标准化难治性低氧血症方案对接受静脉-静脉体外膜肺氧合治疗患者结局的影响。

The Impact of a Standardized Refractory Hypoxemia Protocol on Outcome of Subjects Receiving Venovenous Extracorporeal Membrane Oxygenation.

机构信息

Department of Critical Care Medicine, West China Hospital, Chengdu, Sichuan, China.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.

出版信息

Respir Care. 2021 May;66(5):837-844. doi: 10.4187/respcare.08584. Epub 2021 Mar 2.

DOI:10.4187/respcare.08584

PMID:33653908

Abstract

BACKGROUND

Current mechanical ventilation practice and the use of treatment adjuncts in patients requiring extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia (RH) vary widely and their impact on outcomes remains unclear. In 2015, we implemented a standardized approach to protocolized ventilator settings and guide the escalation of adjunct therapies in patients with RH. This study aimed to investigate ICU mortality, its associated risk factors, and mechanical ventilation practice before and after the implementation of a standardized RH guideline in patients requiring venovenous ECMO (VV-ECMO).

METHODS

This was a single-center, retrospective cohort study of patients undergoing VV-ECMO due to RH respiratory failure between January 2008 and March 2015 (before RH protocol implementation) and between April 2015 and October 2019 (after RH protocol implementation).

RESULTS

A total of 103 subjects receiving VV-ECMO for RH were analyzed. After implementation of the RH protocol, more subjects received prone positioning (6.7% vs 23.3%, = .02), and fewer received high-frequency oscillatory ventilation than before launching the RH protocol (0% vs 13.3%, = .01). Plateau pressure was also lower before initiation of ECMO ( = .04) and at day 1 during ECMO ( = .045). Driving pressure was consistently lower at days 1, 2, and 3 after ECMO initiation: median 13.0 (interquartile range [IQR] 10.6-18.0) vs 16.0 (IQR 14.0-20.0) cm HO at day 1 ( = .003); 13.0 (IQR 11.0-15.9) vs 15.5 (IQR 12.0-20.0) cm HO at day 2 ( = .03); and 12.0 (IQR 10.0-14.5) vs 15.0 (IQR 12.0-19.0) cm HO at day 3 ( = .005).

CONCLUSIONS

The implementation of a standardized RH guideline improved compliance with a lung-protective ventilation strategy and utilization of the prone position and was associated with lower driving pressure during the first 3 days after ECMO initiation in subjects with refractory hypoxemia.

摘要

背景

目前，体外膜肺氧合（ECMO）治疗难治性低氧血症（RH）患者的机械通气实践和治疗辅助手段的应用差异很大，其对结局的影响尚不清楚。2015 年，我们实施了一种标准化的方案，对呼吸机设置进行了方案化，并指导 RH 患者辅助治疗的升级。本研究旨在调查接受静脉-静脉 ECMO（VV-ECMO）的 RH 患者实施标准化 RH 指南前后 ICU 死亡率、相关危险因素和机械通气实践。

方法

这是一项单中心回顾性队列研究，纳入了 2008 年 1 月至 2015 年 3 月（RH 方案实施前）和 2015 年 4 月至 2019 年 10 月（RH 方案实施后）期间因 RH 呼吸衰竭接受 VV-ECMO 的患者。

结果

共分析了 103 例接受 VV-ECMO 治疗 RH 的患者。实施 RH 方案后，更多的患者接受了俯卧位（6.7% vs 23.3%， =.02），接受高频振荡通气的患者少于方案实施前（0% vs 13.3%， =.01）。开始 ECMO 前的平台压也较低（ =.04），在 ECMO 开始后的第 1 天也较低（ =.045）。启动 ECMO 后的第 1、2、3 天，驱动压始终较低：第 1 天的中位数为 13.0（四分位距 [IQR] 10.6-18.0）比 16.0（IQR 14.0-20.0）cm H2O（ =.003）；第 2 天的中位数为 13.0（IQR 11.0-15.9）比 15.5（IQR 12.0-20.0）cm H2O（ =.03）；第 3 天的中位数为 12.0（IQR 10.0-14.5）比 15.0（IQR 12.0-19.0）cm H2O（ =.005）。