基于下肢灌注评估表置入远端灌注导管与预防性置入远端灌注导管在ECMO中的疗效比较

A comparative research of effect on inserting a distal perfusion catheter and preventive insertion of a distal perfusion catheter based on the limb ischemia risk assessment table in patients with extracorporeal membrane oxygenation

目的比较针对接受静脉-动脉体外膜肺氧合(VA-ECMO)治疗患者预防性置入远端灌注导管(DPC)与非预防性置入DPC之间疗效的差异。方法采用前瞻性随机对照试验(RCT)方法,选择2017年1月至2020年6月浙江大学附属金华医院收治的接受VA-ECMO治疗的患者作为研究对象。将纳入患者分为预防性DPC组(VA-ECMO上机后6 h置入DPC)和非预防性DPC组(通过下肢灌注评估表评估出现早期肢体缺血征象后再置入DPC)。比较两组患者临床资料的差异;采用Pearson相关性分析法分析超声检测的动脉端肢体足背动脉峰流速和胫后动脉峰流速与经皮氧分压(TcPO_(2))的相关性。结果最终62例患者纳入分析,预防性DPC组和非预防性DPC组各31例。两组患者在性别构成、年龄、体质量指数(BMI)、吸烟指数、基础疾病、置管地点、复苏至上机时间、体外膜肺氧合(ECMO)运行时间、机械通气时间、重症监护病房(ICU)住院时间、住院病死率、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)等方面差异均无统计学意义;两组患者ECMO指征、ECMO插管位置、管路型号比较差异亦无统计学意义。非预防性DPC组患者渗血发生率明显低于预防性DPC组〔6.5%(2/31)比29.0%(9/31),P<0.05〕;而两组发绀、坏死、截肢、骨筋膜室综合征、动脉血栓、血管重建修补术、假性动脉瘤、肢体缺血、肢体感染等其他下肢并发症的发生率差异均无统计学意义。在ECMO运行期间,非预防性DPC组患者除血流感染发生率明显低于预防性DPC组外〔3.2%(1/31)比19.4%(6/31),P<0.05〕;两组其余并发症发生率差异均无统计学意义。预防性DPC组足背动脉峰流速明显高于非预防性DPC组(cm/s:19.30±10.85比17.85±8.55,P<0.01),胫后动脉峰流速明显低于非预防性DPC组(cm/s:19.90±10.94比21.58±9.77,P<0.05);Pearson相关性分析显示,预防性DPC组和非预防性DPC组足背动脉峰流速、胫后动脉峰流速与TcPO_(2)均呈正相关(r值分别为0.747、0.856、0.850、0.813,P值均为0.000)。结论针对接受VA-ECMO治疗的患者,非预防性置入DPC者ECMO运行期间血流感染和渗血的发生率均较预防性置入DPC明显减少。动脉端肢体胫后动脉、足背动脉峰流速与TcPO_(2)均呈明显正相关。VA-ECMO行股动、静脉穿刺的患者,除了根据症状和体征去判断下肢血供,超声及TcPO_(2)也可以作为一种有效的监测手段。

Objective To compare the treatment effect of venous-arterial extracorporeal membrane oxygenation(VA-ECMO)patients in the prophylactic distal perfusion catheter(DPC)and the non-prophylactic DPC.Methods A prospective randomized controlled trial(RCT)was conducted.Patients who received VA-ECMO treatment were reviewed at Affiliated Jinhua Hospital,Zhejiang University School of Medicine from January 2019 to June 2020 were divided into two groups,the prophylactic DPC group(DPC placed immediately after the patient VA-ECMO)and the non-prophylactic DPC group(the DPC was placed after the early limb ischemic signs by using evaluation of the lower extremity perfusion assessment table).Comparing the differences of clinical data of two group patients.Pearson correlation analysis was used to analyze the correlation between peak velocity of dorsalis pedis artery and peak velocity of posterior tibial artery and transcutaneous oxygen partial pressure(TcPO_(2)).Results A total of 62 patients were included in the analysis,with 31 cases in prophylactic DPC group and another 31 cases in non-prophylactic DPC group.There were no significant differences in sex,age,body mass index(BMI),smoking index,underlying disease,catheterization site,recovery time before on machine,extracorporeal membrane oxygenation(ECMO)operation time,mechanical ventilation time,length of stay in intensive care unit(ICU),mortality rate in hospital,and acute physiology and chronic health evaluationⅡ(APACHEⅡ)between the preventive DPC group and the non-preventive DPC group.There was no significant difference in ECMO indications,ECMO intubation location and pipeline type.The bleeding in the non-prophylactic DPC group was lower than that in the non-prophylactic DPC group[6.5%(2/31)vs.29.0%(9/31),P<0.05].There were no significant differences in limb complications such as cyanosis,necrosis,amputation,compartment syndrome,arterial thrombosis,vascular reconstruction and repair,pseudoaneurysm,limb ischemic or limb infection.During the ECMO operation,except the blood stream infection in the non-prophylactic DPC group was lower than that in the non-prophylactic DPC group[3.2%(1/31)vs.19.4%(6/31),P<0.05],there was no other statistical difference in complications between the two groups.The peak velocity of dorsalis pedis artery in the preventive DPC group was significantly higher than that of the non-preventive DPC group(cm/s:19.30±10.85 vs.17.85±8.55,P<0.05),and the peak velocity of posterior tibial artery was significantly lower than that of the non-preventive DPC group(cm/s:19.90±10.94 vs.21.58±9.77,P<0.05).Pearson correlation analysis showed that the peak velocity of dorsalis pedis artery and peak velocity of posterior tibial artery of the preventive DPC group and the non-preventive DPC group were positively correlated with TcPO_(2)(r values were 0.747,0.856,0.850,0.813,respectively,and P values were all 0.000).Conclusions For patients with VA-ECMO treatment,the incidence of blood stream infection and bleeding during ECMO operation in non-prophylactic DPC implantation patients is lower than that of prophylactic DPC implantation patients.TcPO_(2) is positively correlated with peak velocity of posterior tibial artery and dorsal foot artery in the cannulated limb.In patients with VA-ECMO undergoing femoral artery and vein puncture,in addition to judging the blood supply of lower limbs according to symptoms and signs,ultrasound and TcPO_(2) monitoring can also be used as effective monitoring methods.