Levin Nicholas M, Ciullo Anna L, Overton Sean, Mitchell Nathan, Skidmore Chloe R, Tonna Joseph E
Division of Emergency Medicine, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA.
Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT 84132, USA.
J Clin Med. 2021 Jan 12;10(2):251. doi: 10.3390/jcm10020251.
Extracorporeal membrane oxygenation (ECMO) has expanding indications for cardiopulmonary resuscitation including severe acute respiratory distress syndrome (ARDS). Despite the adjunct of ECMO for patients with severe ARDS, they often have prolonged mechanical ventilation and are subject to many of its inherent complications. Here, we describe patients who were cannulated for venovenous (VV) ECMO and were taken off positive pressure ventilation.
This is a primary analysis of patients admitted at a tertiary medical center between the dates of August 2014 to January 2020 who were cannulated to ECMO for refractory respiratory failure. We included all patients ≥18 years old. Patients who were extubated or had a tracheostomy and taken off positive pressure while on ECMO were classified as "off positive pressure ventilation (PPV)" and were compared to patients who remained "on PPV" while on ECMO. Primary outcome was survival to hospital discharge. Secondary outcomes were ventilator free days at 30 days and 60 days after ECMO cannulation, time from cannulation to date of first out-of-bed (OOB), and hospital length of stay (LOS). Patient characteristics were derived from routine clinical information in the electronic health record (EHR). Categorical characteristics were compared using chi-square test or Fisher exact test. Continuous characteristics were compared using independent samples t-test or Wilcoxon-Mann-Whitney test. -values were reported from all analysis.
Sixty-five patients were included in this retrospective analysis. Forty-eight were managed on ECMO with PPV and 17 patients were removed from PPV. Patients removed from PPV had significantly higher lung injury scores prior to cannulation (2.5 ± 0.6 vs. 1.04 0.3; 0.031) and non-significantly longer duration of ventilation prior to ECMO (6.1 days 2.1 vs. 5.0 days 01.1; 0.634). One hundred percent (100%) of patients removed from PPV survived to hospital discharge compared to 45% who received PPV throughout their duration of ECMO management ( 0.001). The mean ventilator free days at day 60 was 15 with PPV and 36 without PPV ( 0.003). The average duration from cannulation to mobilization (i.e., out-of-bed) was 18 days with PPV and 7 days without PPV ( 0.015).
Patients taken off PPV while on ECMO had a very high likelihood of survival to discharge and were mobilized in half as many days. While this likely reflects patient selection, the benefit of early mobilization is well documented and the approach of extubating while on ECMO warrants further investigation.
体外膜肺氧合（ECMO）在心肺复苏中的应用指征不断扩大，包括严重急性呼吸窘迫综合征（ARDS）。尽管ECMO可辅助治疗重症ARDS患者，但这些患者往往需要长时间机械通气，并易出现许多机械通气的固有并发症。在此，我们描述了接受静脉-静脉（VV）ECMO插管并撤机的患者。
这是对2014年8月至2020年1月期间在一家三级医疗中心因难治性呼吸衰竭接受ECMO插管的患者进行的初步分析。我们纳入了所有年龄≥18岁的患者。在ECMO期间拔管或行气管切开并撤机的患者被归类为“撤机（PPV）”，并与ECMO期间仍“使用PPV”的患者进行比较。主要结局是出院生存率。次要结局是ECMO插管后30天和60天的无呼吸机天数、从插管到首次下床（OOB）的时间以及住院时间（LOS）。患者特征来自电子健康记录（EHR）中的常规临床信息。分类特征采用卡方检验或Fisher精确检验进行比较。连续特征采用独立样本t检验或Wilcoxon-Mann-Whitney检验进行比较。所有分析均报告p值。
本回顾性分析纳入了65例患者。48例患者在ECMO支持下使用PPV，17例患者撤机。撤机患者插管前肺损伤评分显著更高（2.5±0.6 vs. 1.04±0.3；p = 0.031），ECMO前机械通气时间无显著差异（6.1天±2.1 vs. 5.0天±1.1；p = 0.634）。撤机患者100%存活至出院，而在整个ECMO治疗期间使用PPV的患者存活率为45%（p = 0.001）。60天时，使用PPV患者的平均无呼吸机天数为15天，撤机患者为36天（p = 0.003）。插管到活动（即下床）的平均时间，使用PPV患者为18天，撤机患者为7天（p = 0.015）。
在ECMO期间撤机的患者出院生存率非常高，且活动时间减半。虽然这可能反映了患者的选择，但早期活动的益处已有充分记录，在ECMO期间拔管的方法值得进一步研究。
