体外膜肺氧合治疗成人暴发性心肌炎的早期疗效及其对预后的影响

Early effect of extracorporeal membrane oxygenation and factors related to early outcome in adult patients with fulminant myocarditis

目的评估成人暴发性心肌炎(FM)患者使用体外膜肺氧合(ECMO)后24 h的疗效及其对预后的影响。方法本文为回顾性病例分析研究。选取2016年11月至2021年5月于郑州大学第一附属医院住院并使用ECMO治疗的成年FM患者。根据患者住院期间的临床结果将其分为存活组与死亡组。收集并比较两组患者的年龄、性别、治疗情况、药物使用情况、ECMO使用时间及ECMO使用前及使用后24 h的与疗效相关的生化检验指标,并分析生化检验指标的24 h变化速率。采用多因素logistic回归分析FM患者在使用ECMO治疗后发生院内死亡的影响因素,并比较两组在ECMO使用后的并发症情况。结果共纳入使用ECMO治疗的FM患者38例,存活组23例(60.5%),年龄(39.6±13.7)岁,女性17例(73.9%),ECMO使用时间(134.4±71.3)h;死亡组15例(39.5%),年龄(40.0±15.8)岁,女性12例(80.0%),ECMO使用时间(120.1±72.4)h。存活组应用气管插管、肾脏替代治疗的比例和ECMO使用24 h内去甲肾上腺素的用量均低于死亡组(P均<0.05)。ECMO使用前,存活组与死亡组的各项疗效相关生化检验指标差异均无统计学意义(P均>0.05)。ECMO使用后24 h,存活组乳酸、降钙素原、肌酐、丙氨酸氨基转移酶、天冬氨酸氨基转移酶、肌酸激酶同工酶(CKMB)、N末端B型利钠肽原水平低于死亡组(P均<0.05)。多因素logistic回归分析结果显示,肌酐24 h下降速率(OR=0.587,95%CI 0.349~0.986,P=0.044)与CKMB 24 h下降速率(OR=0.177,95%CI 0.037~0.841,P=0.029)与患者院内死亡风险降低相关。并发症方面,存活组发生中枢出血及急性肾损伤的比例低于死亡组(P均<0.05)。结论FM患者早期使用ECMO后24 h,存活组的各项疗效相关生化检验指标改善优于死亡组,肌酐和CKMB 24 h下降速率快与使用ECMO治疗后FM患者的院内死亡风险降低相关。

Objective To evaluate the efficacy within the first 24 h post extracorporeal membrane pulmonary oxygenation(ECMO)and the impact of early efficacy on the prognosis of adult patients with fulminant myocarditis(FM).Methods This retrospective case analysis study included hospitalized patients(age≥18 years)who were diagnosed with fulminant myocarditis from November 2016 to May 2021 in the First Affiliated Hospital of Zhengzhou University.Patients were divided into survival or non-survival groups according to treatment outcomes.The age,sex,treatments,drug use,ECMO use,clinical and laboratory data(before and 24 h after the use of ECMO)were analyzed.The change rate of clinical and laboratory data after 24 h use of ECMO was calculated to find differences between two groups.Multivariate logistic regression was used to analyze the related factors with in-hospital death and complication between the two groups.Results A total of 38 FM patients treated with ECMO were included.There were 23 cases(60.5%)in the survival group,aged(39.6±13.7)years,and 17(73.9%)cases were female.The total ECMO time was(134.4±71.3)h.There were 15 cases(39.5%)in non-survival group,aged(40.0±15.8)years,and there were 12(80.0%)female,the ECMO time was(120.1±72.4)h in this group.The proportion of tracheal intubation and continuous renal replacement therapy in the survivor group and dosage of norepinephrine within 24 h after ECMO implantation were significantly less than in non-survival group(all P<0.05).There was no significant difference in all efficacy related biochemical indexes between two groups before ECMO use.The levels of lactic acid,procalcitonin,creatinine,alanine aminotransferase,aspartate aminotransferase,creatine kinase-MB,cardiac troponin I and N-terminal B-type natriuretic peptide prosoma were significantly less in survival group than in non-survival group at 24 h after the use of ECMO(all P<0.05).Results of multivariate logistic regression analysis showed that the higher 24 h change rate of creatinine(OR=0.587,95%CI 0.349-0.986,P=0.044)and creatine kinase-MB(OR=0.177,95%CI 0.037-0.841,P=0.029)were positively correlated with reduced risk of in-hospital mortality.The central hemorrhage and acute kidney injury in survival group were less than in non-survivor group(P<0.05).Conclusions After 24 h early use of ECMO in FM patients,the improvement of various efficacy related biochemical test indexes in the survival group was better than that in the non-survival group.Faster reduction of creatine kinase-MB and creatinine values within 24 h ECMO use is positively correlated with reduced risk of in-hospital mortality in adult patients with FM.