Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; University of Rennes, University Hospital of Rennes, National Institute of Health and Medical Research, Center of Clinical Investigation of Rennes 1414, Rennes, France; University of Rennes, University Hospital of Rennes, National Research Institute for Agriculture, National Institute of Health and Medical Research, Institute of Nutrition, Metabolism, and Cancer, Mixed Research Unit_1341, Mixed Research Unit_1241, Rennes, France.
Sorbonne University, National Institute of Health and Medical Research, Mixed Research Unit_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Department of Thoracic and Cardiovascular, Cardiology Institute, Public Assistance-Hospitals of Paris, Sorbonne University, Pitié-Salpétriêre Hospital, Paris, France.
Anesthesiology. 2022 May 1;136(5):732-748. doi: 10.1097/ALN.0000000000004168.
Despite expanding use, knowledge on extracorporeal membrane oxygenation support during the COVID-19 pandemic remains limited. The objective was to report characteristics, management, and outcomes of patients receiving extracorporeal membrane oxygenation with a diagnosis of COVID-19 in France and to identify pre-extracorporeal membrane oxygenation factors associated with in-hospital mortality. A hypothesis of similar mortality rates and risk factors for COVID-19 and non-COVID-19 patients on venovenous extracorporeal membrane oxygenation was made.
The Extracorporeal Membrane Oxygenation for Respiratory Failure and/or Heart failure related to Severe Acute Respiratory Syndrome-Coronavirus 2 (ECMOSARS) registry included COVID-19 patients supported by extracorporeal membrane oxygenation in France. This study analyzed patients included in this registry up to October 25, 2020, and supported by venovenous extracorporeal membrane oxygenation for respiratory failure with a minimum follow-up of 28 days after cannulation. The primary outcome was in-hospital mortality. Risk factors for in-hospital mortality were analyzed.
Among 494 extracorporeal membrane oxygenation patients included in the registry, 429 were initially supported by venovenous extracorporeal membrane oxygenation and followed for at least 28 days. The median (interquartile range) age was 54 yr (46 to 60 yr), and 338 of 429 (79%) were men. Management before extracorporeal membrane oxygenation cannulation included prone positioning for 411 of 429 (96%), neuromuscular blockage for 419 of 427 (98%), and NO for 161 of 401 (40%). A total of 192 of 429 (45%) patients were cannulated by a mobile extracorporeal membrane oxygenation unit. In-hospital mortality was 219 of 429 (51%), with a median follow-up of 49 days (33 to 70 days). Among pre-extracorporeal membrane oxygenation modifiable exposure variables, neuromuscular blockage use (hazard ratio, 0.286; 95% CI, 0.101 to 0.81) and duration of ventilation (more than 7 days compared to less than 2 days; hazard ratio, 1.74; 95% CI, 1.07 to 2.83) were independently associated with in-hospital mortality. Both age (per 10-yr increase; hazard ratio, 1.27; 95% CI, 1.07 to 1.50) and total bilirubin at cannulation (6.0 mg/dl or more compared to less than 1.2 mg/dl; hazard ratio, 2.65; 95% CI, 1.09 to 6.5) were confounders significantly associated with in-hospital mortality.
In-hospital mortality was higher than recently reported, but nearly half of the patients survived. A high proportion of patients were cannulated by a mobile extracorporeal membrane oxygenation unit. Several factors associated with mortality were identified. Venovenous extracorporeal membrane oxygenation support should be considered early within the first week of mechanical ventilation initiation.
尽管体外膜肺氧合（ECMO）的应用不断扩大，但在 COVID-19 大流行期间，关于 ECMO 支持的知识仍然有限。本研究的目的是报告在法国 COVID-19 患者中接受 ECMO 治疗的患者的特征、管理和结局，并确定与院内死亡率相关的 ECMO 前因素。假设 COVID-19 患者和非 COVID-19 患者在行 venovenous ECMO 治疗时具有相似的死亡率和危险因素。
体外膜肺氧合治疗与严重急性呼吸综合征冠状病毒 2（SARS-CoV-2）相关的呼吸衰竭和/或心力衰竭（ECMO SARS）登记处包括在法国接受 ECMO 治疗的 COVID-19 患者。本研究分析了截至 2020 年 10 月 25 日纳入该登记处的 COVID-19 患者，并支持至少 28 天的 venovenous ECMO 治疗呼吸衰竭。主要结局是院内死亡率。分析了院内死亡率的危险因素。
在登记处的 494 例 ECMO 患者中，429 例最初接受 venovenous ECMO 支持，并至少随访 28 天。中位（四分位距）年龄为 54 岁（46 至 60 岁），429 例患者中有 338 例（79%）为男性。在 ECMO 置管前的治疗中，429 例患者中有 411 例（96%）接受俯卧位通气，427 例患者中有 419 例（98%）接受神经肌肉阻滞剂治疗，401 例患者中有 161 例（40%）接受一氧化氮（NO）治疗。429 例患者中有 192 例（45%）在移动 ECMO 单元上置管。429 例患者中有 219 例（51%）死亡，中位随访时间为 49 天（33 至 70 天）。在 ECMO 前可改变的暴露变量中，神经肌肉阻滞剂的使用（风险比，0.286；95%CI，0.101 至 0.81）和通气时间（超过 7 天与小于 2 天；风险比，1.74；95%CI，1.07 至 2.83）与院内死亡率独立相关。年龄（每增加 10 岁；风险比，1.27；95%CI，1.07 至 1.50）和置管时总胆红素（6.0mg/dl 或更高与低于 1.2mg/dl；风险比，2.65；95%CI，1.09 至 6.5）均为与院内死亡率显著相关的混杂因素。
院内死亡率高于最近的报告，但近一半的患者存活。相当一部分患者在移动 ECMO 单元上置管。确定了与死亡率相关的几个因素。应在机械通气开始后的第一周内尽早考虑 venovenous ECMO 支持。
