体外心肺复苏患者的动脉血氧和二氧化碳分压与急性脑损伤：体外生命支持组织登记分析。
Arterial oxygen and carbon dioxide tension and acute brain injury in extracorporeal cardiopulmonary resuscitation patients: Analysis of the extracorporeal life support organization registry.
机构信息
Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
出版信息
J Heart Lung Transplant. 2023 Apr;42(4):503-511. doi: 10.1016/j.healun.2022.10.019. Epub 2022 Nov 5.
BACKGROUND
Acute brain injury (ABI) remains common after extracorporeal cardiopulmonary resuscitation (ECPR). Using a large international multicenter cohort, we investigated the impact of peri-cannulation arterial oxygen (PaO) and carbon dioxide (PaCO) on ABI occurrence.
METHODS
We retrospectively analyzed adult (≥18 years old) ECPR patients in the Extracorporeal Life Support Organization registry from 1/2009 through 12/2020. Composite ABI included ischemic stroke, intracranial hemorrhage (ICH), seizures, and brain death. The registry collects 2 blood gas data pre- (6 hours) and post- (24 hours) cannulation. Blood gas parameters were classified as: hypoxia (<60mm Hg), normoxia (60-119mm Hg), and mild (120-199mm Hg), moderate (200-299mm Hg), and severe hyperoxia (≥300mm Hg); hypocarbia (<35mm Hg), normocarbia (35-44mm Hg), mild (45-54mm Hg) and severe hypercarbia (≥55mm Hg). Missing values were handled using multiple imputation. Multivariable logistic regression analysis was used to assess the relationship of PaO and PaCO with ABI.
RESULTS
Of 3,125 patients with ECPR intervention (median age=58, 69% male), 488 (16%) experienced ABI (7% ischemic stroke; 3% ICH). In multivariable analysis, on-ECMO moderate (aOR=1.42, 95%CI: 1.02-1.97) and severe hyperoxia (aOR=1.59, 95%CI: 1.20-2.10) were associated with composite ABI. Additionally, severe hyperoxia was associated with ischemic stroke (aOR=1.63, 95%CI: 1.11-2.40), ICH (aOR=1.92, 95%CI: 1.08-3.40), and in-hospital mortality (aOR=1.58, 95%CI: 1.21-2.06). Mild hypercarbia pre-ECMO was protective of composite ABI (aOR=0.61, 95%CI: 0.44-0.84) and ischemic stroke (aOR=0.56, 95%CI: 0.35-0.89).
CONCLUSIONS
Early severe hyperoxia (≥300mm Hg) on ECMO was a significant risk factor for ABI and mortality. Careful consideration should be given in early oxygen delivery in ECPR patients who are at risk of reperfusion injury.
背景
体外心肺复苏（ECPR）后仍常见急性脑损伤（ABI）。我们使用大型国际多中心队列研究，调查了套管放置前后动脉氧（PaO）和二氧化碳（PaCO）对 ABI 发生的影响。
方法
我们回顾性分析了 2009 年 1 月至 2020 年 12 月期间体外生命支持组织注册中心的成年（≥18 岁）ECPR 患者。复合 ABI 包括缺血性脑卒中、颅内出血（ICH）、癫痫发作和脑死亡。该注册中心收集套管放置前（6 小时）和后（24 小时）的 2 项血气数据。血气参数分为：低氧血症（＜60mmHg）、正常氧（60-119mmHg）和轻度（120-199mmHg）、中度（200-299mmHg）和重度高氧血症（≥300mmHg）；低碳酸血症（＜35mmHg）、正常碳酸血症（35-44mmHg）、轻度（45-54mmHg）和重度高碳酸血症（≥55mmHg）。使用多重插补处理缺失值。多变量逻辑回归分析用于评估 PaO 和 PaCO 与 ABI 的关系。
结果
在 3125 名接受 ECPR 干预的患者中（中位年龄 58 岁，69%为男性），488 名（16%）发生 ABI（7%缺血性脑卒中；3%ICH）。多变量分析显示，ECMO 上中度（aOR=1.42，95%CI：1.02-1.97）和重度高氧血症（aOR=1.59，95%CI：1.20-2.10）与复合 ABI 相关。此外，重度高氧血症与缺血性脑卒中（aOR=1.63，95%CI：1.11-2.40）、ICH（aOR=1.92，95%CI：1.08-3.40）和院内死亡率（aOR=1.58，95%CI：1.21-2.06）相关。ECMO 前轻度高碳酸血症对复合 ABI（aOR=0.61，95%CI：0.44-0.84）和缺血性脑卒中（aOR=0.56，95%CI：0.35-0.89）有保护作用。
结论
ECMO 上早期重度高氧血症（≥300mmHg）是 ABI 和死亡率的显著危险因素。在存在再灌注损伤风险的 ECPR 患者中，应仔细考虑早期的氧输送。
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