Chung Mabel, Cabezas Fausto R, Nunez Jose I, Kennedy Kevin F, Rick Katelyn, Rycus Peter, Mehra Mandeep R, Garan A Reshad, Kociol Robb D, Grandin E Wilson
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
JACC Heart Fail. 2020 Nov;8(11):892-902. doi: 10.1016/j.jchf.2020.09.004.
This study sought to determine the frequency, incidence rates over time, association with mortality, and potential risk factors for hemocompatibility-related adverse events (HRAEs) occurring during venoarterial-extracorporeal life support (VA-ECLS).
HRAEs are common complications of VA-ECLS. Studies examining relevant clinical predictors and the association of HRAEs with survival are limited by small sample size and single-center setting.
We queried adult patients supported with VA-ECLS from 2010 to 2017 in the Extracorporeal Life Support Organization database to assess the impact of HRAEs on in-hospital mortality.
Among 11,984 adults meeting study inclusion, 8,457 HRAEs occurred; 62.1% were bleeding events. The HRAE rate decreased significantly over the study period (p trend <0.001), but rates of medical bleeding and ischemic stroke remained stable. HRAEs had a cumulative association with mortality in adjusted analysis: 1 event, odds ratio (OR) of 1.43; 2 events, OR of 1.86; ≥3 events, OR of 3.27 (p < 0.001 for all). HRAEs most strongly associated with mortality were medical bleeding, including intracranial (OR: 7.71), pulmonary (OR: 3.08), and gastrointestinal (OR: 1.95) hemorrhage and ischemic stroke (OR: 2.31); p < 0.001 for all. Risk factors included the following: for bleeding: older age, lower pH, and female sex; for thrombosis: younger age, male sex, Asian race, and non-polymethylpentene oxygenator; and for both: time on ECLS, central cannulation, and renal failure.
Although decreasing, HRAEs remain common during VA-ECLS and have a cumulative association with survival. Bleeding events are twice as common as thrombotic events, with a hierarchy of HRAEs influencing survival. Differential risk factors for bleeding and thrombotic complications exist and raise the possibility of a tailored approach to ECLS management.
本研究旨在确定静脉 - 动脉体外膜肺氧合（VA - ECLS）期间发生的血液相容性相关不良事件（HRAEs）的频率、随时间的发生率、与死亡率的关联以及潜在风险因素。
HRAEs是VA - ECLS的常见并发症。研究相关临床预测因素以及HRAEs与生存率关联的研究受样本量小和单中心设置的限制。
我们查询了体外膜肺氧合组织数据库中2010年至2017年接受VA - ECLS支持的成年患者，以评估HRAEs对住院死亡率的影响。
在11984名符合研究纳入标准的成年人中，发生了8457例HRAEs；62.1%为出血事件。在研究期间，HRAE发生率显著下降（p趋势<0.001），但医源性出血和缺血性卒中的发生率保持稳定。在调整分析中，HRAEs与死亡率存在累积关联：1次事件，比值比（OR）为1.43；2次事件，OR为1.86；≥3次事件，OR为3.27（所有p<0.001）。与死亡率关联最密切的HRAEs是医源性出血，包括颅内出血（OR：7.71）、肺出血（OR：3.08）和胃肠道出血（OR：1.95）以及缺血性卒中（OR：2.31）；所有p<0.001。风险因素包括：出血方面：年龄较大、pH值较低和女性；血栓形成方面：年龄较小、男性、亚洲种族和非聚甲基戊烯氧合器；两者均相关的因素：ECLS使用时间、中心插管和肾衰竭。
尽管发生率在下降，但HRAEs在VA - ECLS期间仍然常见，并且与生存率存在累积关联。出血事件的发生率是血栓形成事件的两倍，不同类型的HRAEs对生存率有不同影响。出血和血栓形成并发症存在不同的风险因素，这增加了采用个性化方法进行ECLS管理的可能性。
