Machado Desiree S, Tule Manjiri, Philip Joseph, Wynn Tung, Lazarowicz Michael, Machuca Tiago, Pipkin Mauricio, Alnuhaimat Hassan, Ebraheem Mohammad, Peek Giles, Bleiweis Mark
Division of Pediatric Critical Care, Department of Pediatrics, Division of Pediatric Cardiac Critical Care, Department of Pediatrics, Congenital Heart Center, Division of Pediatric Hematology and Oncology, Department of Pediatrics, Division of Vascular and Interventional Radiology, Department of Radiology, Department of Cardiothoracic Surgery, and Subdivision of Pulmonology and Advance Lung Failure, Department of Internal Medicine, University of Florida, Gainesville, Florida.
J Extra Corpor Technol. 2020 Dec;52(4):327-331. doi: 10.1182/ject-2000013.
Saddle pulmonary embolism (PE) remains a challenge to diagnose and manage in pediatric patients. Current literature encourages early consideration of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in high-risk PE patients with impending right ventricular failure. We present a 17-year-old patient who was admitted to a pediatric cardiac intensive care unit with saddle PE requiring emergent VA-ECMO support because of cardiovascular collapse. Despite anticoagulation with bivalirudin and receiving systemic thrombolysis with alteplase, the clot burden was persistent with minimal improvement in right ventricular function. We proceeded to catheter thrombolysis while on VA-ECMO. This ultimately led to a successful resolution of the PE and allowed for weaning off VA-ECMO. PE is rare in children compared with adults, and pediatricians may be unaware of therapies becoming increasingly used in adults such as the use of VA-ECMO, with systemic and local thrombolysis. The concurrent use of a direct thrombin inhibitor for ECMO anticoagulation alongside the thrombolysis is a novel combination in this condition and age-group.
鞍状肺栓塞（PE）在儿科患者中的诊断和管理仍然是一项挑战。当前文献鼓励对即将发生右心室衰竭的高危PE患者尽早考虑采用静脉-动脉体外膜肺氧合（VA-ECMO）。我们报告一名17岁患者，因鞍状PE入住儿科心脏重症监护病房，由于心血管衰竭需要紧急VA-ECMO支持。尽管使用比伐卢定进行抗凝并接受阿替普酶全身溶栓治疗，但血栓负荷持续存在，右心室功能改善甚微。我们在VA-ECMO支持下进行了导管溶栓治疗。这最终成功解决了PE问题，并使患者能够撤离VA-ECMO。与成人相比，PE在儿童中较为罕见，儿科医生可能不了解成人中越来越常用的治疗方法，如VA-ECMO的使用以及全身和局部溶栓治疗。在这种情况下，将直接凝血酶抑制剂用于ECMO抗凝同时进行溶栓治疗，在该年龄段是一种新颖的联合治疗方法。
