Ayers Brian, Wood Katherine, Melvin Amber, Prasad Sunil, Gosev Igor
Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York.
J Card Surg. 2020 Jun;35(6):1275-1282. doi: 10.1111/jocs.14578. Epub 2020 Apr 27.
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method of supporting critically ill patients. However, it is expensive and associated with high morbidity and mortality, making early predictive outcome modeling extremely valuable. The model for end-stage liver disease-excluding international normalized ratio (MELD-XI) scoring system has been shown to have prognostic value in other critically ill patient populations.
A single-center retrospective review was performed for all adult patients managed on VA-ECMO from May 2011 to January 2018 (n = 247). Patients were included in the study if MELD-XI scores could be calculated during the first 48 hours on ECMO (n = 187). Receiver operating characteristic curve analysis was performed for MELD-XI in regard to in-hospital mortality.
Of the 187 patients, 74 (40%) patients had MELD-XI less than 14 (low-risk) and 113 (60%) had a MELD-XI of 14 or greater (high-risk). The cohorts did not differ significantly in terms of patient characteristics or indication for ECMO. The high-risk MELD-XI group had significantly greater mortality during index hospitalization compared to the low-risk group (74% vs 39%; P < .0001). Quartile stratification demonstrated progressively worse prognosis associated with higher MELD-XI scores; the fourth quartile showed a ninefold increased risk of mortality compared to the first quartile (P < .001). The AUC for predicting index hospitalization mortality was 0.69 (95% CI, 0.62-0.77) with a Youden index (J) of 0.36 and optimized cutoff of 12.98.
These findings suggest that the MELD-XI scoring system can be applied to the VA-ECMO patient population early in their course of ECMO as a prognostic tool to aid in complex clinical decision making.
静脉 - 动脉体外膜肺氧合（VA - ECMO）是一种挽救重症患者生命的方法。然而，它成本高昂且与高发病率和死亡率相关，使得早期预测结果模型极具价值。终末期肝病 - 排除国际标准化比值（MELD - XI）评分系统已被证明在其他重症患者群体中具有预后价值。
对2011年5月至2018年1月接受VA - ECMO治疗的所有成年患者进行单中心回顾性研究（n = 247）。如果在ECMO治疗的前48小时内可以计算出MELD - XI评分，则将患者纳入研究（n = 187）。对MELD - XI进行受试者操作特征曲线分析以评估住院死亡率。
187例患者中，74例（40%）患者的MELD - XI小于14（低风险），113例（60%）患者的MELD - XI为14或更高（高风险）。两组在患者特征或ECMO适应证方面无显著差异。与低风险组相比，高风险MELD - XI组在首次住院期间的死亡率显著更高（74%对39%；P <.0001）。四分位数分层显示，MELD - XI评分越高，预后越差；与第一四分位数相比，第四四分位数的死亡风险增加了九倍（P <.001）。预测首次住院死亡率的AUC为0.69（95%CI，0.62 - 0.77），约登指数（J）为0.36，最佳截断值为12.98。
这些发现表明，MELD - XI评分系统可在VA - ECMO患者的ECMO治疗早期应用，作为一种预后工具，以辅助复杂的临床决策。
