Laimoud Mohamed, Alanazi Mosleh
Adult Cardiac Surgical Intensive Care Unit (CSICU), King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
Critical Care Medicine Department, Cairo University, Cairo, Egypt.
Crit Care Res Pract. 2020 Sep 8;2020:3129864. doi: 10.1155/2020/3129864. eCollection 2020.
Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital.
One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI ( < 0.001), more haemodialysis use ( < 0.001), more gastrointestinal bleeding ( = 0.039), more ICH ( = 0.006), and fewer ICU days ( = 0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, < 0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, < 0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791-0.932; < 0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986-1; < 0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913-1; < 0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982-1; < 0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909-1; < 0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681-3.735, < 0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015-1.898, = 0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock.
The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality.
静脉-动脉体外膜肺氧合（VA-ECMO）越来越多地用于心源性休克成年患者的复苏，全球范围内的死亡率报告各不相同。我们的目标是研究接受VA-ECMO支持的成年患者与医院死亡率相关的变量，并确定通过序贯器官衰竭评估（SOFA）评分对这些患者进行重复评估以预测医院死亡率的有效性。我们回顾性研究了2015年1月至2019年8月在我们的三级护理医院心脏外科重症监护病房接受VA-ECMO支持的心源性休克成年患者。
我们的研究纳入了106例接受VA-ECMO支持的患者，住院死亡率为56.6%。研究患者的平均年龄为40.2±14.4岁，患者大多为男性（69.8%），平均体重指数为26.5±7，幸存者和非幸存者之间无统计学显著差异。非幸存者组中慢性肾脏病、慢性心房颤动和心脏手术的发生率明显更高。与幸存者组相比，非幸存者发生急性肾损伤的频率更高（<0.001），使用血液透析的频率更高（<0.001），发生胃肠道出血的频率更高（=0.039），发生颅内出血的频率更高（=0.006），入住重症监护病房的天数更少（=0.002）。幸存者组和非幸存者组的平均血乳酸峰值水平分别为11±3和16.7±3.3，<0.001；在启动ECMO 24小时后的平均乳酸水平分别为2.2±0.9和7.9±5.7，<0.001。入住重症监护病房时初始SOFA评分≥13对预测医院死亡率的敏感性为85%，特异性为73.9%[曲线下面积（AUROC）=0.862，95%置信区间（CI）：0.791-0.932；<0.001]，阳性预测值（PPV）为81%，阴性预测值（NPV）为79.1%，准确率为80.2%；而第3天SOFA评分≥13对预测死亡率的敏感性为100%，特异性为91.3%，PPV为93.8%，NPV为100%，准确率为96.2%[AUROC=0.995，95%CI：0.986-1；<0.001]。SOFA评分变化值（∆1 SOFA）（第3天-第1天）≥2对预测医院死亡率的敏感性为95%，特异性为93.5%[AUROC=0.958，95%CI：0.913-1；<0.001]，PPV为95%，NPV为93.5%，准确率为94.3%。第5天SOFA评分≥15对预测死亡率的敏感性为98%，特异性为100%，准确率为99%[AUROC=0.994，95%CI：0.982-1；<0.001]。SOFA评分变化值（∆2 SOFA）（第5天-第1天）≥2对预测医院死亡率的敏感性为90%，特异性为97.8%[AUROC=0.958，95%CI：0.909-1；<0.001]，PPV为97.8%，NPV为90%，准确率为9
