静脉-动脉体外膜肺氧合启动后即刻血液稀释对心脏疾病患者器官功能和治疗策略的影响

Immediate hemodilution following venoarterial extracorporeal membrane oxygenation initiation: implications for organ function and treatment strategies in cardiacpatients

目的 探讨心脏疾病患者在静脉-动脉体外膜肺氧合(VA-ECMO)辅助启动后血液快速稀释对器官功能改变及临床治疗策略选择的影响。方法 回顾性分析2019年1月至2023年1月于中国人民解放军总医院第一医学中心心血管内科重症监护室接受VA-ECMO辅助的50例患者的临床资料。根据VA-ECMO启动后红细胞压积(Hct)下降的程度,将患者分为Hct下降≥30%组(Hct^(Δ30%+)组,n=17)和Hct下降<30%组(Hct^(Δ30%-)组,n=33)。比较两组患者器官功能相关生物标志物、接受输血、主动脉内球囊反搏(IABP)及持续肾替代治疗(CRRT)情况。采用SPSS 25.0统计软件进行数据分析。根据数据类型,分别采用t检验、Mann-Whitney U检验、χ^(2)检验或Fisher精确检验进行组间比较。结果 Hct^(Δ30%+)组65岁及以上患者占比52.9%(9/17),Hct^(Δ30%-)组65岁及以上患者占比36.4%(12/33)。Hct^(Δ30%+)组与Hct^(Δ30%-)组患者一般临床特征及VA-ECMO辅助前临床指标比较,差异均无统计学意义(P>0.05)。在VA-ECMO启动后,肌酸激酶同工酶、天冬氨酸氨基转移酶及丙氨酸氨基转移酶的峰值在Hct^(Δ30%+)组中更高,差异均有统计学意义(P<0.05)。Hct^(Δ30%+)组与Hct^(Δ30%-)组相比,接受IABP(70.6%和36.4%)和CRRT(64.7%和18.2%)治疗的患者比例更高;Hct^(Δ30%+)组患者输注悬浮红细胞和血浆的单位数更多,差异均有统计学意义(P<0.05)。结论 VA-ECMO启动后Hct降低≥30%的患者输血量更大、器官损伤更重,采用IABP或CRRT联合辅助比例更高。VA-ECMO启动后Hct降低≥30%作为一个新的临床指标,为治疗策略的选择及改善预后提供重要参考依据。

Objective To investigate the effect of immediate hemodilution following venoarterial extracorporeal membrane oxygenation(VA-ECMO)initiation on organ function and treatment strategies in cardiac patients.Methods We retrospectively analyzed the clinical data of 50 patients who received VA-ECMO in the Cardiology Department of First Medical Center of Chinese PLA General Hospital between January 2019 and January 2023.According to the decrease in hematocrit(Hct)after VA-ECMO initiation,the patients were divided into the Hct decrease≥30%(HctΔ30%+)group(n=17)and the Hct decrease<30%(HctΔ30%-)group(n=33).The two groups were compared in their biomarkers of organ function,blood transfusion,intra-aortic balloon pump(IABP),and continuous renal replacement therapy(CRRT).SPSS statistics 25.0 was used for data analysis.Based on the data type,t test,Mann-Whitney U test,Chi-square test,or Fisher′s exact test was used for inter-group comparisons.Results The proportion of patients aged 65 years and over was 52.9%(9/17)in HctΔ30%+group and 36.4%(12/33)in the HctΔ30%-group.There was no statistically significant difference between the two groups in the general clinical characteristics and clinical indicators before VA-ECMO initiation(P>0.05).After VA-ECMO initiation,the HctΔ30%+group had greater peaks than the HctΔ30%-group in creatine kinase-myocardial band(CK-MB),aspartic transaminase,and alanine transaminase with statistically significant differences(P<0.05 for all).Compared with HctΔ30%-group,HctΔ30%+group were more likely to receive treatment of IABP(70.6%vs 36.4%)and CRRT(64.7%vs 18.2%),and had higher dose of transfusion of red blood cell suspensions and plasma(P<0.05 for all).Conclusion Patients with a Hct decrease≥30%after VA-ECMO initiation require greater volume of blood transfusion,is associated with more severe organ damage,and have a higher proportion of those undergoing adjunct IABP or CRRT.A Hct decrease≥30%after VA-ECMO initiation can serve as a new clinical indicator,providing an important reference for selecting treatment strategies and improving prognosis.