体外循环心肺复苏对成人院外心搏骤停患者生存率及神经功能预后影响的Meta分析

Effects of extracorporeal cardiopulmonary resuscitation for adult patients with out-of-hospital cardiac arrest on survival rate and neurological outcome: a Meta-analysis

目的比较体外循环心肺复苏(ECPR)与传统/机械心肺复苏(CCPR/MCPR)对成人院外心搏骤停(OHCA)患者生存率及神经功能预后影响的差异,评价ECPR的效果.方法通过计算机检索美国国立医学图书馆Medline数据库、荷兰医学文摘Embase数据库、荷兰爱思唯尔ScienceDirect数据库、美国斯坦福大学HighWire数据库、Cochrane 图书馆临床随机对照试验资料库、万方数据库及中国知网全文期刊数据库(CNKI) 2000 年1月至2018年10月发表的比较ECPR与CCPR/MCPR对成人OHCA患者生存率及神经功能预后影响的临床研究.按照标准筛查文献,由2名研究员提取资料并进行质量评价.采用RevMan 5.3软件进行Meta 分析;采用敏感性分析评价结果的稳定性;绘制漏斗图,分析文献发表偏倚.结果共纳入12项研究、2 519例患者,其中接受ECPR 615例,接受CCPR/MCPR 1 904例.Meta分析结果显示,与CCPR/MCPR相比,ECPR不能提高OHCA患者短期(出院或1个月内)生存率〔优势比(OR)=2.26,95%可信区间(95%CI)=0.95~5.41,P=0.07〕,但长期(3个月以上)生存率(OR=3.56,95%CI=1.65~7.71,P=0.001)、出院神经功能良好率〔格拉斯哥-匹兹堡脑功能评分(CPC)1~2分为神经功能良好;OR=3.39,95%CI=1.73~6.62,P=0.000 4〕及长期神经功能良好率(OR=3.45,95%CI=2.24~5.32,P<0.000 01)均明显升高.敏感性分析显示,无论是采用固定效应模型与随机效应模型分别分析各效应指标的差异,还是排除研究对象少于50例的1项研究后重新进行数据分析,总体结果均未发生明显变化,说明结果较稳定.漏斗图显示,纳入研究无明显发表偏倚,但由于文献较少,故不能排除发表偏倚.结论 ECPR对OHCA患者出院或1个月内短期生存率的影响与CCPR/MCPR无差异,但是3个月以上的长期生存率以及出院和长期神经功能良好率均较CCPR/MCPR患者升高.

Objective To compare the influences of extracorporeal cardiopulmonary resuscitation (ECPR) and conventional or mechanical cardiopulmonary resuscitation (CCPR/MCPR) on survival rate and neurological outcome for adult patients with out-of-hospital cardiac arrest (OHCA), and to assess the effect of ECPR. Methods Databases such as Medline, Embase, ScienceDirect, HighWire, Cochrane Library, Wanfang Database and China National Knowledge Infrastructure (CNKI) were searched from January 2000 to October 2018 to retrieve clinical trials on comparison of the effect of ECPR and CCPR/MCPR on survival rate and neurological outcome of adult patients with OHCA. Thereafter, the studies retrieved were based on predefined inclusion and exclusion criteria. Data were extracted and the quality of the included studies was evaluated by two researchers. A meta-analysis was performed by using RevMan 5.3 software. Sensitivity analysis was used to evaluate the stability of the results, and funnel plot was used to evaluate publication bias. Results A total of 12 studies and 2?519 patients were enrolled, including 615 patients receiving ECPR and 1?904 patients receiving CCPR/MCPR. Meta-analysis showed that compared with CCPR/MCPR, ECPR could not improve the short-term (at hospital discharge or within 1 month) survival rate in patients with OHCA [odds ratio (OR)= 2.26, 95% confidence interval (95%CI)= 0.95-5.41, P = 0.07], but could increase long-term (at more than 3 months) survival rate (OR = 3.56, 95%CI = 1.65-7.71, P = 0.001), rate of good neurological outcome at hospital discharge [Glasgow-Pittsburgh cerebral performance categories (CPC) 1-2 was defined as good neurological function;OR = 3.39, 95%CI = 1.73-6.62, P = 0.000?4], and rate of good long-term neurological outcome (OR = 3.45, 95%CI = 2.24-5.32, P < 0.000?01). Sensitivity analysis showed that the overall results did not change significantly, whether using fixed-effect model and random-effect model to analyze the differences of each effect index, or excluding one study with fewer than 50 subjects for data analysis, indicating that the results were more stable. The funnel plot suggested that there was no publication bias in the studies. But due to the small number of studies, the publication bias could not be excluded. Conclusion ECPR could not improve the short-term survival rate at hospital discharge or within 1 month in patients with OHCA, but could increase long-term survival rate at more than 3 months, good neurological outcome at hospital discharge and long-term neurological outcome.