Extracorooreal membrane oxvgenation treatment of a child with fulminant myocarditis / 中国小儿急救医学

ABSTRACT

Objective To report the clinical experience of extracorporeal membrane oxygenation (ECMO)in the emergency management of fulminant myocarditis.Methods The patient,an 11 year-old boy,had fever for 4 day and abdominal pain,vomiting for 1 day and anuria for 12 hours.Electrocardiogram showed Ⅲ atrial-ventricular block,multifocal ventricular rhythm,bundle branch block,convulsivum multifocal ventricular tachycardia,extensive low voltage,ST-T elevation at lead Ⅰ,AVR,V1,V2,V3;and there were ST-T intrusion,T wave inversion at lead Ⅱ,Ⅲ,AVR,AVF,V4～5.Blood creatine kinase was 2 161 U/L,reatine kinase isoenzyme 109 U/L,α-hydroxybutyrate dehydrogenase 612 U/L,lactate dehydrogenase 696 U/L,troponin Ⅰ 22.1 U/L.Echocardiogram showed right atrium 4.4 mm,right ventricular 2.3 mm,severe tricuspid valve regurgitation,left ejection fraction 33％,left ventricular fractional shortening 15％,ventricular wall motion dyssynchrony.Blood lactate was 4.0 mmol/L.The patient's condition was still unstable after using dobutamin,dopamine,milrinone,furosemide,large dose methylprednisolone,intravenous human immunoglobin,phosphocreatine and so on.ECMO was used for cardio-pulmonary support.It is necessary to monitoring the consciousness,temperature,heart rate,respiration,blood pression,SaO2,urinary volume,ariterial blood gas,blood electrolytes,blood lactate,blood glucose,liver function,renal function,blood routine,activated clotting time(ACT),lower extremity blood supply and so on.ACT was maintained at 160～200 s.Heparin was used persistently[5～10 U/(kg·min)].Results ECMO system had been successfully used for 7 days.The cardiac function of the patient was improved significantly.There was no complication,such as hemorrhage,infection,and embolism.Heart arrest in the patient occurred three times,ventricular fibrillation and ventricular flutter occurred one time respectively during ECMO.The rhythm was recovered by electric defibrillation and antiarrhythmic drugs.On day 20,the patient was discharged.At the time of hospital discharge,the patient demonstrated good activity,with normal myocardial enzymes.The echocardiogram showed the size of the cardiac chambers and the contractile function of the myocardia were normal.Electrocardiogram showed Ⅰ degree atrial-ventricular block,complete right bundle branch block.Two weeks later,the electrocardiogram demonstrated complete right bundle branch block.Echocardiogram showed septal thickening(0.9 cm).Two months later,the electrocardiogram was just as that of two weeks before.Echocardiogram showed septal thickening(0.7 cm).The children had no symptom after he was discharged and acted without limitation.Conclusion ECMO is a kind of effective treatment for fulminant myocarditis.The key to desirable therapeutic effect is the timing of its application.