Tham Elwin, Amoateng Emmanuel, Campbell Stuart, Sappington Penny, McCarthy Paul, Hayanga J W Awori
Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.
Ann Thorac Surg Short Rep. 2023 Sep 28;2(1):112-116. doi: 10.1016/j.atssr.2023.09.008. eCollection 2024 Mar.
Candidacy for venovenous extracorporeal membrane oxygenation is dictated by ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) criteria. We evaluated the effect of modifying candidacy on the basis of escalating demand and limited resources.
We retrospectively reviewed adult patients diagnosed with COVID-19-related severe acute respiratory distress syndrome who failed to respond to conventional ventilation and required extracorporeal support at our institution. Candidacy was restricted with a published probability model because of supply-demand mismatch and high mortality observed after the first surge. Age <55 years, mechanical ventilation days <3, and minimal comorbidities were prioritized. Primary outcomes included time to decannulation, extubation, tracheostomy, discharge, and death. Hospital and intensive care unit length of stay and hospitalization costs were evaluated. Predictors included cannulation strategy, before and after criteria implementation, use of cytoreductive techniques, timing of tracheostomy, and body mass index. Propensity score matching, multistate Cox proportional hazards models, and generalized linear models were used.
Our sample comprised 105 patients, 26 from before criteria implementation ("before" phase) and 79 after ("after" phase). Propensity score results indicated no significant differences in death ( = .152) and costs ( = .063) between the groups. Patients who received cytoreductive therapy had lower total costs ( = .033). Those who underwent single-site cannulation had higher probability of decannulation ( = .009), discharge ( < .001), tracheostomy ( < .001), and extubation alive ( < .001) and lower risk of death ( = .017).
Modifying candidacy by objective criteria with the use of adjunctive therapies may improve outcomes and lower costs during periods of supply-demand mismatch.
静脉-静脉体外膜肺氧合的入选标准由“体外膜肺氧合挽救重症急性呼吸窘迫综合征（EOLIA）”标准决定。我们评估了基于不断增加的需求和有限资源来调整入选标准的效果。
我们回顾性分析了在我院被诊断为新型冠状病毒肺炎相关重症急性呼吸窘迫综合征、对传统通气治疗无反应且需要体外支持的成年患者。由于供需不匹配以及在第一波疫情高峰后观察到的高死亡率，采用已发表的概率模型来限制入选标准。优先考虑年龄<55岁、机械通气天数<3天且合并症最少的患者。主要结局包括拔管时间、脱机时间、气管切开时间、出院时间和死亡时间。评估了住院时间、重症监护病房住院时间和住院费用。预测因素包括插管策略、标准实施前后、细胞减灭技术的使用、气管切开时间和体重指数。采用倾向评分匹配、多状态Cox比例风险模型和广义线性模型。
我们的样本包括105例患者，26例在标准实施前（“之前”阶段），79例在标准实施后（“之后”阶段）。倾向评分结果表明，两组之间在死亡（P = 0.152）和费用（P = 0.063）方面无显著差异。接受细胞减灭治疗的患者总费用较低（P = 0.033）。接受单部位插管的患者拔管概率较高（P = 0.009）、出院概率较高（P < 0.001）、气管切开概率较高（P < 0.001）、脱机存活概率较高（P < 0.001）且死亡风险较低（P = 0.017）。
在供需不匹配期间，通过客观标准并使用辅助治疗来调整入选标准可能会改善结局并降低费用。
