Azzam F J, Fiore A C
Department of Anesthesiology, Saint Louis University Medical Center, MO 63110, USA.
Can J Anaesth. 1998 Sep;45(9):898-902. doi: 10.1007/BF03012227.
To report the management of junctional ectopic tachycardia after cardiac surgery in an infant. Postoperatively, the patient suffered profound cardiac decompensation secondary to the accelerated rhythm and required extracorporeal membrane oxygenation (ECMO) for haemodynamic support.
A 14-day-old, 3.5 kg boy exhibited junctional ectopic tachycardia after cardiopulmonary bypass. Left atrial pressure was 25-28 mmHg. No impact on the tachycardia was seen after rapid overdrive atrial pacing or after 20 micrograms fentanyl i.v., 45 micrograms digitalis, 100 mg magnesium or procainamide (loading dose 15 mg, then 30 mg.kg-1.min-1). Active cooling decreased the nasopharyngeal temperature to 35.2 degrees C, when the heart rate decreased below 180 bpm with a left atrial pressure of 8-10 mmHg. Dopamine (2 micrograms.kg-1.min-1) and dobutamine (5 micrograms.kg-1.min-1) were added to improve the cardiac output. Sodium nitroprusside (0.25 to 1 microgram.kg-1.min) maintained the systolic pressure < 100 mmHg. On arrival in ICU, heart rate increased to 200 bpm. The patient received cardiac massage for severe hypotension 75 min after surgery. Emergency ECMO was instituted for circulatory support. Procainamide, digoxin, dopamine, dobutamine, sodium nitroprusside and hypothermia were continued. Sinus rhythm resumed on the first postoperative day, but procainamide and induced hypothermia at 34 degrees C were maintained for 36 hr after normalization of the rhythm to prevent recurrence of the tachycardia. Total duration of ECMO was three and a half days. Recovery was uneventful.
The use of ECMO, as a first line of defence, is suitable for the emergency support of patients with JET because of the ease of support of circulation and precise control of hypothermia.
报告一名婴儿心脏手术后交界性异位性心动过速的处理情况。术后，患者因心率加快继发严重心脏代偿失调，需要体外膜肺氧合（ECMO）进行血流动力学支持。
一名14日龄、体重3.5千克的男婴在体外循环后出现交界性异位性心动过速。左心房压力为25 - 28毫米汞柱。快速超速心房起搏或静脉注射20微克芬太尼、45微克洋地黄、100毫克镁或普鲁卡因胺（负荷剂量15毫克，然后30毫克·千克⁻¹·分钟⁻¹）后，对心动过速均无影响。主动降温使鼻咽温度降至35.2摄氏度时，心率降至180次/分钟以下，左心房压力为8 - 10毫米汞柱。添加多巴胺（2微克·千克⁻¹·分钟⁻¹）和多巴酚丁胺（5微克·千克⁻¹·分钟⁻¹）以改善心输出量。硝普钠（0.25至1微克·千克⁻¹·分钟）维持收缩压<100毫米汞柱。到达重症监护病房时，心率增至200次/分钟。术后75分钟患者因严重低血压接受心脏按摩。启动紧急ECMO进行循环支持。继续使用普鲁卡因胺、地高辛、多巴胺、多巴酚丁胺、硝普钠并进行低温治疗。术后第一天恢复窦性心律，但心律恢复正常后，继续使用普鲁卡因胺并在34摄氏度诱导低温36小时，以防止心动过速复发。ECMO总持续时间为三天半。恢复过程顺利。
由于易于支持循环和精确控制低温，使用ECMO作为一线防御措施适用于交界性异位性心动过速患者的紧急支持。
