Petermichl Walter, Philipp Alois, Foltan Maik, Stadlbauer Andrea, Ellmauer Peter-Paul, Merten Christian, Blecha Sebastian, Müller Thomas, Ulm Bernhard, Graf Bernhard, Lunz Dirk
Department of Anesthesiology, University Medical Center Regensburg, Franz Josef Strauß Allee 11, 93053, Regensburg, Germany.
Department of Cardio Technology, University Medical Center Regensburg, Regensburg, Germany.
Scand J Trauma Resusc Emerg Med. 2025 May 12;33(1):81. doi: 10.1186/s13049-025-01401-7.
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has served as a crucial intervention for critically ill patients with persistent cardiopulmonary failure. A standardized approach improves VA ECMO outcomes, which is why ECMO is currently limited to specialized centers. However, transferring critically ill patients to these ECMO centers is not without risk. Portable ECMO devices allow implantation in out-of-center settings prior to transportation. Despite efforts to standardize decision-making, significant variability remains, particularly in out-of-center (OoC) settings with limited data. Due to persistently high mortality, accurate indications are needed to optimize outcomes. This study aims to identify key factors associated with favorable outcomes in OoC VA ECMO and to develop practical decision-making tools for clinicians in these settings.
We retrospectively investigated the outcomes of VA ECMO implantation in out-of-center settings between 2006 and 2022 at our institution. Parameters assessed prior to VA ECMO implantation, including organ failure count, mean arterial pressure (MAP), and laboratory data, were analyzed. Follow-up data were collected to evaluate functional (Eastern Cooperative Oncology Group [ECOG] performance status) and neurological (cerebral performance category score [CPC]) (outcomes. Statistical analyses were performed using non-parametric methods and SHAP importance analysis.
A total of 56.5% (195 of 345 patients) who underwent VA ECMO implantation in OoC survived, and 43.8% had a favorable neurological outcome (CPC 1). 37.6% of patients had good functional outcomes (ECOG 0-1). Patients with a MAP > 54 mmHg had better long-term functional outcomes, and those with a MAP > 64 mmHg had better mid-term neurological outcomes. Poor outcomes were associated with reduced coagulation activity and increased thrombogenicity. Renal and multi-organ failure prior to VA ECMO implantation were associated with poor neurological and functional outcomes.
Through importance analyses, we identified key and secondary factors associated with favorable outcomes in OoC VA ECMO. The extent and severity of organ failure prior to VA ECMO implantation are crucial in determining outcomes. Hemodynamic status, as reflected by MAP, along with organ failure prior to VA-ECMO implantation, significantly influences neurological and functional outcomes. Patients with better hemodynamic stability and coagulation profiles had significantly improved chances of survival with favorable neurological and functional outcomes.
静脉-动脉体外膜肺氧合（VA ECMO）一直是治疗持续性心肺衰竭重症患者的关键干预措施。标准化方法可改善VA ECMO治疗效果，这也是目前ECMO仅限于专业中心开展的原因。然而，将重症患者转运至这些ECMO中心并非毫无风险。便携式ECMO设备可在转运前在中心外场所植入。尽管努力实现决策标准化，但仍存在显著差异，尤其是在数据有限的中心外（OoC）环境中。由于死亡率持续居高不下，需要准确的适应症来优化治疗效果。本研究旨在确定与OoC VA ECMO良好治疗效果相关的关键因素，并为这些环境中的临床医生开发实用的决策工具。
我们回顾性研究了2006年至2022年期间在我院中心外场所植入VA ECMO的治疗结果。分析了VA ECMO植入前评估的参数，包括器官衰竭计数、平均动脉压（MAP）和实验室数据。收集随访数据以评估功能（东部肿瘤协作组[ECOG]功能状态）和神经学（脑功能类别评分[CPC]）结局。使用非参数方法和SHAP重要性分析进行统计分析。
在OoC接受VA ECMO植入的患者中，共有56.5%（345例患者中的195例）存活，43.8%的患者有良好的神经学结局（CPC 1）。37.6%的患者有良好的功能结局（ECOG 0-1）。MAP > 54 mmHg的患者长期功能结局更好，MAP > 64 mmHg的患者中期神经学结局更好欠佳结局与凝血活性降低和血栓形成增加有关。VA ECMO植入前的肾和多器官衰竭与不良的神经学和功能结局相关。
通过重要性分析，我们确定了与OoC VA ECMO良好结局相关的关键和次要因素。VA ECMO植入前器官衰竭的程度和严重程度对确定结局至关重要。MAP反映的血流动力学状态以及VA-ECMO植入前的器官衰竭，显著影响神经学和功能结局。血流动力学稳定性和凝血指标较好的患者存活且获得良好神经学和功能结局的机会显著提高。
