体外膜氧合在救治危重新型冠状病毒肺炎患者中的应用:回顾性队列研究

Extracorporeal membrane oxygenation as rescue therapy for critically ill COVID-19 patients:a retrospective study

目的探讨对危重症新型冠状病毒肺炎(COVID-19)患者行有创机械通气(IMV)或体外膜氧合(ECMO)干预的疗效及相关危险因素分析。方法回顾性分析武汉150例实验室确诊的COVID-19危重症患者临床资料。比较接受IMV治疗患者(IMV组)和接受无创通气、经鼻高流量氧疗(HFNC)和无辅助通气治疗患者(非IMV组)的临床转归,同时将IMV患者分为ECMO组和非ECMO组进行亚组分析。采用单变量分析和多变量logistic回归分析方法,分析COVID-19危重症患者入ICU后行IMV治疗、ECMO治疗的危险因素。结果IMV组死亡率明显高于非IMV组(69.7%vs.8.2%,P<0.001)。单因素分析显示,IMV组与非IMV组间患者白细胞(WBC)、血红蛋白(Hb)、C反应蛋白、降钙素原(PCT)、总胆红素(Tbil)、肌红蛋白(Mb)有显著性差异。多变量回归显示,较高WBC(OR 4.897,95%CI 2.165~11.073,P<0.001)、PCT(OR 2.865,95%CI 1.309~6.269,P=0.008)和较低Hb(OR 0.313,95%CI 0.134~0.735,P=0.008)是患者接受IMV治疗的独立危险因素。而相对于非ECMO组患者,接受ECMO治疗患者年龄更小,合并冠心病比例更高(P=0.01),以及更高水平的PCT、天冬氨酸氨基转移酶、Tbil、Mb、纤维蛋白原、部分凝血原时间、以及D-二聚体>0.5的比例,并且入院至接受IMV治疗的间隔时间更短,而氧合指数(PaO2/FiO2)更低。多元回归分析结果提示年龄大于65岁(OR 0.175,95%CI 0.036~0.855,P=0.031)和较高的PaO2/FiO2(OR 0.014,95%CI 0.001~0.143,P<0.001)是患者接受非ECMO治疗的独立危险因素。ECMO组的存活率显著高于非ECMO组(52.6%vs.13.7%,P<0.001)。结论入ICU时患者WBC、Hb水平是患者行IMV治疗的独立危险因素,而患者年龄以及PaO2/FiO2是患者行ECMO治疗的独立危险因素。与IMV支持相比,ECMO治疗是一种相对可靠的治疗方案,可显著降低COVID-19危重症患者死亡率。

Objective To evaluate therapeutic effect of invasive mechanical ventilation and ECMO on COVID-19 patients and to determine related risk factors.Methods Clinical data of 150 critical patients with COVID-19 diagnosed by the laboratory test in Wuhan were analyzed retrospectively.Clinical outcomes of the patients receiving IMV treatment(IMV group)and the patients receiving noninvasive ventilation,high-flow nasal cannula oxygen therapy and non-auxiliary ventilation(non-IMV group)were compared.Meanwhile,the IMV patients were divided into ECMO group and non-ECMO group for subgroup analysis.Univariate analysis and multivariate logistic regression analysis were used to analyze the risk factors of IMV treatment and ECMO treatment for critical COVID-19 patients after admission to ICU.Results The mortality of the IMV group was significantly higher than that of the non-IMV group(69.7%vs.8.2%,P<0.001).Univariate analysis showed that there were significant differences in WBC,Hb,CRP,PCT,TBil and MB between the IMV group and non IMV group.Multivariate regression analysis showed that higher leukocytes(OR 4.897,95%CI2.165,11.073,P<0.001),PCT(OR 2.865,95%CI 1.309,6.269,P=0.008),and lower HB(OR 0.313,95%CI 0.134,0.735,P=0.008)were independent predictors for IMV treatment.Compared with the non-ECMO group,ECMO patients were younger,had a higher proportion of coronary heart disease(P=0.01)and higher levels of PCT,AST,TBil,MB,FBG,PT,as well as a larger proportion of D-dimer>0.5.The shorter of the interval from admission to IMV treatment was,the lower PaO2/FiO2 would be.Multivariate regression analysis showed that age older than 65 years(OR 0.175,95%CI 0.036,0.855,P=0.031)and higher PaO2/FiO2(OR0.014,95%CI 0.001,0.143,P<0.001)were independent risk factors for non ECMO treatment.The survival rate of the ECMO group was significantly higher than that of the non-ECMO group(52.6%vs.13.7%,P<0.001).Conclusion The levels of leukocyte and hemoglobin are independent predictors for IMV treatment,while the age and PaO2/FiO2 are independent risk factors for ECMO treatment.Compared with IMV support,ECMO is a relatively reliable treatment associated with a significantly reduced mortality rate in the critically ill patients with COVID-19.