体外膜氧合技术治疗儿童严重急性呼吸窘迫综合征的预后因素分析

Prognostic factors of extracorporeal membrane oxygenation in the treatment of severe pediatric acute respiratory distress syndrome

目的探索影响体外膜氧合(ECMO)技术治疗严重儿童急性呼吸窘迫综合征(ARDS)预后的因素。方法多中心前瞻性观察性研究。以中国9家主要儿童ECMO中心2018年1月至2022年12月收治的95例ECMO挽救性治疗的严重ARDS患儿为研究对象,记录其一般资料、疾病危重度和脏器功能、综合治疗情况以及预后,根据出院时的转归分为存活组和死亡组,应用t检验、χ^(2)检验、多因素Logistic回归和混合线性模型分析ECMO启动前基线情况和ECMO过程中连续监测的指标(小儿危重评分、血小板计数、白蛋白、纤维蛋白原等)与预后的关系。结果95例接受了ECMO治疗的严重ARDS患儿中男55例(58%)、女40例(42%),年龄36.9(0.5,72.0)月龄。12例患儿(13%)存在免疫缺陷。68例(72%)患儿采用静脉动脉模式,27例(28%)采用静脉静脉模式。95例患儿出院存活率为51%(48例),静脉动脉和静脉静脉模式分别为47%(32/68)和59%(16/27)。死亡组患儿比存活组免疫缺陷的例数更多,小儿危重评分、血小板计数、白蛋白、纤维蛋白原和氧合指数均更低,呼吸机驱动压(ΔP)和氧指数均更高,ECMO前ARDS持续时间更长(均P<0.05)。年龄、性别、体重及ECMO模式等在不同预后组间差异均无统计学意义(均P>0.05)。高ΔP、高氧指数、低氧合指数和低白蛋白均是影响预后的高危因素(均P<0.05)。ΔP≥25 cmH_(2)O(1 cmH_(2)O=0.098 kPa)、氧合指数≤67 mmHg(1 mmHg=0.133 kPa)和氧指数≥35均是预测不良预后的阈值(均P<0.05)。死亡组和存活组的ΔP、氧合指数、氧指数在ECMO后24 h起差异均有统计学意义(均P<0.05),并且随着ECMO进程差异逐步扩大;血小板水平从ECMO后7 d开始差异有统计学意义(P<0.05),并逐渐扩大;血乳酸水平在ECMO应用前、后差异有统计学意义(P<0.05),并从ECMO后24 h逐步扩大。结论ECMO前高ΔP、高氧指数、低氧合指数、低白蛋白是影响ECMO治疗严重儿童ARDS预后的高危因素。ECMO过程中第24小时起ΔP、氧指数逐渐降低和氧合指数逐渐升高预示预后良好,而ECMO应用后乳酸逐步升高预示预后不良。

Objective To explore the factors affecting the prognosis of severe pediatric acute respiratory distress syndrome(ARDS)after receiving extracorporeal membrane oxygenation(ECMO)support.Methods It was a multicenter prospective observational study.A total of 95 children with severe ARDS who were treated with ECMO salvage therapy from January 2018 to December 2022 in 9 pediatric ECMO centers in China were enrolled in the study.The general data,disease severity,organ function,comprehensive treatment and prognosis were recorded,and they were divided into survival group and death group according to the outcome at discharge.T test,chi-square test,multivariate Logistic regression and mixed linear model were used to analyze the relationship among baseline before ECMO treatment,some important indicators(pediatric critical scores,platelet count,albumin,fibrinogen,etc)during ECMO treatment and prognosis.Results Among the 95 children with severe ARDS who received ECMO,55(58%)were males and 40(42%)were females,aged 36.9(0.5,72.0)months.Twelve children(13%)were immunodeficient.Sixty-eight(72%)children were treated with venous artery(VA)mode and 27(28%)with venous vein(VV)mode.The discharge survival rates of overall,VA,and VV mode children were 51%(48/95),47%(32/68),and 59%(16/27),respectively.The number of immunodeficient children in the death group was higher,and there were lower pediatric critical scores,platelet count,albumin,fibrinogen and arterial oxygen partial pressure/fraction of inspired oxygen(PaO_(2)/FiO_(2)),higher ventilator driving pressure(ΔP),oxygenaion index(OI),and longer ARDS duration before ECMO(all P<0.05).There were no statistically significant differences in other indicators,including age,gender,weight,and ECMO mode among different prognostic groups(all P>0.05).HighΔP,high OI,low P/F,and low albumin were high-risk factors affecting prognosis(all P<0.05).After further grouping,it was found thatΔP≥25 cmH_(2)O(1 cmH_(2)O=0.098 kPa),P/F≤67 mmHg(1 mmHg=0.133 kPa)and OI≥35 were the thresholds for predicting poor prognosis(P<0.05).From 24 h after ECMO,there were significant differences inΔP,P/F and OI between the dead group and the survival group(all P<0.05),and the differences gradually increased with the ECMO process.The platelet level was significant from 7 days after ECMO(P<0.05)and gradually expanded.Blood lactate levels showed a significant difference between the 2 groups on before and after ECMO(P<0.05)and gradually increased from 24 h after ECMO.Conclusions The risk factors affecting the prognosis of severe ARDS in ECMO include highΔP,high OI,low P/F and low albumin purification therapy before ECMO.The gradual decrease ofΔP,OI and increase of P/F from 24 h of ECMO predicted a good prognosis,while the gradual increase of lactate after ECMO application showed a poor prognosis.