影响静脉-静脉体外膜肺治疗重症肺炎患者预后的因素分析

何小贝; 蔡靓; 张晓程; 王凯; 康骊泉; 常平; 王华

doi:10.13201/j.issn.1009-5918.2021.11.011

影响静脉-静脉体外膜肺治疗重症肺炎患者预后的因素分析

- 1. 南方医科大学珠江医院重症医学科(广州, 510282);
- 2. 广州广钢新城医院
基金项目:
广东省科技计划项目(No:2014A020212670)

南方医科大学临床研究启动计划培育项目(No:LC2016PY036)

详细信息

通讯作者: 王华,E-mail:icuwanghua@163.com

中图分类号: R459.3

收稿日期: 2021-07-24

The factors afecting the outcome of severe pneumonia patients treated with venovenous extracorporeal membrane oxygenation

- 1 Division of Intensive Care Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China;
- 2 Guangzhou Guanggang New City Hospital

More Information

Corresponding author: WANG Hua, E-mail: icuwanghua@163.com

Received Date: 24 July 2021

摘要

摘要: 目的:分析重症肺炎患者的病例资料,探讨静脉-静脉体外膜肺氧合(VV-ECMO)治疗的影响因素。方法:采用回顾性病例分析方法。收集我院2018年5月-2020年12月期间行VV-ECMO治疗的全部58例重症肺炎患者的病历资料,按治疗结局,分为存活组和死亡组。记录并比较两组的基线资料、治疗参数和结局,分析启动时机和临床因素对预后的影响。计量资料组间比较采用t检验或非参数检验,计数资料采用χ²检验。结果:30例存活,28例死亡,病死率48.3%。病因学方面,细菌性肺炎占40(69%)例次,流感病毒性肺炎11(19%)例次,其他7(12%)例次。两组差异无统计学意义(P>0.05)。VV-ECMO启动前,存活组和死亡组机械通气的中位数时间分别为(1 vs.2) d(P<0.05);启动前6 h内,两组的PaO₂/FiO₂分别为(60.54±16.69) mmHg(1 mmHg=0.133 kPa)和(69.22±18.95) mmHg(P>0.05);启动前24 h内,两组的APACHEⅡ评分分别为(28.43±7.77)分和(33.04±7.84)分(P<0.05)。统计显示,存活组从发病到ECMO启动的中位数时间显著低于死亡组,分别为(2 vs.5.5) d(P<0.05)。VV-ECMO治疗期间,两组的平均液体入量分别为(2118.53.0±386.04)和(2642.50±1251.02) mL/d,液体净平衡分别为(-802.20±530.08)和(265.94±2055.66) mL/d(均P<0.05)。存活组的血浆白蛋白水平、血红蛋白浓度、血小板计数,以及右美托咪定和舒芬太尼用量均高于死亡组(P<0.05)。预后方面,存活组和死亡组入住重症监护室(ICU)天数、住院天数均差异有统计学意义(P<0.05),但住院总费用差异无统计学意义(P>0.05)。结论:VV-ECMO启动指征除了参考前期的机械通气时间和氧合指数外,病程和疾病严重程度对预后也有显著性影响。准确把握启动时机有望进一步降低重症肺炎患者的病死率。优化液体管理、合理镇痛镇静、维持正常的血浆白蛋白和血红蛋白浓度可提高治疗的效果。
- 重症肺炎 /
- 体外膜肺 /
- 回顾性分析
Abstract: Objective:To explore the factors of venoveneous extracorporeal membrane oxygenation(VV-ECMO) therapy in patients with severe pneumonia.Methods:Medical records were reviewed retrospectively in 58 patients with severe pneumonia caused by a variety of etiologies who were treated with VV-ECMO in a tertiary teaching hospital from May 2018 to December2020. Patients were designated into survivor or non-survivor group according to their outcomes. Data of the demographic characteristics, clinical parameters and outcomes were collected and analyzed. Comparison of difference for quanlitative data was performed by using the Student t test or nonparametric test, and categorical data by the Chi-square test. P<0.05 was defined as statistical significance.Results:Thirty patients were survival and 28 died(48.3%). Forty-two cases were confirmed with bacterial pneumonia and 12 influenza viral lung infection, and no significant difference was found in etiological spectrum between the two groups(P>0.05). Prior to VV-ECMO, the median days were 1 day and 2 days from mechanical ventilation to ECMO initiation in the survivor and non-survior groups(P<0.05), respectively. Within 6 and 24 hours to VV-ECMO, the PaO₂/FiO₂were 60.54±16.69) and(69.22±18.95) mmHg(P>0.05) and the APACHE Ⅱ scores were(28.43±7.77) and(33.04±7.84) points in the two groups(P<0.05), respectively. Moreover, data shown that the median days were 2 days and 5.5 days from attack of disease to VV-ECMO onset in the two groups(P<0.05), and the optimal timing of point was 4 days for VV-ECMO initiation, with more cumulative survival cases. During the period of VV-ECMO therapy, the averaged amount of fluid infusion was 2119 mL/d and 2643 mL/d, and the net fluid balance was-802.2 mL/d and 265.9 mL/d in the survivor and non-survivor groups, respectively(P<0.05). The blood platelet count, hemoglobin and plasma protein concentrations were higher, and the total dosages of sufentanil and dexmedetomidine were larger in the survivor group than in the non-survivor group(P<0.05). Finally, the time spent on VV-ECMO and on ventilator, length of ICU and hospital stay shown indifference between the two groups(P>0.05), but there was no significant difference in the total medical expenses(P>0.05).Conclusion:The indications for VV-ECMO initiation for rescue of patient with severe pneumonia might not only focus on the duration of mechanical ventilation and oxygenation index prior to VV-ECMO, but take into account of the degree of severity and course of the primary illness, prompt initiation of VV-ECMO might have mortality benefit. Optimal fluid management, prudent use of analgesics or sedatives, maintaining normal plasma hemoglobin and albumin levels during VV-ECMO might improve patient outcome.
- severe pneumonia /
- extracorporeal membrane oxygenation /
- Retrospective study

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参考文献(36)

[1]	Kalil AC,Metersky ML,Klompas M,et al.Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia:2016 Clinical Practice Guidelines by the Infectious Diseases Society of A-merica and the American Thoracic Society[J].Clin Infect Dis,2016,63(5):e61-e111.
[2]	Mandell LA,Wunderink RG,Anzueto A,et al.Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults[J].Clin Infect Dis,2007,44(Suppl 2):S27-72.
[3]	Combes A,Bacchetta M,Brodie D,et al.Extracorporeal membrane oxygenation for respiratory failure in adults[J].Curr Opin Crit Care,2012,18:99-104.
[4]	MacLaren G,Combes A,Bartlett RH.Contemporary extracorporeal membrane oxygenation for adult respiratory failure:life support in the new era[J].Intensive Care Med,2012,38(2):210-220.
[5]	Marasco SF,Lukas G,McDonald M,et al.Review of ECMO(extra corporeal membrane oxygenation)support in critically ill adult patients[J].Heart Lung Circ,2008,17Suppl 4:S41-47.
[6]	Combes A,Pesenti A,Ranieri VM.Fifty Years of Research in ARDS.Is Extracorporeal Circulation the Future of Acute Respiratory Distress Syndrome Management?[J].Am J Respir Crit Care Med,2017,195(9):1161-1170.
[7]	张华东,潘楚云,江意春,等.体外膜肺抢救危重症合并严重心肺功能衰竭的Meta分析[J].临床急诊杂志,2020,21(4):292-295.
[8]	Munshi L,Telesnicki T,Walkey A,et al.Extracorporeal life support for acute respiratory failure.A systematic review and metaanalysis[J].Ann Am Thorac Soc,2014,11(5):802-810.
[9]	中华医学会呼吸病学分会.中国成人社区获得性肺炎诊断和治疗指南(2016年版)[J].中华结核和呼吸杂志,2016,39(4):253-279.
[10]	中华医学会呼吸病学分会感染学组.中国成人医院获得性肺炎与呼吸机相关性肺炎诊断和治疗指南(2018年版)[J].中华结核和呼吸杂志,2018,41(4):255-280.
[11]	Peek GJ,Mugford M,Tiruvoipati R,et al.Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure(CESAR):a multicentre randomised controlled trial[J].Lancet,2009,374(9698):1351-1363.
[12]	ANZIC Influenza Investigators,Webb SA,PettiläV,et al.Critical care services and 2009 H1N1 influenza in Australia and New Zealand[J].N Engl J Med,2009,361(20):1925-1934.
[13]	Combes A,Pellegrino V.Extracorporeal membrane oxygenation for 2009influenza A(H1N1)-associated acute respiratory distress syndrome[J].Semin Respir Crit Care Med,2011,32(2):188-194.
[14]	Patroniti N,Zangrillo A,Pappalardo F,et al.The Italian ECMO network experience during the 2009influenza A(H1N1)pandemic:preparation for severe respiratory emergency outbreaks[J].Intensive Care Med,2011,37(9):1447-1457.
[15]	Pham T,Combes A,RozéH,et al.Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome:a cohort study and propensity-matched analysis[J].Am J Respir Crit Care Med,2013,187(3):276-285.
[16]	唐晓,蒲琳,张佳莹,等.体外膜肺氧合治疗危重症新型冠状病毒肺炎和新型甲型H1N1流感病毒性肺炎临床特征和预后比较[J].中华医学杂志,2021,101(8):579-585.
[17]	孙兵.体外膜肺氧合在治疗新型冠状病毒肺炎中的应用[J].中华医学杂志,2021,101(8):605-605.
[18]	汪璐芸,陈铿铨,陈鹏,等.体外膜肺氧合在救治新型冠状病毒肺炎相关严重急性呼吸窘迫综合征中的应用及预后分析[J].内科急危重症杂志,2020,26(6):458-463.
[19]	Kurniawati ER,Weerwind PW.Extracorporeal Life Support in Adult Patients:A Global Perspective of the Last Decade[J].Dimens Crit Care Nurs,2019,38(3):123-130.
[20]	Combes A,Hajage D,Capellier G,et al.Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome[J].N Engl J Med,2018,378(21):1965-1975.
[21]	Hilder M,Herbstreit F,Adamzik M,et al.Comparison of mortality prediction models in acute respiratory distress syndrome undergoing extracorporeal membrane oxygenation and development of a novel prediction score:the PREdiction of Survival on ECMOTherapy-Score(PRESET-Score)[J].Crit Care,2017,21(1):301.
[22]	Fan E,Gattinoni L,Combes A,et al.Venovenous extracorporeal membrane oxygenation for acute respiratory failure:A clinical review from an international group of experts[J].Intensive Care Med,2016,42(5):712-724.
[23]	Zapol WM,Snider MT,Hill JD,et al.Extracorporeal membrane oxygenation in severe acute respiratory failure.A randomized prospective study[J].JAMA,1979,242(20):2193-216.
[24]	Goligher EC,Tomlinson G,Hajage D,et al.Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Clinical Trial[J].JAMA,2018,320(21):2251-2259.
[25]	Kanji HD,McCallum J,Norena M,et al.Early venovenous extracorporeal membrane oxygenation is associated with lower mortality in patients who have severe hypoxemic respiratory failure:A retrospective multicenter cohort study[J].J Crit Care,2016,33:169-173.
[26]	Tillmann BW,Klingel ML,Iansavichene AE,et al.Extracorporeal membrane oxygenation(ECMO)as a treatment strategy for severe acute respiratory distress syndrome(ARDS)in the low tidal volume era:Asystematic review[J].J Crit Care,2017,41:64-71.
[27]	Kelly RE Jr,Phillips JD,Foglia RP,et al.Pulmonary edema and fluid mobilization as determinants of the duration of ECMO support[J].J Pediatr Surg,1991,26(9):1016-1022.
[28]	Schmidt M,Bailey M,Kelly J,et al.Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation[J].Intensive Care Med,2014,40(9):1256-1266.
[29]	赵千文,李秋红,谢玉萍.限制性液体负平衡治疗急性呼吸窘迫综合征患者的效果观察[J].临床急诊杂志,2020,21(9):707-710.
[30]	Devlin JW,Skrobik Y,Gélinas C,et al.Executive Summary:Clinical Practice Guidelines for the Prevention and Management of Pain,Agitation/Sedation,Delirium,Immobility,and Sleep Disruption in Adult Patients in the ICU[J].Crit Care Med,2018,46(9):1532-1548.
[31]	Schmidt M,Bailey M,Sheldrake J,et al.Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure.The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction(RESP)score[J].Am J Respir Crit Care Med,2014,189(11):1374-1382.
[32]	Enger T,Philipp A,Videm V,et al.Prediction of mortality in adult patients with severe acute lung failure receiving veno-venous extracorporeal membrane oxygenation:aprospective observational study[J].Crit Care,2014,18(2):R67.
[33]	Barbaro RP,Odetola FO,Kidwell KM,et al.Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality.Analysis of the extracorporeal life support organization registry[J].Am J Respir Crit Care Med,2015,191(8):894-901.
[34]	Noah MA,Peek GJ,Finney SJ,et al.Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009influenza A(H1N1)[J].JAMA,2011,306(15):1659-1668.
[35]	Huang L,Li T,Xu L,et al.Extracorporeal Membrane Oxygenation Outcomes in Acute Respiratory Distress Treatment:Case Study in a Chinese Referral Center[J].Med Sci Monit,2017,23:741-750.
[36]	Muñoz J,Santa-Teresa P,Tomey MJ,et al.Extracorporeal membrane oxygenation(ECMO)in adults with acute respiratory distress syndrome(ARDS):A 6-year experience and case-control study[J].Heart Lung,2017,46(2):100-105.