Department of Pediatrics, University of Michigan, Ann Arbor.
Child Health Evaluation and Research Center, University of Michigan, Ann Arbor.
JAMA Pediatr. 2021 May 1;175(5):510-517. doi: 10.1001/jamapediatrics.2020.5921.
Extracorporeal membrane oxygenation (ECMO) is a form of advanced life support that may be used in children with refractory respiratory or cardiac failure. While it is required infrequently, in the US, ECMO is used to support childhood respiratory failure as often as children receive kidney or heart transplants. ECMO is complex, resource intensive, and potentially lifesaving, but it is also associated with risks of short-term complications and long-term adverse effects, most importantly with neurodevelopmental outcomes that are relevant to all pediatric clinicians, even those remote from the child's critical illness.
The 2009 influenza A(H1N1) pandemic, along with randomized clinical trials of adult respiratory ECMO support and conventional management, have catalyzed sustained growth in the use of ECMO. The adult trials built on earlier neonatal ECMO randomized clinical trials that demonstrated improved survival in severe perinatal lung disease. For children outside of the neonatal period, there appear to have been no respiratory ECMO clinical trials. Applying evidence from adult respiratory failure or perinatal lung disease to children outside the neonatal period has important potential pitfalls. For these children, the underlying diseases and risks of ECMO are different. Despite these differences, both neonates and older children are at risk of neurologic complications, such as intracranial hemorrhage, ischemic stroke, and seizures, and those complications may contribute to adverse neurodevelopmental outcomes. Without specific screening, subtle neurodevelopmental impairments may be missed, but when they are identified, children have the opportunity to receive therapy to optimize long-term development.
All pediatric clinicians should be aware not only of the potential benefits and complications of ECMO but also that survivors need effective screening, support, and follow-up.
体外膜肺氧合（ECMO）是一种高级生命支持形式，可用于治疗难治性呼吸或心力衰竭的儿童。虽然在美国很少需要使用 ECMO，但它用于支持儿童呼吸衰竭的频率与儿童接受肾脏或心脏移植的频率一样高。ECMO 复杂、资源密集且具有潜在的救生作用，但也与短期并发症和长期不良后果相关的风险有关，最重要的是与神经发育结局有关，这些结局与所有儿科临床医生有关，即使是远离儿童危重病的临床医生。
2009 年甲型 H1N1 流感大流行以及成人呼吸 ECMO 支持和常规治疗的随机临床试验，推动了 ECMO 使用的持续增长。这些成人试验建立在早期新生儿 ECMO 随机临床试验的基础上，这些试验表明严重围产期肺部疾病的生存率得到了提高。对于新生儿期以外的儿童，似乎没有进行过呼吸 ECMO 临床试验。将成人呼吸衰竭或围产期肺部疾病的证据应用于新生儿期以外的儿童，存在重要的潜在陷阱。对于这些儿童，ECMO 的潜在疾病和风险是不同的。尽管存在这些差异，但新生儿和较大的儿童都有患神经并发症的风险，如颅内出血、缺血性中风和癫痫发作，这些并发症可能导致不良的神经发育结局。如果没有进行特定的筛查，可能会错过轻微的神经发育障碍，但当这些障碍被识别出来时，儿童有机会接受治疗以优化长期发育。
所有儿科临床医生不仅应该意识到 ECMO 的潜在益处和并发症，还应该意识到幸存者需要有效的筛查、支持和随访。
