Brunetti Marissa A, Gaynor J William, Zhang Wenying, Banerjee Mousumi, Domnina Yuliya A, Gaies Michael
Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Cardiol Young. 2024 Dec;34(12):2543-2550. doi: 10.1017/S1047951124026568. Epub 2024 Oct 4.
It is unclear how extracorporeal membrane oxygenation use varies across paediatric cardiac surgical programmes and how it relates to post-operative mortality. We aimed to determine hospital-level variation in post-operative extracorporeal membrane oxygenation use and its association with case-mix adjusted mortality.
Retrospective analysis of 37 hospitals contributing to the Pediatric Cardiac Critical Care Consortium clinical registry from 1 August 2014 to 31 December 2019. Hospitalisations including cardiothoracic surgery and post-operative admission to paediatric cardiac ICUs were included. Two-level multivariable logistic regression with hospital random effect was used to determine case-mix adjusted post-operative extracorporeal membrane oxygenation use rates and in-hospital mortality. Hospitals were grouped into extracorporeal membrane oxygenation use tertiles, and mortality was compared across tertiles.
There were 43,640 eligible surgical hospitalisations; 1397 (3.2%) included at least one post-operative extracorporeal membrane oxygenation run. Case-mix adjusted extracorporeal membrane oxygenation rates varied more than sevenfold (0.9-6.9%) across hospitals, and adjusted mortality varied 10-fold (0-5.5%). Extracorporeal membrane oxygenation rates were 2.0%, 3.5%, and 5.2%, respectively, for low, middle, and high extracorporeal membrane oxygenation use tertiles ( < 0.0001), and mortality rates were 1.9%, 3.0%, and 3.1% ( < 0.0001), respectively. High extracorporeal membrane oxygenation use hospitals were more likely to initiate extracorporeal membrane oxygenation support intraoperatively (1.6% vs. 0.6% low and 1.1% middle, < 0.0001). Extracorporeal membrane oxygenation indications were similar across hospital tertiles. When extracorporeal cardiopulmonary resuscitation was excluded, variation in extracorporeal membrane oxygenation use rates persisted (1.5%, 2.6%, 3.8%, < 0.001).
There is hospital variation in adjusted post-operative extracorporeal membrane oxygenation use after paediatric cardiac surgery and a significant association with adjusted post-operative mortality. These findings suggest that post-operative extracorporeal membrane oxygenation use could be a complementary quality metric to mortality to assess performance of cardiac surgical programmes.
目前尚不清楚体外膜肺氧合（ECMO）在小儿心脏外科手术项目中的使用情况如何变化，以及它与术后死亡率之间的关系。我们旨在确定医院层面术后ECMO使用情况的差异及其与病例组合调整后死亡率的关联。
对2014年8月1日至2019年12月31日期间向小儿心脏重症监护联盟临床登记处提供数据的37家医院进行回顾性分析。纳入包括心胸外科手术及术后入住小儿心脏重症监护病房的住院病例。采用具有医院随机效应的二级多变量逻辑回归分析来确定病例组合调整后的术后ECMO使用率和院内死亡率。将医院分为ECMO使用三分位数组，并比较各三分位数组之间的死亡率。
共有43640例符合条件的外科住院病例；其中1397例（3.2%）至少进行了一次术后ECMO治疗。各医院病例组合调整后的ECMO使用率差异超过七倍（0.9% - 6.9%），调整后的死亡率差异达十倍（0 - 5.5%）。低、中、高ECMO使用三分位数组的ECMO使用率分别为2.0%、3.5%和5.2%（P < 0.0001），死亡率分别为1.9%、3.0%和3.1%（P < 0.0001）。高ECMO使用医院更有可能在术中启动ECMO支持（1.6%，而低分组为0.6%，中分组为1.1%，P < 0.0001）。各医院三分位数组的ECMO适应证相似。排除体外心肺复苏后，ECMO使用率的差异仍然存在（1.5%、2.6%、3.8%，P < 0.001）。
小儿心脏手术后，医院在调整后的术后ECMO使用方面存在差异，且与调整后的术后死亡率显著相关。这些发现表明，术后ECMO的使用可能是评估心脏外科手术项目绩效的死亡率之外的一个补充质量指标。
