静脉-动脉体外膜肺氧合术后严重下肢缺血的危险因素：一项基于全国住院患者数据库的分析
Risk factors for severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation: an analysis using a nationwide inpatient database.
作者信息
Honda Akira, Michihata Nobuaki, Iizuka Yoichi, Uda Kazuaki, Morita Kojiro, Mieda Tokue, Takasawa Eiji, Ishiwata Sho, Tajika Tsuyoshi, Matsui Hiroki, Fushimi Kiyohide, Yasunaga Hideo, Chikuda Hirotaka
机构信息
Orthopaedic Surgery, Gunma University Graduate School of Medicine School of Medicine Faculty of Medicine, Gunma, Japan.
Health Services Research, Graduate School of Medicine, The University of Tokyo Graduate School of Medicine Faculty of Medicine, Tokyo, Japan.
出版信息
Trauma Surg Acute Care Open. 2022 Apr 13;7(1):e000776. doi: 10.1136/tsaco-2021-000776. eCollection 2022.
OBJECTIVES
Venoarterial extracorporeal membrane oxygenation is increasingly being used as a life-saving modality in critically ill patients. Despite its necessity, severe lower extremity ischemia associated with venoarterial extracorporeal membrane oxygenation remains a potentially devastating complication. We aimed to investigate the incidence and risk factors for severe lower extremity ischemia requiring fasciotomy or amputation following venoarterial extracorporeal membrane oxygenation.
METHODS
All patients who received venoarterial extracorporeal membrane oxygenation during hospitalization were identified in a Japanese national inpatient database from July 1, 2010 to March 31, 2018. The primary outcome was occurrence of severe lower extremity ischemia that required fasciotomy or amputation. We used cause-specific proportional hazard models to examine the associations between potential risk factors and outcomes. We also performed a competing-risk analysis to estimate the cause-specific HR for severe lower extremity ischemia using a multivariable competing-risk Cox proportional hazard model with adjustment for potential risk factors.
RESULTS
A total of 29 231 patients who underwent venoarterial extracorporeal membrane oxygenation during hospitalization were identified. Of these, 98 patients (0.3%) had lower extremity ischemia requiring fasciotomy or amputation. The young group (≤18 years) had a significantly higher proportion of severe lower extremity ischemia cases than the adult (19-59 years) and elderly (≥60 years) groups (1.4%, 0.5%, and 0.2%, respectively; p<0.001). In a multivariable competing-risk Cox proportional hazards regression model, younger age (HR 3.06; 95% CI 1.33 to 7.02; p<0.008) and consciousness disturbance on admission (HR 2.53; 95% CI 1.60 to 3.99; p<0.001) were significantly associated with higher likelihood of severe lower extremity ischemia.
CONCLUSION
In this study using a nationwide database, younger age and consciousness disturbance on admission were associated with higher risk of severe lower extremity ischemia following venoarterial extracorporeal membrane oxygenation.
LEVEL OF EVIDENCE
Level Ⅲ-prognostic and epidemiological.
目的
静脉 - 动脉体外膜肺氧合（VA - ECMO）越来越多地被用作危重症患者的一种挽救生命的治疗方式。尽管其有必要性，但与VA - ECMO相关的严重下肢缺血仍然是一种潜在的毁灭性并发症。我们旨在调查VA - ECMO后需要进行筋膜切开术或截肢的严重下肢缺血的发生率及危险因素。
方法
在一个日本全国住院患者数据库中识别出2010年7月1日至2018年3月31日期间住院接受VA - ECMO治疗的所有患者。主要结局是发生需要筋膜切开术或截肢的严重下肢缺血。我们使用病因特异性比例风险模型来检验潜在危险因素与结局之间的关联。我们还进行了竞争风险分析，使用多变量竞争风险Cox比例风险模型并对潜在危险因素进行调整，以估计严重下肢缺血的病因特异性风险比（HR）。
结果
共识别出29231例住院期间接受VA - ECMO治疗的患者。其中，98例（0.3%）发生了需要筋膜切开术或截肢的下肢缺血。年轻组（≤18岁）严重下肢缺血病例的比例显著高于成人组（19 - 59岁）和老年组（≥60岁）（分别为1.4%、0.5%和0.2%；p<0.001）。在多变量竞争风险Cox比例风险回归模型中，年龄较小（HR 3.06；95%CI 1.33至7.02；p<0.008）和入院时意识障碍（HR 2.53；95%CI 1.60至3.99；p<0.001）与严重下肢缺血的较高可能性显著相关。
结论
在这项使用全国性数据库的研究中，年龄较小和入院时意识障碍与VA - ECMO后严重下肢缺血的较高风险相关。
证据水平
Ⅲ级 - 预后和流行病学研究。
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