接受体外膜肺氧合治疗急性呼吸窘迫综合征的异基因造血干细胞移植患者的特征及预后
Characteristics and Outcome of Patients After Allogeneic Hematopoietic Stem Cell Transplantation Treated With Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.
作者信息
Wohlfarth Philipp, Beutel Gernot, Lebiedz Pia, Stemmler Hans-Joachim, Staudinger Thomas, Schmidt Matthieu, Kochanek Matthias, Liebregts Tobias, Taccone Fabio Silvio, Azoulay Elie, Demoule Alexandre, Kluge Stefan, Svalebjørg Morten, Lueck Catherina, Tischer Johanna, Combes Alain, Böll Boris, Rabitsch Werner, Schellongowski Peter
机构信息
1Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria. 2Department of Hematology, Hemostaseology, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany. 3Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany. 4Department of Medicine III, Intensive Care Unit I3, LMU Munich, Campus Großhadern, Munich, Germany. 5Medical Intensive Care Unit, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France. 6Department of Internal Medicine I, University of Cologne, Cologne, Germany. 7Department of Bone Marrow Transplantation, University Hospital Essen, West German Cancer Center, University of Duisburg-Essen, Essen, Germany. 8Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium. 9Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris, France. 10Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France. 11Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France. 12Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. 13Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway.
出版信息
Crit Care Med. 2017 May;45(5):e500-e507. doi: 10.1097/CCM.0000000000002293.
OBJECTIVES
The acute respiratory distress syndrome is a frequent condition following allogeneic hematopoietic stem cell transplantation. Extracorporeal membrane oxygenation may serve as rescue therapy in refractory acute respiratory distress syndrome but has not been assessed in allogeneic hematopoietic stem cell transplantation recipients.
DESIGN
Multicenter, retrospective, observational study.
SETTING
ICUs in 12 European tertiary care centers (Austria, Germany, France, and Belgium).
PATIENTS
All allogeneic hematopoietic stem cell transplantation recipients treated with venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome between 2010 and 2015.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
Thirty-seven patients, nine of whom underwent noninvasive ventilation at the time of extracorporeal membrane oxygenation initiation, were analyzed. ICU admission occurred at a median of 146 (interquartile range, 27-321) days after allogeneic hematopoietic stem cell transplantation. The main reason for acute respiratory distress syndrome was pneumonia in 81% of patients. All but one patient undergoing noninvasive ventilation at extracorporeal membrane oxygenation initiation had to be intubated thereafter. Overall, seven patients (19%) survived to hospital discharge and were alive and in remission of their hematologic disease after a follow-up of 18 (range, 5-30) months. Only one of 24 patients (4%) initiated on extracorporeal membrane oxygenation within 240 days after allogeneic hematopoietic stem cell transplantation survived compared to six of 13 (46%) of those treated thereafter (p < 0.01). Fourteen patients (38%) experienced bleeding events, of which six (16%) were associated with fatal outcomes.
CONCLUSIONS
Discouraging survival rates in patients treated early after allogeneic hematopoietic stem cell transplantation do not support the use of extracorporeal membrane oxygenation for acute respiratory distress syndrome in this group. On the contrary, long-term allogeneic hematopoietic stem cell transplantation recipients otherwise eligible for full-code ICU management may be potential candidates for extracorporeal membrane oxygenation therapy in case of severe acute respiratory distress syndrome failing conventional measures.
目的
急性呼吸窘迫综合征是异基因造血干细胞移植后常见的病症。体外膜肺氧合可作为难治性急性呼吸窘迫综合征的挽救治疗方法，但尚未在异基因造血干细胞移植受者中进行评估。
设计
多中心、回顾性、观察性研究。
地点
12家欧洲三级医疗中心（奥地利、德国、法国和比利时）的重症监护病房。
患者
2010年至2015年间接受静脉-静脉体外膜肺氧合治疗急性呼吸窘迫综合征的所有异基因造血干细胞移植受者。
干预措施
无。
测量指标及主要结果
分析了37例患者，其中9例在开始体外膜肺氧合时接受了无创通气。重症监护病房入住时间中位数为异基因造血干细胞移植后146天（四分位间距，27 - 321天）。81%的患者急性呼吸窘迫综合征的主要原因是肺炎。除1例在开始体外膜肺氧合时接受无创通气的患者外，其余患者此后均需插管。总体而言，7例患者（19%）存活至出院，在18个月（范围5 - 30个月）的随访后仍存活且血液系统疾病缓解。在异基因造血干细胞移植后240天内开始体外膜肺氧合治疗的24例患者中只有1例（4%）存活，而在此后接受治疗的13例患者中有6例（46%）存活（p < 0.01）。14例患者（38%）发生出血事件，其中6例（16%）与致命结局相关。
结论
异基因造血干细胞移植后早期治疗患者令人沮丧的生存率不支持在该组患者中使用体外膜肺氧合治疗急性呼吸窘迫综合征。相反，对于原本有资格接受全面重症监护病房管理的长期异基因造血干细胞移植受者，在常规措施治疗严重急性呼吸窘迫综合征失败的情况下，可能是体外膜肺氧合治疗的潜在候选者。
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