Fisher Jason C, Stolar Charles J H, Cowles Robert A
Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, New York 10032, USA.
J Surg Res. 2008 Jul;148(1):100-8. doi: 10.1016/j.jss.2008.03.023. Epub 2008 Apr 10.
Extracorporeal membrane oxygenation (ECMO) is accepted therapy for cardiorespiratory failure. Even after a successful ECMO course, patient deterioration may occur and a second course of ECMO may be contemplated. Although data regarding second ECMO courses exist in neonates, there are no reports describing second ECMO courses in pediatric patients. We hypothesized that data from a national ECMO registry would be useful in identifying which pediatric patients would be optimal candidates for a second course of ECMO.
We obtained data from the national Extracorporeal Life Support Organization registry from 1981 to 2007 on all patients 1-18 years old who required single-run ECMO (SRE) or multiple-run ECMO (MRE). Primary outcome measures were complications and survival. Continuous variables were assessed for distribution normality by using a Shaprio-Wilk statistic to guide nonparametric testing. SRE and MRE patients were compared by using chi2 tests (Fisher's exact and McNemar's) to assess differences in categorical variables; continuous data were assessed by using Mann-Whitney U or Wilcoxon signed-rank testing. Two multivariate regression models were constructed to identify independent predictors of survival and complications in MRE patients. Statistical significance was assumed at P < 0.05.
A total of 3937 pediatric patients received ECMO for cardiac or respiratory failure. Of them, 3810 (96.8%) children underwent a single course of ECMO, whereas 127 (3.2%) required multiple ECMO runs. Compared with SRE patients, the first ECMO course in MRE patients was notable for higher rates of cardiac ECMO (61% versus 44%, P < 0.001), venoarterial ECMO (88% versus 78%, P = 0.04), and central cannulation (28% versus 17%, P = 0.007). There was no survival difference between MRE and SRE patients (44% versus 49%, P = 0.28). Median time between MRE courses was 9.0 days (interquartile range = 5-20 days). The mean number of complications per MRE patient was higher in the second ECMO run compared with the first (3.93 versus 3.12, P = 0.008). Multivariate regression identified 2 variables as independent predictors of survival in MRE patients: (1) renal complications during first ECMO run (P = 0.04); and (2) total number of complications during second ECMO run (P = 0.005). A separate multivariate analysis identified 3 variables independently predictive of complications in MRE patients: (1) age (P < 0.001); (2) duration of second run (P < 0.001); and (3) total number of complications during first ECMO run (P < 0.001).
ECMO therapy achieves 49% survival in children 1-18 years of age. When a second ECMO course becomes necessary, survival rates comparable to the first ECMO course are possible. Patients developing renal complications during their first ECMO course have worse outcome with a second ECMO course. Patients are at greater risk for complications during a second ECMO course if they experience a high number of first-run complications, are >3 years old, or undergo a prolonged second ECMO course. These data are useful when deciding whether to offer a second ECMO course to an eligible pediatric patient.
体外膜肺氧合（ECMO）是治疗心肺衰竭的公认疗法。即使在成功完成ECMO治疗疗程后，患者仍可能病情恶化，此时可能会考虑进行第二次ECMO治疗。虽然新生儿中有关第二次ECMO治疗疗程的数据已有报道，但尚无关于儿科患者第二次ECMO治疗疗程的报告。我们推测，来自全国ECMO登记处的数据将有助于确定哪些儿科患者是第二次ECMO治疗疗程的最佳候选者。
我们从全国体外生命支持组织登记处获取了1981年至2007年期间所有1至18岁需要单次ECMO（SRE）或多次ECMO（MRE）治疗的患者的数据。主要结局指标为并发症和生存率。通过使用Shaprio-Wilk统计量评估连续变量的分布正态性，以指导非参数检验。使用卡方检验（Fisher精确检验和McNemar检验）比较SRE和MRE患者，以评估分类变量的差异；连续数据通过Mann-Whitney U检验或Wilcoxon符号秩检验进行评估。构建了两个多变量回归模型，以确定MRE患者生存和并发症的独立预测因素。当P<0.05时，认为具有统计学意义。
共有3937例儿科患者因心脏或呼吸衰竭接受了ECMO治疗。其中，3810例（96.8%）儿童接受了单次ECMO治疗，而127例（3.2%）需要多次ECMO治疗。与SRE患者相比，MRE患者的首次ECMO治疗疗程中心脏ECMO使用率更高（61%对44%，P<0.001）、静脉-动脉ECMO使用率更高（88%对78%，P = 0.04）以及中心插管使用率更高（28%对17%，P = 0.007）。MRE和SRE患者的生存率无差异（44%对49%，P = 0.28）。MRE疗程之间的中位时间为9.0天（四分位间距 = 5 - 20天）。与首次相比，第二次ECMO治疗时每位MRE患者的并发症平均数量更高（3.93对3.12，P = 0.008）。多变量回归确定了2个变量为MRE患者生存的独立预测因素：（1）首次ECMO治疗期间的肾脏并发症（P = 0.04）；（2）第二次ECMO治疗期间的并发症总数（P = 0.005）。另一项多变量分析确定了3个独立预测MRE患者并发症的变量：（1）年龄（P<0.001）；（2）第二次治疗疗程的持续时间（P<0.001）；（3）首次ECMO治疗期间的并发症总数（P<0.001）。
ECMO治疗可使1至18岁儿童的生存率达到49%。当有必要进行第二次ECMO治疗疗程时，生存率有可能与首次ECMO治疗疗程相当。在首次ECMO治疗疗程中出现肾脏并发症的患者，第二次ECMO治疗疗程预后较差。如果患者首次治疗疗程并发症数量多、年龄>3岁或第二次ECMO治疗疗程时间延长，则在第二次ECMO治疗疗程中发生并发症的风险更高。这些数据在决定是否为符合条件的儿科患者提供第二次ECMO治疗疗程时很有用。
