静脉-静脉体外膜肺氧合在成人重度急性呼吸窘迫综合征中的临床应用研究

Clinical Application of Veno⁃venous Extracorporeal Membrane Oxygenation in Adults with Severe Acute Respiratory Distress Syndrome

目的:探讨影响体外膜肺氧合(ECMO)救治成功率的相关影响因素,以期为ECMO在重度急性呼吸窘迫综合征(ARDS)患者中的应用提供更好的临床决策。方法:回顾性分析2018年1月至2023年12月在中山市人民医院接受ECMO治疗的成人重度ARDS患者的临床资料,建立数据库。根据患者是否存活出院,分为生存组及死亡组。通过单因素及Logistic回归分析,探索ECMO治疗的相关影响因素。结果:56例研究对象,平均年龄(45±12)岁,主要病因为肺部感染,其中成功撤机28例(50%),生存出院25例(44.6%)。ECMO建立48小时后,患者PaO_(2)、PaCO_(2)的确较前明显改善(P<0.05)。ECMO维持期间最常见的并发症是穿刺口或切口出血(55.4%),其次是感染(46.4%)、高胆红素血症(41.1%)、急性肾衰竭(35.7%)和MODS(35.7%)等。单因素分析发现ECMO前潮气量、在FiO_(2)>0.9条件下PaO_(2)/FiO_(2)<100 mmHg至启动ECMO的时间间隔以及ECMO期间MODS并发症和总胆红素最高值(pTB)、血清肌酐最高值(pCr)在两组中具有统计学差异(P<0.05)。多因素Logistic回归模型中发现,ECMO前潮气量(P=0.041)、在FiO_(2)>0.9条件下PaO_(2)/FiO_(2)<100 mmHg至启动ECMO时间间隔(P=0.003)及MODS并发症(P=0.004)具有统计学意义,是独立的死亡危险因素。结论:VV-ECMO可为机械通气治疗效果欠佳的重度ARDS患者提供有效的辅助支持。ECMO前高潮气量、在FiO_(2)>0.9条件下PaO_(2)/FiO_(2)<100 mmHg至启动ECMO时间间隔长以及ECMO维持期间出现MODS是影响ECMO救治成功率的重要因素。

Objectives:To explore the efficiency and potential prognostic factors of VV-ECMO for severe ARDS in adults by analyzing our institutional results and experience.Methods:All patients with severe ARDS supported by VV-ECMO and admitted to our hospital from Jul 2018 and Dec 2023.Patients were identified on the basis of the Berlin defi-nition of severe ARDS were analyzed retrospectively.The baseline data,clinical parameters were collected retrospectively.The patients were divided into two groups according to in-hospital mortality.Successful weaning was defined as weaning from ECMO support followed by survival for more than 48 h.Univariate analysis and Logistic regression identified risk factors for death in hospital.Results:56 VV-ECMO patients were included in this study.The mean age was(45±12)years,pneumonia was the main cause.Finally,28 patients were successfully weaned off VV-ECMO,but only 25 patients were discharged.As the result showed,VV-ECMO was effective in improving oxygenation and promoting carbon dioxide removal in patients with severe ARDS in the first 48 hours(P<0.05).Percutaneous catheterization was the preferred means of VV-ECMO(78.6%).And bleeding from site of catheterization or surgery(55.4%)was the most common compli-cation during ECMO,followed by infection (46.4%),hyperbilirubinemia(41.1%),acute renal failure(35.7%)and MODS(35.7%).In univariate analysis,there was statistical difference in ventilation tidal volume before ECMO,time interval from PaO_(2)/FiO_(2)<100 mmHg at FiO_(2)>0.9 to ECMO,the peak value of TB and Cr and MODS during ECMO between the two groups(P<0.05).In addition,logistic regression identified that higher ventilation tidal volume before ECMO(OR=2.457,95%CI:1.037-5.821),the longer time interval from PaO_(2)/FiO_(2)<100 mmHg at FiO_(2)>0.9 to ECMO(OR=1.464,95%CI:1.140-1.880)and MODS during ECMO(OR=23.732,95%CI:2.720-207.072)increase risk of death in hospi-tal.Conclusion:VV-ECMO is effective in improving oxygenation and promoting carbon dioxide removal in patients with severe ARDS.The higher ventilation tidal volume before ECMO,the longer time interval from PaO_(2)/FiO_(2)<100 mmHg at FiO_(2)>0.9 to ECMO and MODS duration ECMO are independent risk factors for death in hospital.