Division of Nephrology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.
Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
Crit Care. 2018 Oct 27;22(1):270. doi: 10.1186/s13054-018-2211-x.
Extracorporeal membrane oxygenation (ECMO) is a cardiorespiratory support technique for patients with circulatory or pulmonary failure. Frequently, large-volume fluid resuscitation is needed to ensure sufficient extracorporeal blood flow in patients initiating ECMO. However, excessive overhydration is known to increase mortality in critically ill patients. Therefore, in order to define a tolerant volume range in patients undergoing ECMO treatment, the association between cumulative fluid balance (CFB) and outcome was evaluated in patients undergoing ECMO.
This retrospective multicenter cohort study was conducted with 723 patients who underwent ECMO in three tertiary care hospitals between 2005 and 2016. CFB was calculated as total fluid input minus total fluid output during the first 3 days from ECMO initiation. The patients were divided into groups that initiated ECMO owing to cardiovascular disease (CVD)-related or non-cardiovascular disease (non-CVD)-related causes. The primary endpoint was mortality within 90 days after ECMO commencement.
Totals of 406 and 317 patients were included in the CVD and non-CVD groups, respectively. In the CVD group, the mean age was 58.4 ± 17.7 years, and 68.2% were male. The mean age was 55.7 ± 15.7 years, and 65.3% were male in the non-CVD group. The median CFB values were 64.7 and 53.5 ml/kg in the CVD and non-CVD groups, respectively. Multivariable analysis using Cox proportional hazards models revealed a significantly increased risk of 90-day mortality in patients with higher CFB values in both the CVD and non-CVD groups. However, the risks were elevated only in the two CFB quartile groups with the largest CFB amounts. Cubic spline models showed that mortality risk began to increase significantly when CFB was 82.3 ml/kg in the CVD group. In patients with respiratory diseases, the mortality risk increase was significant for those with CFB levels above 189.6 ml/kg.
Mortality risk did not increase until a certain level of fluid overload was reached in patients undergoing ECMO. Adequate fluid resuscitation is critical to improving outcomes in these patients.
体外膜肺氧合（ECMO）是一种用于循环或呼吸衰竭患者的心肺支持技术。通常，需要大量液体复苏以确保开始 ECMO 的患者有足够的体外血液流动。然而，大量液体超负荷已知会增加危重病患者的死亡率。因此，为了确定接受 ECMO 治疗的患者能够耐受的容量范围，本研究评估了在接受 ECMO 的患者中，累积液体平衡（CFB）与结局之间的关系。
本回顾性多中心队列研究纳入了 2005 年至 2016 年期间在 3 家三级护理医院接受 ECMO 的 723 例患者。CFB 定义为 ECMO 开始后 3 天内的总液体输入减去总液体输出。患者分为因心血管疾病（CVD）相关或非心血管疾病（非-CVD）相关原因而开始 ECMO 的两组。主要终点是 ECMO 开始后 90 天内的死亡率。
CVD 组和非-CVD 组分别纳入了 406 例和 317 例患者。CVD 组的平均年龄为 58.4±17.7 岁，68.2%为男性。非-CVD 组的平均年龄为 55.7±15.7 岁，65.3%为男性。CVD 组和非-CVD 组的中位 CFB 值分别为 64.7 和 53.5 ml/kg。使用 Cox 比例风险模型的多变量分析显示，在 CVD 组和非-CVD 组中，CFB 值较高的患者 90 天死亡率风险显著增加。然而，风险仅在 CFB 量最大的两个 CFB 四分位组中升高。三次样条模型显示，当 CVD 组的 CFB 达到 82.3 ml/kg 时，死亡率风险开始显著增加。在患有呼吸系统疾病的患者中，CFB 水平高于 189.6 ml/kg 的患者死亡率增加显著。
在接受 ECMO 的患者中，只有达到一定水平的液体超负荷，死亡率风险才会增加。充分的液体复苏对改善这些患者的结局至关重要。
