Grant April A, Badiye Amit, Mehta Christina, Wu Ziyue, Koerner Michael, Vianna Rodrigo, Loebe Matthias, Ghodsizad Ali
Department of surgery, Trauma and Surgical Critical Care, Grady Hospital, Emory University School of Medicine, Atlanta, Georgia.
Department of Cardiology, University of Miami Miller School of Medicine, Miami, Florida.
J Card Surg. 2020 Oct;35(10):2495-2499. doi: 10.1111/jocs.14923. Epub 2020 Sep 16.
Since the initiation of an adult extracorporeal membrane oxygenation (ECMO) program at our institution, the program has managed well over 200 patients with ECMO in a 3-year time frame. While there is a plethora of research evaluating ECMO for acute respiratory distress syndrome (ARDS), few studies have evaluated the impact that ventilator management after cannulation might have on outcomes. We hypothesized that failure to properly protect the lungs after cannulation would lead to higher mortality.
This was a retrospective observational study performed from 1 January 2014 to 8 July 2018.
A total of 196 patients were treated with ECMO, 57 of whom were diagnosed with ARDS and treated with venovenous ECMO. The univariable analysis revealed a statistically higher total serum bilirubin and lower total days on ECMO in those who died vs those who lived. During ECMO, higher mean peak inspiratory pressures (PIP) and higher FiO were found in those who died vs those who lived. In multivariable analysis, increasing age (odds ratio [OR] = 1.2; confidence interval [CI] = 1.04-1.39, P = .02), increasing mean PIP, and increasing mean FiO concentration during ECMO (PIP: OR = 1.40, CI = 1.03-1.89, P = .03; FiO : OR = 1.16, CI = 1.02-1.32, P = .02) were all associated with increased mortality.
Failing to protect the lungs with a lung protective strategy such as the EMPROVE protocol after ECMO cannulation was associated with mortality. For every 1 mm Hg increase in the mean PIP, the odds of dying increased 1.4 times, and for every 1% increase in the mean FiO , the odds of dying increased 1.16 times. For lung rest to truly be effective, the lungs must be relieved of the burden of gas exchange.
自我院启动成人体外膜肺氧合（ECMO）项目以来，该项目在3年时间里成功管理了200多名接受ECMO治疗的患者。虽然有大量研究评估ECMO用于急性呼吸窘迫综合征（ARDS）的情况，但很少有研究评估插管后呼吸机管理对预后的影响。我们假设插管后未能妥善保护肺部会导致更高的死亡率。
这是一项于2014年1月1日至2018年7月8日进行的回顾性观察研究。
共有196例患者接受了ECMO治疗，其中57例被诊断为ARDS并接受了静脉-静脉ECMO治疗。单变量分析显示，死亡患者的总血清胆红素在统计学上更高，且接受ECMO治疗的总天数比存活患者更低。在ECMO治疗期间，死亡患者的平均吸气峰压（PIP）和吸入氧分数（FiO）均高于存活患者。多变量分析显示，年龄增加（比值比[OR]=1.2；置信区间[CI]=1.04-1.39，P=0.02）、平均PIP增加以及ECMO治疗期间平均FiO浓度增加（PIP：OR=1.40，CI=1.03-1.89，P=0.03；FiO：OR=1.16，CI=1.02-1.32，P=0.02）均与死亡率增加相关。
ECMO插管后未能采用如EMPROVE方案等肺保护策略来保护肺部与死亡率相关。平均PIP每增加1 mmHg，死亡几率增加1.4倍；平均FiO每增加1%，死亡几率增加1.16倍。为使肺休息真正有效，必须减轻肺部气体交换的负担。
