非常规抗凝策略降低体外膜肺氧合不良事件发生的荟萃分析

Unconventional anticoagulation strategies to reduce the occurrence of adverse events of extracorporeal membrane oxygenation:a Meta-analysis

目的比较非常规抗凝与常规抗凝在体外膜肺氧合(ECMO)患者中不良事件的发生情况。方法使用预设的检索策略检索PubMed、EMbase、Cochrane Library及中国知网、维普、万方医学等数据库,纳入数据库从建立起至2023年10月期间接受ECMO支持的患者中非常规抗凝与常规抗凝比较的随机对照研究及队列研究。效应大小由比值比(OR)和95%置信区间(CI)确定。结果共纳入14项研究(1151例患者),562例患者接受非常规抗凝治疗,其余589例患者接受常规抗凝治疗。与接受常规抗凝患者相比,接受非常规抗凝患者颅内出血(OR=0.3295%CI 0.17~0.59)、胃肠道出血(OR=0.37,95%CI 0.22~0.63)发生率显著降低,而手术部位出血(OR=0.65,95%CI 0.37~1.15)、胸腔出血(OR=0.50,95%CI 0.20~1.27)差异无统计学意义,肺栓塞(OR=0.81,95%CI 0.21~3.05)、管路血栓形成(OR=0.67,95%CI 0.29~1.58)差异无统计学意义。静脉-动脉ECMO应用中,两组医院病死率(OR=0.85,95%CI 0.60~1.19)、ECMO成功撤机率(OR=0.92,95%CI 0.85~1.44)差异无统计学意义;静脉-静脉ECMO应用中,非常规抗凝组病死率均低于常规抗凝组(OR=0.30,95%CI 0.09~0.93),且有更低的管路更换概率(OR=0.28,95%CI 0.10~0.79)。结论非常规抗凝可以降低ECMO患者颅内出血、胃肠道出血发生率,并且不增加血栓事件发生概率及医院病死率,还可以降低静脉-静脉ECMO应用中管路更换概率,是一种可行且安全的抗凝策略,受限于纳入研究质量及样本量等因素,未来的研究需关注非常规抗凝能否降低在院病死率、缩短戴机时长等长期效益。

Objective To compare the safety and efficacy between unconventional anticoagulation and conventional anticoagulation in the patients with extracorporeal membrane oxygenation(ECMO).Methods PubMed,EMbase,Cochrane Library,CNKI,VIP,Wanfang Medicine and other databases were screened for original articles.SCreening was performed by using predefined search terms to identify randomized controlled trials and cohort studies reporting the comparison of unconventional anticoagulation with conventional anticoagulation in the patients supported with ECMO from the establishment of the database to October 2023.Effect sizes were determined by the odds ratio(OR)and the 95%confidence interval(CI).Results A total of 14 studies(1151 patients)were included.562 patients received unconventional anticoagulant therapy,and the remaining 589 patients received conventional anticoagulant therapy.The incidence of intracranial hemorrhage(OR=0.32,95%CI 0.17-0.59)and gastrointestinal bleeding(OR=0.37,95%CI 0.22-0.63)were significantly lower in the patients with unconventional anticoagulation compared with those with conventional anticoagulation.But there was no significant difference in surgical site bleeding(OR=0.65,95%CI 0.37-1.15)and thoracic bleeding(OR=0.50,95%CI 0.20-1.27).In thrombotic events,there was no significant difference in pulmonary embolism(OR=0.81,95%CI 0.21-3.05)and circuit thrombosis(OR=0.67,95%CI 0.29-1.58)between unconventional anticoagulation and conventional anticoagulation.In the mode of VA-ECMO,there was no significant difference in the hospital mortality(OR=0.85,95%CI 0.60-1.19)and successful weaning off of ECMO(OR=0.92,95%CI 0.85-1.44).In the mode of VV-ECMO,the rates of hospital mortality(OR=0.30,95%CI 0.09-0.93)and the rates of pipeline replacement(OR=0.28,95%CI 0.10-0.79)were significantly lower in the patients with unconventional anticoagulation than those with conventional anticoagulation.Conclusions For the patients received ECMO,unconventional anticoagulation can not only reduce the incidence of intracranial hemorrhage and gastrointestinal bleeding without increasing the probability of thrombotic events and hospital mortality,but also reduce the probability of pipeline replacement in VV-ECMO.It is a feasible and safe anticoagulation strategy.Limited by factors such as the quality and sample size of the included studies,future studies need to focus on whether unconventional anticoagulation can reduce in-hospital mortality and shorten the time on the machine.