早期的静脉-静脉体外膜肺氧合是治疗创伤性呼吸衰竭患者的有效策略。
Early veno-venous extracorporeal membrane oxygenation is an effective strategy for traumatically injured patients presenting with refractory respiratory failure.
机构信息
From the Department of Emergency Medicine (E.K.P., M.K.), Program in Trauma, R Adams Cowley Shock Trauma Center (E.K.P., R.K., M.K., J.V.O., D.M.S., T.M.S.), University of Maryland School of Medicine, Baltimore, Maryland; 720 Operational Support Squadron (E.K.P., T.S.R., J.K.W.), Hurlburt Field, Florida; Department of Surgery, Emory University School of Medicine (T.S.R.), Atlanta, Georgia; Malcolm Grow Medical Clinics & Surgery Center (J.K.W.), Joint Base Andrews; United States Air Force Material Command (J.C.), Baltimore, Maryland; Air Force Special Operations Command (M.P.H.), Hurlburt Field, Florida; Division of Cardiac Surgery, Department of Surgery (B.S.T.), and Department of Anesthesiology (S.M.G.), University of Maryland School of Medicine, Baltimore, Maryland.
出版信息
J Trauma Acute Care Surg. 2023 Aug 1;95(2S Suppl 1):S50-S59. doi: 10.1097/TA.0000000000004057. Epub 2023 May 29.
BACKGROUND
Venovenous extracorporeal membrane oxygenation (VV ECMO) is used for respiratory failure when standard therapy fails. Optimal trauma care requires patients be stable enough to undergo procedures. Early VV ECMO (EVV) to stabilize trauma patients with respiratory failure as part of resuscitation could facilitate additional care. As VV ECMO technology is portable and prehospital cannulation possible, it could also be used in austere environments. We hypothesize that EVV facilitates injury care without worsening survival.
METHODS
Our single center, retrospective cohort study included all trauma patients between January 1, 2014, and August 1, 2022, who were placed on VV ECMO. Early VV was defined as cannulation ≤48 hours from arrival with subsequent operation for injuries. Data were analyzed with descriptive statistics. Parametric or nonparametric statistics were used based on the nature of the data. After testing for normality, significance was defined as a p < 0.05. Logistic regression diagnostics were performed.
RESULTS
Seventy-five patients were identified and 57 (76%) underwent EVV. There was no difference in survival between the EVV and non-EVV groups (70% vs. 61%, p = 0.47). Age, race, and gender did not differ between EVV survivors and nonsurvivors. Time to cannulation (4.5 hours vs. 8 hours, p = 0.39) and injury severity scores (34 vs. 29, p = 0.74) were similar. Early VV survivors had lower lactic acid levels precannulation (3.9 mmol/L vs. 11.9 mmol/L, p < 0.001). A multivariable logistic regression analysis examining admission and precannulation laboratory and hemodynamic values demonstrated that lower precannulation lactic acid levels predicted survival (odds ratio, 1.2; 95% confidence interval, 1.02-1.5; p = 0.03), with a significant inflection point of 7.4 mmol/L corresponding to decreased survival at hospital discharge.
CONCLUSION
Patients undergoing EVV did not have increased mortality compared with the overall trauma VV ECMO population. Early VV resulted in ventilatory stabilization that allowed subsequent procedural treatment of injuries.
LEVEL OF EVIDENCE
Therapeutic Care/Management; Level III.
背景
当标准治疗失败时，静脉-静脉体外膜肺氧合（VV ECMO）用于呼吸衰竭。最佳的创伤护理需要患者稳定到可以进行手术的程度。作为复苏的一部分，早期 VV ECMO（EVV）稳定呼吸衰竭的创伤患者可能会促进更多的治疗。由于 VV ECMO 技术具有便携性和院前置管的可能性，因此也可以在恶劣环境中使用。我们假设 EVV 有助于改善创伤护理，而不会降低生存率。
方法
我们的单中心回顾性队列研究包括 2014 年 1 月 1 日至 2022 年 8 月 1 日期间所有接受 VV ECMO 治疗的创伤患者。早期 VV 定义为入院后≤48 小时内进行置管，随后进行损伤手术。采用描述性统计分析数据。根据数据的性质，使用参数或非参数统计。在检验正态性后，显著性定义为 p < 0.05。进行逻辑回归诊断。
结果
共确定了 75 名患者，其中 57 名（76%）接受了 EVV。EVV 组和非 EVV 组的生存率无差异（70%比 61%，p=0.47）。EVV 幸存者和非幸存者之间的年龄、种族和性别没有差异。置管时间（4.5 小时比 8 小时，p=0.39）和创伤严重程度评分（34 分比 29 分，p=0.74）相似。早期 VV 幸存者在置管前的乳酸水平较低（3.9 mmol/L 比 11.9 mmol/L，p<0.001）。检查入院和置管前实验室及血液动力学值的多变量逻辑回归分析表明，较低的置管前乳酸水平预测生存率（优势比，1.2；95%置信区间，1.02-1.5；p=0.03），乳酸水平的拐点为 7.4 mmol/L，对应于出院时生存率降低。
结论
与总体创伤 VV ECMO 患者相比，接受 EVV 的患者死亡率没有增加。早期 VV 导致通气稳定，从而允许随后对损伤进行手术治疗。
证据水平
治疗/管理；III 级。
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