治疗严重心肺衰竭患儿。预防ECMO所致颅脑损伤的关键在于密切关注EC- M()术前、术中各个相关危险因索，把握ECMO置入时机。对于小儿ECMO
5、颈部血管入路是比较好 的选择。结扎颈部血管并不增加颅脑损伤的发生【关键词】体外循环;颅脑损伤;颈总动脉基金项目：国家科技支撐计划项目(2012BAI04B05)；浙江省科技厅公益技术研究社会发展项目 (2014C33168)；浙江省医药卫生科技计(2012ZDA030,2012ZDA031) ； 江省卫生高层次创新人才 培养工程项目(2016-6)Mult卜factorial analysis of cerebral injury in children with a ligation of right carotid artery after extracorporeal membrane
6、oxygenation Ying Li yang 9 Xiong Qixing Ye Li fen 9 Fan Yong 9 Yang Lijun Zhang Chenmei 9 Shu Qiang, Du Lizhong Lin RuCardiac Surgery Department Childrens Hospital t Zhejiang University School of Medicine, Hangzhou 310052 ChinaCorresponding Author: Xiong Qixing Email: xiongqx63. comAbstract Objectiv
7、e To explore the high-risk factors of cerebral injury with a ligation of right carotid artery after extracorporeal membrane oxygenation (ECMO). Methods A total of 19 patients with severe cardiopulmonary failure were selected for ECMO from July 2009 to November 2015. Right common carotid arery and ri
8、ght internal jugular vein were performed with a ligation of distal blood vessels. Results There were low perfusion (13/19). high lactic acid (10/19). oliguria (10/19), E-CPR (extracorporeal membrane oxygenation-cardiopulmonary resuscitation) (7/19) and hypoxia (16/19) prior to ECMO. VA-ECMO (n= 18)
9、and W-ECMO (n= 1) were employed. And 17 cases showed obvious tissue perfusion improvement after effective circulation within 1 hour. The duration of support time was 65-572 (172. 0 141. 0) h for 14 cases of successful weaning. The outcomes were survival (n = 13) and death (n = 6). The rates of weani
10、ng, survival and mcrtality were 73. 7%. 6& 4% and 31. 6% respectively. Cerebral injury occurred in 4 cases and the mortality of brain injury was 50% (2/4). Among 3 cases of cardiac arrest* there were out-of-hospital (n = 1) and E-CPR (n = 2). Two cases of difficult intubation failed to achieve tissu
11、e perfusion improvement after 24 h ECMO. Sustained severe hypoxia existed in one case before ECMO. The rates of mortality and cerebral injury was the same 28.6%(2/7) as those of E-CPR cases. Two neonate cases had nc cerebral injury()nc case of diaphragmatic hernia survived while another one with mec
12、onium aspiration syndrome died of severe hemolytic failure. And 13 survivors were followed up from 1 month to 6 years There was only 1 case of obvious cerebral injury. Neck vascular ultrasound showed that blood flow was normal in distal right carotid artery and carotid internal jugular vein of 9 sur
13、viors. For 6 survivors, magnetic resonance angiography (MRA) examination showed no abnormalities in bilateral anterior, middle and posterior cerebral arteries. Two cases of intracranial hemorrhage were detected by magnetic resonance imaging (MRI) and computed tomography (CT). Electroencephalogram sh
14、owed no obvious abnuiiiialilics in 9 sui vivuib ax id bi aiiibtein auditory evoked potential was normal. Conclusions ECMO can significantly improve the survival of children with severe heart and lung failure. The key of preventing cerebral injury after ECMO is monitoring the risk factors before and
15、during ECMO. Neck vascular accessing is excellent and vascular ligation does not increase the incidence of cerebral injury.【Key words Extracorporeal circulation； Craniocerebral trauma； Carotid artery commonFund program： National Sci-tech Support Plan 2012(2012BA104B05) ； Zhejiang Province Science &
16、Technology (2014C33168) j Zhejiang Medical & Health Science & Technology Program (2012ZDA030. 2012ZDA031 ); Zhejiang Provincial Program for the Cultivation of High-level Innovation Health talents (2016-6)中华小儿外科杂志 2016 年 6 月第 37 卷第 6 期 Chin J Pediatr Surg.Junc 2016, Vol. 37,No. 6#中华小儿外科杂志 2016 年 6 月第 37 卷第 6 期 Chin J Pediatr Surg.Junc 2016, Vol. 37,No. 6#体外膜肺氧合(extracorporeal membrane oxy- genation,ECMD)治疗可明显改善可
