Gerhardinger Felix, Fisser Christoph, Malfertheiner Maximilian V, Philipp Alois, Foltan Maik, Zeman Florian, Stadlbauer Andrea, Wiest Clemens, Lunz Dirk, Müller Thomas, Lubnow Matthias
Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.
Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany.
Crit Care Med. 2024 Jan 1;52(1):54-67. doi: 10.1097/CCM.0000000000006041. Epub 2023 Sep 5.
Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency.
Single-center retrospective observational study.
Sixteen beds medical ICU at the University Hospital Regensburg.
Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017.
None.
Patients meeting our ECMO weaning criteria (Sp o2 ≥ 90% with F io2 ≤ 0.4 or Pa o2 /F io2 > 150 mm Hg, pH = 7.35-7.45, positive end-expiratory pressure ≤ 10 cm H 2 O, driving pressure < 15 cm H 2 O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90-160 mm Hg, norepinephrine < 0.2 µg/[kgmin]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co2 : odds ratio [OR] 1.05; 95% CI, 1.001-1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04-1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/Lmin), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o2 and Pa o2 /F io2 during EWTs was higher in failed than successful trials.
Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure.
分析严重急性呼吸功能不全患者静脉-静脉体外膜肺氧合（VV-ECMO）撤机失败的发生率及危险因素。
单中心回顾性观察研究。
雷根斯堡大学医院的16张床位的医学重症监护病房。
2011年10月至2017年12月期间227例需要VV-ECMO支持的严重急性呼吸功能不全患者。
无。
符合我们ECMO撤机标准（吸入氧分数值（Fio2）≤0.4时动脉血氧饱和度（Sp o2）≥90%或动脉血氧分压（Pa o2）/Fio2>150 mmHg，pH = 7.35 - 7.45，呼气末正压（PEEP）≤10 cmH₂O，驱动压<15 cmH₂O，呼吸频率<30次/分钟，潮气量>5 mL/kg，ECMO血流量≈1.5 L/分钟，扫气流量≈1 L/分钟，心率<120次/分钟，收缩压90 - 160 mmHg，去甲肾上腺素<0.2 μg/（kg·分钟））的患者进行撤机试验（EWT），暂停扫气流量。在EWT前、期间和之后记录动脉血气分析、呼吸和呼吸机参数。插管时记录包括人口统计学、生命体征、呼吸、呼吸机和实验室参数在内的基线数据。227例患者中有179例（79%）成功拔管。10例患者（4%）在成功拔管前经历了至少3次失败的EWT的长时间撤机。失败的EWT前呼吸频率（19次/分钟 vs 16次/分钟，p = 0.002）和动脉血二氧化碳分压（Pa co2）（44 mmHg vs 40 mmHg，p = 0.003）高于成功的EWT。在多变量分析中，这两个参数都是ECMO撤机失败的危险因素（Pa co2：比值比[OR] 1.05；95%置信区间，1.001 - 1.10；p = 0.045；呼吸频率：OR 1.10；95%置信区间，1.04 - 1.15；p < 0.001）。失败的EWT前快速浅呼吸指数[42（次/升·分钟），vs 35（次/升·分钟），p = 0.052]高于成功的EWT。失败试验中EWT期间动脉血氧饱和度（Sa o2）和Pa o2 /Fio2的下降高于成功试验。
79%的患者成功拔管，仅4%的患者需要长时间的ECMO撤机。在EWT前，仅通气功能受损（脱羧不足、呼吸频率较高）而非氧合功能的参数可预测撤机失败，而在EWT期间，氧合功能受损与撤机失败相关。
