联合血管活性药物-正性肌力药物评分及乳酸预测体外膜肺氧合辅助心脏术后心源性休克患者的预后

Combined assessment of vasoactive-inotropic score and lactate to predict mortality in postcardiotomy patients supported with venoarterial extracorporeal membrane oxygenation

目的探讨血管活性药物-正性肌力药物评分(VIS)联合乳酸对静脉-动脉体外膜肺氧合(VA-ECMO)辅助心脏术后心源性休克患者预后的预测作用。方法回顾性收集北京安贞医院2015年1月至2018年12月期间因心脏外科术后心源性休克行VA-ECMO辅助的222例成人患者病例资料。根据ECMO运行24 h的VIS及乳酸的临界值将患者分为四组:组1(59例):VIS≤14.5,乳酸≤2.45 mmol/L;组2(17例):VIS>14.5,乳酸≤2.45 mmol/L;组3(90例):VIS≤14.5,乳酸>2.45 mmol/L;组4(56例):VIS>14.5,乳酸>2.45 mmol/L。分析四组住院病死率、ECMO成功脱机率等临床结局,Kaplan-Meier法分析四组患者60天累计生存率,Cox比例风险模型分析VIS、乳酸与住院病死率的关系。结果四组患者的住院病死率分别为18.6%、58.8%、63.3%及71.4%(P<0.001),ECMO成功脱机率分别为88.1%、88.2%、58.9%及33.9%(P<0.001),组1患者的住院病死率及ECMO成功脱机率较其他三组差异均有统计学意义(P<0.05),且组1患者的60天累计生存率较其他三组患者显著提高,差异有统计学意义(P<0.05)。Cox比例风险模型结果显示,年龄(HR=1.03,95%CI:1.01~1.05,P=0.001)、女性(HR=1.87,95%CI:1.27~2.76,P=0.002)、ECMO运行24 h的VIS(HR=1.02,95%CI:1.00~1.05,P=0.020)及乳酸值(HR=1.12,95%CI:1.08~1.16,P<0.001)是患者住院死亡的独立风险因素。结论对于VA-ECMO辅助心脏术后心源性休克的患者,联合评估上机24 h的VIS和乳酸值对判断预后有指导意义,ECMO辅助24 h后可减少血管活性药量至VIS≤14.5及乳酸值降至≤2.45 mmol/L提示患者预后较好。

Objective To determine the predictive role of combined assessment of vasoactive-inotropic score(VIS)and lactate for the prognosis of patients with postcardiotomy cardiogenic shock(PCS)requiring venoarterial extracorporeal membrane oxygenation(VA-ECMO).Methods 222 adults with PCS requiring VA-ECMO were retrospectively analyzed and divided into four groups according to the cut-off values of VIS and lactate(Lac)at 24 h after ECMO initiation:group 1(59 cases):VIS≤14.5,Lac≤2.45 mmol/L;group 2(17 cases):VIS>14.5,Lac≤2.45 mmol/L;group 3(90 cases):VIS≤14.5,Lac>2.45 mmol/L;group 4(56 cases):VIS>14.5,Lac>2.45 mmol/L.The incidence of in-hospital mortality and other clinical outcomes were analyzed.The associations of VIS and lactate and in-hospital mortality were analyzed using Cox proportional hazards analysis.Results The in-hospital mortality was 18.6%,58.8%,63.3%and 71.4%in the four groups(P<0.001),while the rate of successful weaning off ECMO was 88.1%,88.2%,58.9%and 33.9%respectively(P<0.001).The group 1 significantly differed from other three groups with regards to in-hospital mortality and ECMO weaning rate(P<0.05).The groups 1 also showed significantly improved cumulative 60-day survival compared with other three groups(log-rank test,P<0.05).Cox proportional hazards analysis showed age(HR=1.03,95%CI:1.01-1.05,P=0.001),female(HR=1.87,95%CI:1.27-2.76,P=0.002),VIS at 24 h after ECMO initiation(HR=1.02,95%CI:1.00-1.05,P=0.020),and lactate at 24h after ECMO initiation(HR=1.12,95%CI:1.08-1.16,P<0.001)were independently predictive of in-hospital mortality.Conclusion Patients with VIS≤14.5 and Lac≤2.45 within 24 h after ECMO initiation had better in-hospital and 60-day outcomes,suggesting that combined assessment of VIS and lactate may be instructive for determining the prognosis of PCS patients requiring VA-ECMO support.