体外膜肺氧合支持中发生严重溶血的危险因素及结局：一项5年的单中心回顾分析

Risk factors and outcomes of severe hemolysis during extracorporeal membrane oxygenation： a 5-year single-center retrospective analysis

【摘要】目的探讨体外膜肺氧合（ECMO）过程中发生严重溶血的危险因素。方法回顾性分析2010年12月至2015年10月阜外医院收治的心脏手术后需要ECMO辅助支持的成人患者临床资料，记录其人口学特征、肾功能基础值、原发疾病、手术资料、ECMO辅助过程中临床资料及结局。根据ECMO辅助过程中游离血红蛋白（FHB）值将患者分为FHB正常组（FHB≤500mg／L）和严重溶血组（FHB〉500mg／L）。比较两组患者ECMO建立前后的临床资料，采用logistic回归分析筛选导致严重溶血发生的独立危险因素。结果共81例患者纳入本研究，其中严重溶血组19例、FHB正常组62例。两组患者ECMO建立前体外循环（CPB）时间、阻断时间、血乳酸水平、行心肺复苏、主动脉内球囊反搏术（IABP）、中心静脉插管的比例等临床资料均无明显差异。在ECMO辅助过程中，严重溶血组血肌酐（SCr）和FHB的最高值明显高于FHB正常组[最高SCr（umol／L）：281．02±164．11比196．67±87．31，最高FHB（mg／L）：600（600，700）比200（100，300）]，且氧合器或管路血栓、感染发生率和血液滤过应用率均较FHB正常组明显升高[分别为26．3％（5／19）比4．8％（3／62），31．6％（6／19）比12．9％（8／62），36．8％（7／19）比14．5％（9／62），均P〈0．1]。在临床结局中，严重溶血组患者插管或手术部位出血、急性肾衰竭（ARF）发生率均明显高于FHB正常组[分别为57．9％（11／19）比30．6％（19／62），94．7％（18／19）比41．9％（26／62），均P〈0．05]，存活率明显低于FHB正常组[10．5％（2／19）比51．6％（32／62）。P〈0．05]。将单因素回归分析中P〈0．1的3项因素（血液滤过、感染、氧合器或管路血栓）纳入logistic回归分析，结果显示，氧合器或管路血栓是ECMO辅助过程中发生严重溶血的危险因素[优势比（OR）=6．262，95％可信区间（95％CI）=1．244～31．515，P=O．026]。结论氧合器或管路血栓形成是ECMO辅助过程中发生严重溶血的独立危险因素。严重溶血可引起插管或手术部位出血和ARF发生率升高，并使存活率降低。

Objective To investigate the risk factors of severe hemolysis during extracorporeal membrane oxygenation （ECMO）. Methods The clinical data of adult patients undergoing ECMO after cardiac surgery admitted to Fuwai Hospital from December 2010 to October 2015 were retrospectively analyzed. Demographic characteristics, renal function, primary disease, operation data, ECMO related data and outcomes were recorded. Patients were divided into normal free hemoglobin （FHB） group （FHB ≤500 mg/L） and severe hemolysis group （FHB 〉 500 mg/L） according to the FHB level during ECMO support. The parameters before and after ECMO support were compared between the two groups. Logistic regression was used to identify the independent risk factors of severe hemolysis. Results A total of 81 patients including 19 patients with severe hemolysis was enrolled, and 62 in normal FHB group. There was no difference in cardiopulmonary bypass （CPB） time, clamping time, lactate level before ECMO, cardiopulmonary resuscitation, intra- aortic balloon pump use and central catheter insertion between two groups. The maximums of serum creatinine （SCr） and FHB levels were higher in severe hemolysis group as compared with those in normal FHB group [maximal SCr （μmol/L）： 281.02 ± 164.11 vs. 196.67 ± 87.31, maximal FHB （mg/L）： 600 （600, 700） vs. 200 （100, 300）], the incidence of clots in circuit or oxygenator, infection, and hemofiltration in severe hemolysis group was increased [26.3% （5/19） vs. 4.8% （3/62）,31.6% （6/19） vs. 12.9% （8/62）, 36.8% （7/19） vs. 14.5% （9/62）, all P 〈 0.1]. As well as outcomes including the rate of site of surgery or intubation bleeding and acute renal failure [ARF, 57.9 % （11/19） vs. 30.6% （19/62）, 94.7% （18/19） vs. 41.9% （26/62）], and the survival rate was lowered [10.5% （2/19） vs. 51.6% （32/62）, all P 〈 0.05]. As result of univariate analysis, clots in circuit or oxygenator, infection and hemofihration were associated with severe hemolysis. It was showed by logistic regression analysis that the clots in circuit or oxygenator was a risk factor of severe hemolysis during ECMO [odds ratio （OR） = 6.262, 95% confidence interval （95%CI） = 1.244-31.515, P = 0.026]. Conclusions The clots in circuit or oxygenator were independent risk factors of severe hemolysis during ECMO. Severe hemolysis can induce the increase of the rate of bleeding in the operation site or intubatiou and the rate of ARF, and decrease of the survival rate.