创伤性脑损伤和严重呼吸衰竭患者的静脉-静脉体外膜肺氧合：单中心回顾性分析。
Venovenous extracorporeal membrane oxygenation in patients with traumatic brain injuries and severe respiratory failure: A single-center retrospective analysis.
机构信息
From the Program in Trauma (S.E.A., W.A.T., R.K., D.J.H., D.M.S., T.M.S., E.K.P.), R Adams Cowley Shock Trauma Center, Department of Surgery (S.E.A., R.K., D.J.H., D.M.S., T.M.S.), Department of Anesthesiology (S.M.G.), Neurocritical Care (J.E.P.), Program in Trauma, Department of Neurology, Department of Emergency Medicine (W.A.T., D.J.H., E.K.P.), and Department of Surgery (B.S.T.), Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and Department of Trauma and Acute Care Surgery (R.B.), University of Alabama at Birmingham, Birmingham, Alabama.
出版信息
J Trauma Acute Care Surg. 2024 Feb 1;96(2):332-339. doi: 10.1097/TA.0000000000004159. Epub 2023 Oct 27.
BACKGROUND
Venovenous extracorporeal membrane oxygenation (VV ECMO) can support trauma patients with severe respiratory failure. Use in traumatic brain injury (TBI) may raise concerns of worsening complications from intracranial bleeding. However, VV ECMO can rapidly correct hypoxemia and hypercarbia, possibly preventing secondary brain injury. We hypothesize that adult trauma patients with TBI on VV ECMO have comparable survival with trauma patients without TBI.
METHODS
A single-center, retrospective cohort study involving review of electronic medical records of trauma admissions between July 1, 2014, and August 30, 2022, with discharge diagnosis of TBI who were placed on VV ECMO during their hospital course was performed.
RESULTS
Seventy-five trauma patients were treated with VV ECMO; 36 (48%) had TBI. Of those with TBI, 19 (53%) had a hemorrhagic component. Survival was similar between patients with and without a TBI (72% vs. 64%, p = 0.45). Traumatic brain injury survivors had a higher admission Glasgow Coma Scale (7 vs. 3, p < 0.001) than nonsurvivors. Evaluation of prognostic scoring systems on initial head computed tomography demonstrated that TBI VV ECMO survivors were more likely to have a Rotterdam score of 2 (62% vs. 20%, p = 0.03) and no survivors had a Marshall score of ≥4. Twenty-nine patients (81%) had a repeat head computed tomography on VV ECMO with one incidence of expanding hematoma and one new focus of bleeding. Neither patient with a new/worsening bleed received anticoagulation. Survivors demonstrated favorable neurologic outcomes at discharge and outpatient follow-up, based on their mean Rancho Los Amigos Scale (6.5; SD, 1.2), median Cerebral Performance Category (2; interquartile range, 1-2), and median Glasgow Outcome Scale-Extended (7.5; interquartile range, 7-8).
CONCLUSION
In this series, the majority of TBI patients survived and had good neurologic outcomes despite a low admission Glasgow Coma Scale. Venovenous extracorporeal membrane oxygenation may minimize secondary brain injury and may be considered in select patients with TBI.
LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level IV.
背景
静脉-静脉体外膜肺氧合（VV ECMO）可用于支持严重呼吸衰竭的创伤患者。在创伤性脑损伤（TBI）中的应用可能会引发颅内出血并发症恶化的担忧。然而，VV ECMO 可以迅速纠正低氧血症和高碳酸血症，从而可能防止继发性脑损伤。我们假设，接受 VV ECMO 治疗的创伤性 TBI 成年患者的存活率与未患有 TBI 的创伤患者相当。
方法
进行了一项单中心、回顾性队列研究，纳入了 2014 年 7 月 1 日至 2022 年 8 月 30 日期间因 TBI 出院诊断而入住我院的创伤患者的电子病历回顾，这些患者在住院期间接受了 VV ECMO 治疗。
结果
75 例创伤患者接受了 VV ECMO 治疗；其中 36 例（48%）患有 TBI。在 TBI 患者中，19 例（53%）有出血性成分。有 TBI 和无 TBI 的患者的存活率相似（72%对 64%，p=0.45）。TBI 幸存者的入院格拉斯哥昏迷量表评分较高（7 分对 3 分，p<0.001）。对初始头部 CT 评估的预后评分系统进行评估显示，TBI-VV ECMO 幸存者更有可能出现 Rotterdam 评分 2 分（62%对 20%，p=0.03），且无幸存者的 Marshall 评分≥4 分。29 例（81%）在接受 VV ECMO 治疗时进行了重复头部 CT 检查，其中 1 例出现血肿扩大，1 例出现新的出血灶。新发/加重出血的患者均未接受抗凝治疗。根据他们的平均 Rancho Los Amigos 量表（6.5；标准差，1.2）、中位数脑功能状态量表（2；四分位距，1-2）和中位数格拉斯哥预后量表-扩展版（7.5；四分位距，7-8），幸存者在出院和门诊随访时表现出良好的神经功能结局。
结论
在本系列中，尽管入院格拉斯哥昏迷量表评分较低，但大多数 TBI 患者存活且神经功能结局良好。VV ECMO 可能最大限度地减少继发性脑损伤，可考虑用于选择性 TBI 患者。
证据水平
预后和流行病学；IV 级。
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