过去二十年体外生命支持中出血并发症的纵向趋势——体外生命支持组织登记分析。
Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support Over the Past Two Decades-Extracorporeal Life Support Organization Registry Analysis.
机构信息
ECLS Centrum, Cardiothoracic Surgery Department and Cardiology Department, Heart & Vascular Center, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands.
Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany.
出版信息
Crit Care Med. 2022 Jun 1;50(6):e569-e580. doi: 10.1097/CCM.0000000000005466. Epub 2022 Feb 3.
OBJECTIVES
Data about inhospital outcomes in bleeding complications during extracorporeal life support (ECLS) have been poorly investigated.
DESIGN
Retrospective observational study.
SETTING
Patients reported in Extracorporeal Life Support Organization Registry.
PATIENTS
Data of 53.644 adult patients (greater than or equal to 18 yr old) mean age 51.4 ± 15.9 years, 33.859 (64.5%) male supported with single ECLS run between 01.01.2000 and 31.03.2020, and 19.748 cannulated for venovenous (V-V) ECLS and 30.696 for venoarterial (V-A) ECLS.
INTERVENTIONS
Trends in bleeding complications, bleeding risk factors, and mortality.
MEASUREMENT AND MAIN RESULTS
Bleeding complications were reported in 14.786 patients (27.6%), more often in V-A ECLS compared with V-V (30.0% vs 21.9%; p < 0.001). Hospital survival in those who developed bleeding complications was lower in both V-V ECLS (49.6% vs 66.6%; p < 0.001) and V-A ECLS (33.9 vs 44.9%; p < 0.001). Steady decrease in bleeding complications in V-V and V-A ECLS was observed over the past 20 years (coef., -1.124; p < 0.001 and -1.661; p < 0.001). No change in mortality rates was reported over time in V-V or V-A ECLS (coef., -0.147; p = 0.442 and coef., -0.195; p = 0.139).Multivariate regression revealed advanced age, ecls duration, surgical cannulation, renal replacement therapy, prone positioning as independent bleeding predictors in v-v ecls and female gender, ecls duration, pre-ecls arrest or bridge to transplant, therapeutic hypothermia, and surgical cannulation in v-a ecls.
CONCLUSIONS
A steady decrease in bleeding over the last 20 years, mostly attributable to surgical and cannula-site-related bleeding has been found in this large cohort of patients receiving ECLS support. However, there is not enough data to attribute the decreasing trends in bleeding to technological refinements alone. Especially reduction in cannulation site bleeding is also due to changes in timing, patient selection, and ultrasound guided percutaneous cannulation. Other types of bleeding, such as CNS, have remained stable, and overall bleeding remains associated with a persistent increase in mortality.
目的
体外生命支持（ECLS）期间出血并发症的住院结局数据研究甚少。
设计
回顾性观察性研究。
地点
在体外生命支持组织登记处报告的患者。
患者
纳入 53644 名成年患者（年龄大于或等于 18 岁）的数据，平均年龄 51.4±15.9 岁，33859 名（64.5%）男性，2000 年 1 月 1 日至 2020 年 3 月 31 日期间接受单次 ECLS 支持，19748 例行静脉-静脉（V-V）ECLS 置管，30696 例行静脉-动脉（V-A）ECLS 置管。
干预措施
出血并发症的趋势、出血危险因素和死亡率。
测量和主要结果
14786 名（27.6%）患者报告出血并发症，V-A ECLS 中出血并发症发生率高于 V-V ECLS（30.0%比 21.9%；p<0.001）。V-V ECLS（49.6%比 66.6%；p<0.001）和 V-A ECLS（33.9%比 44.9%；p<0.001）中发生出血并发症的患者的住院生存率较低。在过去 20 年中，V-V 和 V-A ECLS 中出血并发症呈稳定下降趋势（V-V 的系数为-1.124；p<0.001 和 V-A 的系数为-1.661；p<0.001）。在 V-V 或 V-A ECLS 中，报告的死亡率随时间变化没有变化（V-V 的系数为-0.147；p=0.442 和 V-A 的系数为-0.195；p=0.139）。多变量回归显示，高龄、ECLS 持续时间、手术置管、肾脏替代治疗、俯卧位是 V-V ECLS 出血的独立预测因素，而女性、ECLS 持续时间、ECLS 前停搏或桥接移植、治疗性低温和手术置管是 V-A ECLS 出血的独立预测因素。
结论
在接受 ECLS 支持的大量患者中，发现过去 20 年出血呈稳定下降趋势，这主要归因于手术和置管部位相关出血。然而，还没有足够的数据将出血减少的趋势归因于技术的改进。尤其是置管部位出血的减少也与置管时机、患者选择和超声引导经皮置管有关。其他类型的出血，如中枢神经系统出血，保持稳定，总体出血仍然与死亡率持续增加相关。
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