APHP.Nord, Department of Intensive Care Medicine, Hôpital Bichat - Claude Bernard, Paris, France.
Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont Ferrand, France.
Eur J Cardiothorac Surg. 2023 Apr 3;63(4). doi: 10.1093/ejcts/ezad083.
Upper gastrointestinal bleeding (UGIB) is a common complication in adults treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock or cardiac arrest. We aimed to determine risk factors, prevalence and outcomes associated with VA-ECMO-associated UGIB in adult patients.
We conducted a retrospective cohort study (2014-2022) on consecutive VA-ECMO patients in the medical and infectious disease intensive care unit of Bichat-Claude Bernard University Hospital, Paris, France. UGIB was defined as (i) an overt bleeding (haematemesis, melena, haematochezia) or (ii) acute anaemia associated with a lesion diagnosed on upper gastrointestinal endoscopy. VA-ECMO-associated UGIB was defined as an UGIB occurring during VA-ECMO, or up to 10 days after decannulation in patients weaned off extracorporeal membrane oxygenation (ECMO). Cause-specific models were used to identify factors associated with UGIB and death, respectively.
Among the 455 patients included, 48 (10%) were diagnosed with UGIB after a median of 12 [7; 23] days following ECMO cannulation. Mortality occurred in 36 (75%) patients with UGIB and 243 (60%) patients without. UGIB patients had longer intensive care unit stays (32 [19; 60] vs 18 [7; 37] days; P < 0.01), longer ECMO (14 [9; 18] vs 7 [4; 11] days; P < 0.01) and mechanical ventilation durations (21 [16; 36] vs 10 [5; 20] days; P < 0.01), as compared to non-UGIB patients. Ninety upper gastrointestinal endoscopies were performed, and the most frequent lesions detected were gastro-duodenal ulcers (n = 23, 26%), leading to 11/90 therapeutic procedures. By multivariable analysis, a history of peptic ulcer [cause-specific hazard ratio (CSHR) 2.93, 95% confidence interval (CI) [1.01; 8.51]], a dual antiplatelet therapy (CSHR 2.0, 95% CI [1.07; 3.72]) and extracorporeal cardiopulmonary resuscitation (CSHR 2.78, 95% CI [1.42; 5.45]) were independently associated with an increased risk of UGIB.
In adult patients under VA-ECMO, a history of gastric ulcer, dual antiplatelet therapy and extracorporeal cardiopulmonary resuscitation were independently associated with an increased risk of UGIB. This study highlights the potential role of acute ischaemia-reperfusion injury in the pathophysiology of VA-ECMO-associated UGIB.
上消化道出血（UGIB）是因难治性心源性休克或心脏骤停而行静脉-动脉体外膜肺氧合（VA-ECMO）治疗的成人常见并发症。本研究旨在确定与成人患者 VA-ECMO 相关的 UGIB 的相关风险因素、发生率和结局。
我们进行了一项回顾性队列研究（2014 年至 2022 年），纳入了法国巴黎比沙克-克劳德伯纳德大学医院内科和传染病重症监护病房的连续 VA-ECMO 患者。UGIB 的定义为（i）显性出血（呕血、黑便、血便）或（ii）上消化道内镜诊断的病变相关的急性贫血。VA-ECMO 相关 UGIB 定义为 VA-ECMO 期间发生的 UGIB，或在体外膜氧合（ECMO）脱机患者中，在脱机后 10 天内发生的 UGIB。使用病因特异性模型分别确定与 UGIB 和死亡相关的因素。
在纳入的 455 例患者中，48 例（10%）在 ECMO 置管后中位时间 12[7；23]天后被诊断为 UGIB。UGIB 患者中有 36 例（75%）死亡，243 例（60%）无 UGIB 死亡。UGIB 患者的 ICU 住院时间更长（32[19；60]vs 18[7；37]天；P<0.01）、ECMO 时间更长（14[9；18]vs 7[4；11]天；P<0.01）和机械通气时间更长（21[16；36]vs 10[5；20]天；P<0.01）。与非 UGIB 患者相比。进行了 90 次上消化道内镜检查，最常见的病变是胃十二指肠溃疡（n=23，26%），导致 11/90 例治疗性操作。多变量分析显示，既往消化性溃疡史[病因特异性风险比（CSHR）2.93，95%置信区间（CI）[1.01；8.51]]、双联抗血小板治疗（CSHR 2.0，95%CI[1.07；3.72]）和体外心肺复苏（CSHR 2.78，95%CI[1.42；5.45]）与 UGIB 风险增加独立相关。
在接受 VA-ECMO 的成年患者中，胃溃疡史、双联抗血小板治疗和体外心肺复苏与 UGIB 风险增加独立相关。本研究强调了急性缺血再灌注损伤在 VA-ECMO 相关 UGIB 发病机制中的潜在作用。
