体外心肺复苏患者术后早期脉压损失是ECMO撤机失败的独立预测因素

Pulse pressure loss after extracorporeal cardiopulmonary resuscitation is an independent predictor of ECMO weaning failure

目的探讨体外心肺复苏(ECPR)患者成功撤离体外膜肺氧合(ECMO)的预测因素。方法回顾性分析2018年7月至2022年9月因心搏骤停行ECPR在湖南省人民医院(湖南师范大学附属第一医院)进行治疗的56例患者的临床资料。按是否成功撤离ECMO辅助分为撤机成功组和撤机失败组,比较两组患者基本资料、传统心肺复苏(CCPR)时间、ECMO辅助时间、是否发生脉压损失、是否发生并发症、远端灌注管及主动脉球囊反搏术(IABP)的使用情况。对ECMO撤机失败的因素进行单因素及多因素Logistic回归分析。结果56例ECPR患者中有23例成功撤离ECMO,撤机成功率为41.07%。与撤机成功组比较,撤机失败组患者年龄更大(岁:46.7±15.6比37.8±16.8,P<0.05),脉压损失及ECMO并发症发生率更高〔81.8%(27/33)比21.7%(5/23),84.8%(28/33)比39.1%(9/23),均P<0.01〕,CCPR时间更长(min:72.3±19.5比54.4±24.6,P<0.01),ECMO辅助时间更短(h:87.3±81.1比147.7±50.8,P<0.01),ECPR辅助后动脉血pH及乳酸(Lac)水平改善更差〔pH:7.1±0.1比7.3±0.1,Lac(mmol/L):12.6±2.4比8.9±2.1,均P<0.01〕。两组间远端灌注管和IABP使用率差异无统计学意义。单因素Logistic回归分析显示,影响ECPR患者撤机失败的因素有脉压损失、ECMO并发症、装机后动脉血pH和Lac〔脉压损失:优势比(OR)=3.37,95%可信区间(95%CI)为1.39~8.17,P=0.007;ECMO并发症:OR=2.88,95%CI为1.11~7.45,P=0.030;装机后pH:OR=0.01,95%CI为0.00~0.16,P=0.002;装机后Lac:OR=1.21,95%CI为1.06~1.37,P=0.003〕。校正患者的年龄、性别、ECMO并发症、装机后动脉血pH和Lac、CCPR时间的影响后发现,脉压损失是ECPR患者撤机失败的独立预测因素(OR=1.27,95%CI为1.01~1.61,P=0.049)。结论ECPR术后早期脉压损失是ECPR患者撤离ECMO失败的独立预测因素。加强ECPR术后的血流动力学监测和管理对ECMO的成功脱机至关重要。

Objective To analyze the predictors of successful weaning off extracorporeal membrane oxygenation(ECMO)after extracorporeal cardiopulmonary resuscitation(ECPR).Methods The clinical data of 56 patients with cardiac arrest who underwent ECPR in Hunan Provincial People's Hospital(the First Affiliated Hospital of Hunan Normal University)from July 2018 to September 2022 were retrospectively analyzed.According to whether ECMO was successfully weaning off,patients were divided into the successful weaning off group and the failed weaning off group.The basic data,duration of conventional cardiopulmonary resuscitation(CCPR,the time from cardiopulmonary resuscitation to ECMO),duration of ECMO,pulse pressure loss,complications,and the use of distal perfusion tube and intra-aortic balloon pump(IABP)were compared between the two groups.Univariate and multivariate Logistic regression analyses were performed to identify the risk factors for weaning failure of ECMO.Results Twenty-three patients(41.07%)were successfully weaned from ECMO.Compared with the successful weaning off group,patients in the failed weaning off group were older(years old:46.7±15.6 vs.37.8±16.8,P<0.05),higher incidence of pulse pressure loss and ECMO complications[81.8%(27/33)vs.21.7%(5/23),84.8%(28/33)vs.39.1%(9/23),both P<0.01],and longer CCPR time(minutes:72.3±19.5 vs.54.4±24.6,P<0.01),shorter duration of ECMO support(hours:87.3±81.1 vs.147.7±50.8,P<0.01),and worse improvement in arterial blood pH and lactic acid(Lac)levels after ECPR support[pH:7.1±0.1 vs.7.3±0.1,Lac(mmol/L):12.6±2.4 vs.8.9±2.1,both P<0.01].There were no significant differences in the utilization rate of distal perfusion tube and IABP between the two groups.Univariate Logistic regression analysis showed that the factors affecting the weaning off ECMO of ECPR patients were pulse pressure loss,ECMO complications,arterial blood pH and Lac after installation[pulse pressure loss:odds ratio(OR)=3.37,95%confidence interval(95%CI)was 1.39-8.17,P=0.007;ECMO complications:OR=2.88,95%CI was 1.11-7.45,P=0.030;pH after installation:OR=0.01,95%CI was 0.00-0.16,P=0.002;Lac after installation:OR=1.21,95%CI was 1.06-1.37,P=0.003].After adjusting for the effects of age,gender,ECMO complications,arterial blood pH and Lac after installation,and CCPR time,showed that pulse pressure loss was an independent predictor of weaning failure in ECPR patients(OR=1.27,95%CI was 1.01-1.61,P=0.049).Conclusions Early loss of pulse pressure after ECPR is an independent predictor of failed weaning off ECMO in ECPR patients.Strengthening hemodynamic monitoring and management after ECPR is very important for the successful weaning off ECMO in ECPR.