成人体外循环脱机困难的体外膜式人工肺氧合治疗单中心早期临床结果

Analysis of the early outcomes for patients with failure to wean from cardiopulmonary bypass necessitating extracorporeal membrane oxygenation support: from a single center

目的：回顾性分析成人心脏术后体外循环脱机困难接受体外膜式人工肺氧合（ECMO）辅助治疗临床资料,评估影响辅助结果的风险因素.方法：2004年10月至2014年4月,北京安贞医院共89例成人脱离体外循环困难患者进行ECMO辅助治疗.按照临床结果将患者分为出院存活组（S组,n=44）和死亡组（D组,n =45）.结果：67例（75.3％）患者顺利脱机,44例存活出院,出院生存率为49.4％.ECMO辅助前D组乳酸水平较S组高[（15.22±5.16） vs.（12.35±3.50） mmol/L,P=0.024],差异有统计学意义.D组术后24小时胸腔引流量较多[2 500（1 500,3 600）vs.950（450,2 450） mL,P=0.005],D组患者ECMO辅助期间悬浮红细胞[24（17,34）vs.18（10,24）U,P=0.019]和血小板[6（3,11）vs.3（0,5）U,P=0.030]输入量均较S组高,差异均有统计学意义.Logistic回归分析结果表明,ECMO辅助前高乳酸（≥12.0 mmol/L,OR=2.75,95％ CI：1.79 ～4.52,P=0.005）和经胸插管建立ECMO（OR =3.17,95％ CI：1.09～9.07,P=0.001）是患者死亡的高危风险因素.结论：ECMO可为成人心脏术后脱离体外循环困难患者提供有效的循环辅助,积极推荐采用股动静脉插管建立ECMO辅助.

Objective： The aim of this study was to evaluate the early outcomes of extracorporeal membrane oxygenation （ECMO） application on those who cannot be weaned from cardiopulmonary bypass after cardiac surgery and determine the predictors of mortality. Methods： From October 2004 to April 2014, 89 consecutive patients required venoarterial ECMO for failure to wean from cardiopulmonary bypass after cardiac surgery. These patients were divided into two groups [ survival to discharge （ S group, n = 44） and death group （D group, n = 45 ） ] by clinical outcome. Results： Sixty-seven （75.3%） were successfully weaned from ECMO and 44 （49.4%） survived to hospital discharge. The blood lactate level before ECMO in group D patients was significantly higher than in Group S（ 15.22 ± 5.16） vs. （ 12. 35 ± 3.50） mmol/L（P = 0. 024）. Twenty-four hour chest tube drainage in group D patients was significantly more than that in group S 2 500 （ 1 500,3 600）vs. 950（450,2 450）mL （P =0. 005）. Group D patients received more units of red blood cells 24 （ 17,34） vs. 18（ 10,24） U （P =0. 019） and platelets 6（ 3,11 ） vs. 3 （0,5） U （ P = 0. 030） in comparison with group S. High blood lactate level before ECMO initiation （ ≥ 12.0 retool/L, OR = 2. 75, 95% CI： 1.79 - 4. 52, P = 0. 005 ） and centrally cannulation （ OR = 3. 17, 95 % C1：1.09 - 9.07, P = 0. 001 ） were significant predictors of mortality. Conclusion： ECMO can provide effective circulatory support for patients with acute heart failure after cardiopulmonary bypass. The peripherally inserted ECMO under direct vision was recommend to those critically ill patients.