Pinheiro Machado Bruna, Ziylan Yadigar, Detheux Alexia, Willems Ariane, De Maertelaer Viviane, De Laet Corinne, Rooze Shancy
Department of Paediatrics, Hôpital Universitaire de Bruxelles (H.U.B), Université Libre de Bruxelles, Brussels, Belgium.
Centre Métabolique ULB-VUB (HUDERF), Hôpital Universitaire de Bruxelles (H.U.B), Brussels, Belgium.
Eur J Pediatr. 2025 Apr 28;184(5):315. doi: 10.1007/s00431-025-06150-4.
Early enteral nutrition in patients undergoing extracorporeal membrane oxygenation (ECMO) is particularly challenging due to metabolic instability, feeding intolerance, and the risk of intestinal ischemia. This study aimed to identify risk factors for gastrointestinal intolerance (GI) and necrotizing enterocolitis (NEC) in pediatric patients supported with veno-arterial (VA) or veno-venous (VV) ECMO. This monocentric and retrospective cohort study involved 127 pediatric patients who underwent ECMO in the pediatric intensive care unit of the Queen Fabiola Children's University Hospital, Belgium, between January 2011 and December 2023. Diarrhea on Day 2 (D2) occurred in 13.7% of the VV-ECMO patients (10/73) but not in any of the VA-ECMO patients (p = 0.013). The frequencies of other gastrointestinal symptoms, such as vomiting, abdominal distension, and gastrointestinal hemorrhage, did not significantly differ between the groups during the study period. NEC occurred in 5.1% of VV-ECMO patients (4/78) and 10.2% of VA-ECMO patients (5/49) (p = 0.230). Enteral nutrition was initiated within 48 h of ECMO cannulation in 110/127 patients (86.6%). Patients who presented with gastrointestinal complications on D2 had a low lactate value at ECMO initiation (3.61 ± 0.56 mmol/l versus 5.42 ± 0.44 mmol/l (p = 0.013)) and a low PRISM (19 ± 3 versus 25 ± 1 (p = 0.033)) and PIM (12 ± 5 versus 18 ± 2 (p = 0.288)). Patients with NEC presented non significantly higher lactate levels on D0 and D2. Lactatemia was significantly lower for living patients on D0 and D2.
This study suggests that early EN in pediatric ECMO patients should be approached with caution. Mild digestive complications can occur, and the incidence of NEC can be high. High lactate levels at ECMO cannulation appear to be associated with severe complications such as death and NEC.
• Hyperlactatemia is a valuable indicator of low tissue perfusion.
• The findings of this study suggest that patients who developed NEC had higher lactate levels at the time of cannulation than at the time of NEC diagnosis. • Lactatemia seems to be a risk factor for severe complications such as NEC and death rather than a risk factor for mild GI complications.
对于接受体外膜肺氧合（ECMO）治疗的患者，早期肠内营养面临诸多挑战，原因包括代谢不稳定、喂养不耐受以及肠道缺血风险。本研究旨在确定接受静脉 - 动脉（VA）或静脉 - 静脉（VV）ECMO支持的儿科患者发生胃肠道不耐受（GI）和坏死性小肠结肠炎（NEC）的风险因素。这项单中心回顾性队列研究纳入了127例儿科患者，他们于2011年1月至2023年12月期间在比利时女王法比奥拉儿童医院的儿科重症监护病房接受了ECMO治疗。在VV - ECMO患者中，13.7%（10/73）在第2天（D2）出现腹泻，而VA - ECMO患者中无一例出现腹泻（p = 0.013）。在研究期间，两组患者的其他胃肠道症状，如呕吐、腹胀和胃肠道出血的发生率无显著差异。NEC在5.1%的VV - ECMO患者（4/78）和10.2%的VA - ECMO患者（5/49）中发生（p = 0.230）。127例患者中有110例（86.6%）在ECMO插管后48小时内开始肠内营养。在D2出现胃肠道并发症的患者在ECMO开始时乳酸值较低（3.61±0.56 mmol/L对5.42±0.44 mmol/L（p = 0.013）），PRISM评分较低（19±3对25±1（p = 0.033）），PIM评分较低（12±5对18±2（p = 0.288））。NEC患者在D0和D（此处原文可能有误，推测为D2）时乳酸水平无显著升高。存活患者在D0和D2时的血乳酸水平显著较低。
本研究表明，儿科ECMO患者的早期肠内营养应谨慎进行。可能会出现轻度消化并发症，NEC的发生率可能较高。ECMO插管时高乳酸水平似乎与死亡和NEC等严重并发症相关。
• 高乳酸血症是低组织灌注的重要指标。
• 本研究结果表明，发生NEC的患者在插管时的乳酸水平高于NEC诊断时。 • 血乳酸水平似乎是NEC和死亡等严重并发症的风险因素，而非轻度GI并发症的风险因素。
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