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体外膜肺氧合支持在儿童经软式支气管镜介入治疗中的应用 预览

Application of extracorporeal membrane oxygenation support for undergoing flexible bronchoscopy interventional therapy in children
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摘要 目的 通过1 例在体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)支持下经软式支气管镜成功取出异物的儿童病例,初步探讨在ECMO 支持下行支气管镜介入治疗的临床应用及经验。方法 患儿女,1 岁2 个月,因“肺炎”在外院住院治疗,2018 年1 月1 日突发呛咳,胸部CT 提示气管内异物不除外,当地医院予有创呼吸机呼吸支持,患儿仍持续存在低氧血症,心率不稳。2018 年1 月6 日,解放军总医院第七医学中心儿童ECMO 团队在当地医院为患儿安装V-A ECMO 并转院,在ECMO 支持下,拔出气管插管后行经鼻咽软式支气管镜异物取出术。结果 ECMO 转运小组在当地医院安装V-A ECMO 设备,初始流量为0.7 L/min,氧流量与血流量之比为1 ︰ l,FiO2 为60%。ECMO 使用30 min 后,动脉血气示:PaO2 由35 mmHg(1 mmHg=0.133 kPa)升至160 mmHg,PCO2 由76 mmHg 下降至45 mmHg,血乳酸由3.5 mmol/L 降至0.9 mmol/L。当患儿情况稳定后,经过6 h 长途转运至我院儿童重症科。入院4 h 后在ECMO 支持下行经鼻咽软式支气管镜异物取出术。术中心率、血氧稳定。术后30 min,PaO2 为202 mmHg,PaCO2 为44 mmHg,血乳酸为1.5 mmoL/L。将ECMO 流量调至0.5 L/min,FiO2 调至50%,患儿心率波动在100 ~ 110 次/min,PaO2 维持在150 ~ 200 mmHg。使用ECMO 期间,患儿心功能明显好转,胸部X 线片提示肺部炎症逐渐吸收。使用ECMO 后72 h,流量下调到0.3 L/min,FiO2 下调到30%,动脉血气分析示:PaO2 为190 mmHg,PaCO2 为36 mmHg,SaO2为100%,血乳酸0.9 mmol/L。术后90 h 撤除ECMO,2 周后痊愈出院。ECMO并发症主要为出血和渗血,对症治疗后好转。结论 ECMO 可有效地为支气管镜介入治疗争取时间及改善入镜方式,并在介入治疗过程中维持患者生命体征的稳定。 Objective To preliminary explore the clinical application and experience of extracorporeal membrane oxygenation (ECMO)-supported underwent bronchoscope interventional therapy through a case with foreign bodies in trachea were removed by a flexible bronchoscope with ECMO supporting. Methods The infant was female with one year and two months, who was treated as pneumonia at other hospital. On January 01, 2018 the infant had a cough suddenly, and received the invasive respiratory support (invasive ventilator mainly) at the local hospital due to chest CT showed foreign bodies in trachea possiblely, but the child still had persistent hypoxemia and fluctuating heart rate. On January 06, 2018 the child was received the ECMO therapy and was transferred to that hospital by the ECMO group of The Seventh Medical Center, General Hospital of PLA . With the support of ECMO, tracheal intubation was pulled out and the foreign bodies were removed by nasopharyngeal soft bronchoscope. Results The transshipment team installed V-A ECMO equipment at local hospital, initial flow was 0.7 L/min, the ratio of oxygen flow to blood flow was 1:1, FiO2 was 60%. After 30 min, arterial blood gas showed: PaO2 rose from 35 mmHg (1 mmHg=0.133 kPa) to 160 mmHg, PCO2 dropped from 76 mmHg to 45 mmHg and blood lactic acid (Lac) dropped from 3.5 mmol/L to 0.9 mmol/L. The child was transferred to the pediatric intensive care unit of hospital after 6 h with stable condition, tracheal intubation was extracted with ECMO support and foreign bodies were removed via nasopharyngeal soft bronchoscope. During operation whose heart rate and transcutaneous oxygen saturation were stable. 30 min after surgery, PaO2 was 202 mmHg, PaCO2 was 44 mmHg and Lac was 1.5 mmoL/L. The flow rate of ECMO was adjusted to 0.5 L/min and the FiO2 was adjusted to 50%. The heart rate of the case ranged from 100-110 beats per min, PaO2 maintained at 150- 200 mmHg. During the use of ECMO, the heart function of the infant was significantly improved, and pulmonary inflammation was absorbe
作者 祝彬 许煊 张晓娟 王猛 兰莹 沈晓丽 ZHU Bin;XU Xuan;ZHANG Xiao-juan;WANG Meng;LAN Ying;SHEN Xiao-li(Pediatric Intensive Care Unit, The Seventh Medical Center, General Hospital of PLA, Beijing 100700,China)
出处 《发育医学电子杂志》 2019年第2期151-155,160共6页 Journal of Developmental Medicine (Electronic Version)
基金 深圳市医疗卫生三名工程(SZSM201606088).
关键词 体外膜肺氧合 儿童重症监护 支气管异物 介入肺科学 心肺功能衰竭 Extracorporeal membrane oxygenation Pediatric intensive care Foreign body bronchus Interventional pulmonary Cardiopulmonary failure
作者简介 通讯作者:许煊(Email:xuxuan2008-gz@163.com).
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