Glenfield Hospital Extracorporeal Membrane Oxygenation Unit, University Hospitals of Leicester National Health Service Trust, Glenfield, Groby Road, Leicester, LE3 9QP, UK.
Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
Intensive Care Med. 2024 Sep;50(9):1411-1425. doi: 10.1007/s00134-024-07551-z. Epub 2024 Aug 5.
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an integral part of the management algorithm of patients with severe respiratory failure refractory to evidence-based conventional treatments. Right ventricular injury (RVI) pertaining to abnormalities in the dimensions and/or function of the right ventricle (RV) in the context of VV-ECMO significantly influences mortality. However, in the absence of a universally accepted RVI definition and evidence-based guidance for the management of RVI in this very high-risk patient cohort, variations in clinical practice continue to exist.
Following a systematic search of the literature, an international Steering Committee consisting of eight healthcare professionals involved in the management of patients receiving ECMO identified domains and knowledge gaps pertaining to RVI definition and management where the evidence is limited or ambiguous. Using a Delphi process, an international panel of 52 Experts developed Expert position statements in those areas. The process also conferred RV-centric overarching open questions for future research. Consensus was defined as achieved when 70% or more of the Experts agreed or disagreed on a Likert-scale statement or when 80% or more of the Experts agreed on a particular option in multiple-choice questions.
The Delphi process was conducted through four rounds and consensus was achieved on 31 (89%) of 35 statements from which 24 Expert position statements were derived. Expert position statements provided recommendations for RVI nomenclature in the setting of VV-ECMO, a multi-modal diagnostic approach to RVI, the timing and parameters of diagnostic echocardiography, and VV-ECMO settings during RVI assessment and management. Consensus was not reached on RV-protective driving pressure thresholds or the effect of prone positioning on patient-centric outcomes.
The proposed definition of RVI in the context of VV-ECMO needs to be validated through a systematic aggregation of data across studies. Until further evidence emerges, the Expert position statements can guide informed decision-making in the management of these patients.
静脉-静脉体外膜肺氧合（VV-ECMO）是治疗对证据为基础的常规治疗无效的严重呼吸衰竭患者的管理算法的重要组成部分。VV-ECMO 中右心室损伤（RVI）与右心室（RV）的大小和/或功能异常有关，对死亡率有显著影响。然而，由于缺乏普遍接受的 RVI 定义以及针对这一极高风险患者群体中 RVI 管理的循证指南，临床实践中的差异仍然存在。
在对文献进行系统搜索后，一个由 8 名参与 ECMO 患者管理的医疗保健专业人员组成的国际指导委员会确定了与 RVI 定义和管理相关的领域和知识空白，这些领域的证据有限或不明确。使用 Delphi 流程，一个由 52 名专家组成的国际小组在这些领域制定了专家立场声明。该流程还为未来的研究提出了以 RV 为中心的总体开放性问题。当 70%或更多的专家对 Likert 量表上的陈述表示同意或不同意，或当 80%或更多的专家对多项选择题中的特定选项表示同意时，即达成共识。
Delphi 流程进行了四轮，就 35 项声明中的 31 项（89%）达成了共识，由此产生了 24 项专家立场声明。专家立场声明为 VV-ECMO 环境中的 RVI 命名、RVI 的多模式诊断方法、诊断超声心动图的时机和参数，以及在 RVI 评估和管理期间的 VV-ECMO 设置提供了建议。在 RV 保护驱动压力阈值或俯卧位对患者为中心的结局的影响方面，没有达成共识。
需要通过对来自多个研究的数据进行系统汇总来验证 VV-ECMO 中 RVI 的拟议定义。在进一步的证据出现之前，专家立场声明可以指导这些患者管理的决策。
