To investigate the risk factors of bleeding complications during peripherally inserted extracorporeal membrane oxygenation support in adults
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摘要: 目的 探讨成人外周置管体外膜肺氧合(extracorporeal membrane oxygenation，ECMO)运行期间出血的危险因素。方法 收集2017年9月—2022年9月就诊于首都医科大学附属北京潞河医院急诊重症监护病房的50例心肺功能衰竭需ECMO支持的患者，其中10例48 h内死亡被排除在外，40例纳入本研究，根据有无出血分为两组，分析两组患者一般临床资料，出血前24 h内凝血等指标。结果 40例患者中，出血组16例(40%)，无明显出血组24例，两组患者在年龄、性别、ECMO适应证、ECMO类型差异无统计学意义，ECMO前APACHEⅡ评分差异有统计学意义(P=0.026)，两组患者ICU死亡率差异有统计学意义(P=0.038)，ECMO启动后到出血中位时间约67 h，收集出血前24 h内凝血最差指标，出血前24 h纤维蛋白原(pre-fibrinogen，pre-FIB)差异有统计学意义(P=0.039)，经logistic多因素回归分析排除混杂因素后，pre-FIB(P=0.039)是出血的独立预测因子(OR=0.655)，pre-FIB预测ECMO期间出血的ROC曲线下面积为0.747(95%CI：0.581~0.914)，最佳诊断阈值2.92 ng/mL，灵敏度87.5%，特异度68.7%。结论 成人ECMO支持期间，纤维蛋白原的持续下降预示患者出血风险增加。Abstract: Objective Exploring the risk factors for bleeding during adult peripheral veno-venous extracorporeal membrane oxygenation (ECMO) support.Methods A retrospective analysis was conducted on 50 patients with cardiopulmonary failure requiring ECMO support in the Emergency Intensive Care Unit of Peking University Affiliated Beijing Luhe Hospital from September 2017 to September 2022. Ten patients who died within 48 hours were excluded, leaving 40 patients included in this study. Patients were divided into two groups based on the presence or absence of bleeding, and general clinical data and coagulation indicators within 24 hours before bleeding were analyzed.Results Forty patients were included in this study, with 16 cases (40%) in the bleeding group and 24 cases in the non-bleeding group. There were no statistically significant differences between the two groups in terms of age, gender, indications for ECMO, or ECMO type. However, there was a statistically significant difference in pre-ECMO APACHE Ⅱ scores between the two groups (P=0.026), and the ICU mortality was also significantly different(P=0.038). There was a statistically significant difference in pre-fibrinogen (pre-FIB) levels within 24 hours before bleeding (P=0.039). Logistic multivariate regression analysis, after adjusting for confounding factors, identified pre-FIB (P=0.039) as an independent predictor of bleeding, with an OR value of 0.655. The area under the ROC curve for pre-FIB predicting bleeding during ECMO was 0.747 (95%CI: 0.581-0.914), with the optimal diagnostic threshold at 2.92 ng/mL sensitivity of 87.5%, and specificity of 68.7%.Conclusion A sustained decrease in fibrinogen levels during adult ECMO support indicates an increased risk of bleeding in patients.
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表 1 有出血并发症与无出血并发症患者基本资料比较
项目 总数(40例) 出血组(16例) 无出血组(24例) P 年龄/岁 55±15 54±15 55±15 0.729 APACHEⅡ评分/分 32.7±2.1 39.1±15.9 28.5±8.9 0.026 ECMO适应证/例 心源性 27 13 14 肺源性 13 3 10 ECPR/例 9 6 3 ECMO类型/例 0.130 VA 27 13 14 VV 13 3 10 结局 ECMO支持时间/d 8.67(4.00，11.00) 8.80(4.00，11.00) 8.58(4.25，11.75) 0.598 ECMO撤机率/% 20(50) 5 15 0.053 ICU死亡/例(%) 22(55) 12 10 0.038 
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表 2 有出血并发症与无出血并发症患者出血前凝血指标比较
指标 出血组(16例) 无出血组(24例) P FIB/(g/L) 3.02(1.74，4.30) 4.47(3.20，6.24) 0.039 D-D/(μg/mL) 12.48(0.70，16.35) 2.44(0.65，2.74) 0.058 PLT/(×109/L) 183.31± 85.77 179.38±82.28 0.885 APTT/s 65.01(31.10，95.87) 55.26(28.40，46.73) 0.233 PT/s 15.77(12.25，19.05) 15.34(12.20，16.95) 0.613
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