心脏术后体外生命支持临床实践的异质性：来自PELS-1多中心研究的初步调查

Heterogeneity in Clinical Practices for Post-Cardiotomy Extracorporeal Life Support: a Pilot Survey from the PELS-1 Multicenter Study.

作者信息

Mariani Silvia, Bari Gabor, Ravaux Justine M, van Bussel Bas C T, De Piero Maria Elena, Schaefer Ann-Kristin, Jawad Khalil, Pozzi Matteo, Loforte Antonio, Kalampokas Nikolaos, Jankuviene Agne, Flecher Erwan, Hou Xiaotong, Bunge Jeroen J H, Sriranjan Kogulan, Salazar Leonardo, Meyns Bart, Mazzeffi Michael A, Matteucci Sacha, Sponga Sandro, Ramanathan Kollengode, Costetti Alessandro, Formica Francesco, Sakiyalak Pranya, Fiore Antonio, Schmid Chistof, Raffa Giuseppe Maria, Castillo Roberto, Wang I-Wen, Jung Jae-Seung, Grus Tomas, Pellegrino Vin, Bianchi Giacomo, Pettinari Matteo, Barbone Alessandro, Garcia José P, Kowalewski Mariusz, Shekar Kiran, Whitman Glenn

机构信息

Cardio-Thoracic Surgery Department, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.

Clinic of Internal Medicine, Department of Cardiac Surgery, University of Szeged, Szeged, Hungary.

出版信息

Artif Organs. 2023 Jun 23. doi: 10.1111/aor.14601.

DOI:10.1111/aor.14601

PMID:37351569

Abstract

BACKGROUND

High-quality evidence for post-cardiotomy extracorporeal life support (PC-ECLS) management is lacking. This study investigated the real-world PC-ECLS clinical practices.

METHODS

This cross-sectional, multi-institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC-ECLS monitoring and transfusions practices. Twenty-nine questions were distributed among 34 hospitals participating in the Post-cardiotomy Extra-Corporeal Life Support Study.

RESULTS

Of the 32 centers [16 low-volume (50%); 16 high-volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty-six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patient's bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged 7-10 g/dL. Most centers used cardiac venting on a case-by-case basis (78.1%) and regular distal limb perfusion (84.4%). Nineteen (54.9%) centers reported dedicated monitoring protocols including daily echocardiography (87.5%), Swan-Ganz catheterization (40.6%), cerebral near-infrared spectroscopy (53.1%) and multimodal assessment of limb ischemia. Inspection of the circuit (71.9%), oxygenator pressure drop (68.8%), plasma free hemoglobin (75%), d-dimer (59.4%), lactate dehydrogenase (56.3%) and fibrinogen (46.9%) are used to diagnose hemolysis and thrombosis.

CONCLUSIONS

This study shows remarkable heterogeneity in clinical practices for PC-ECLS management. More standardized protocols and better implementation of available evidence are recommended.

摘要

背景

缺乏关于心脏术后体外生命支持（PC-ECLS）管理的高质量证据。本研究调查了PC-ECLS在现实世界中的临床实践。

方法

这项横断面、多机构、国际试点调查探讨了中心组织、抗凝管理、左心室卸载、远端肢体灌注、PC-ECLS监测和输血实践。29个问题分发给参与心脏术后体外生命支持研究的34家医院。

结果

在回复的32个中心中[16个低容量中心（50%）；16个高容量中心（50%）]，16个（50%）有专门的ECLS专家。26个中心（81.3%）报告使用了额外的机械循环支持。抗凝实践高度异质：24家医院（75%）报告以患者出血状态为指导，54.2%的病例没有具体阈值。输血目标范围为7-10 g/dL。大多数中心根据具体情况使用心脏排气（78.1%）和定期进行远端肢体灌注（84.4%）。19个（54.9%）中心报告了专门的监测方案，包括每日超声心动图（87.5%）、Swan-Ganz导管插入术（40.6%）、脑近红外光谱（53.1%）和肢体缺血的多模式评估。通过检查回路（71.9%）、氧合器压降（68.8%）、血浆游离血红蛋白（75%）、D-二聚体（59.4%）、乳酸脱氢酶（56.3%）和纤维蛋白原（46.9%）来诊断溶血和血栓形成。