体外膜肺氧合在成人心外科术后心源性休克应用早期死亡率及临床结果危险因素分析  

Extracorporeal membrane oxygenation for refractory cardiogenic shock after cardiac surgery: risk factors of early mortality and outcome

作　　者：杜中涛[1] 杨峰[1] 江春景[1] 邢家林[1] 缪娜[1] 刘锋[1] 杨晓芳[1] 江瑜[1] 李蛟[1] 侯晓彤[1] 

机构地区：[1]首都医科大学附属北京安贞医院心脏外科危重症中心,体外循环及机械循环辅助科,北京100029

出　　处：《中国体外循环杂志》2014年第4期210-214,共5页Chinese Journal of Extracorporeal Circulation

摘　　要：目的探讨体外膜肺氧合(ECMO)对心脏手术后难治性心源性休克提供临时机械循环支持的应用效果及早期死亡率危险因素分析。方法回顾分析本院2012年1月至2012年12月期间,6 986名成人心脏术后患者中有54例(0.77%)患者因为术后心源性休克而应用静脉动脉(VA)ECMO支持。使用指证包括:心脏术后难以脱离体外循环,容量合适的情况下大剂量的血管活性药物应用和/或者应用主动脉内气囊反搏(IABP)仍难以维持血流动力学稳定。其中有11例(20%)患者因为各种原因支持时间少于24 h未纳入统计分析。结果 43例患者平均年龄为59.0岁,男性30例,女性13例。ECMO平均支持时间是5.1 d。31例(72.1%)患者成功脱离ECMO辅助。30 d及1年死亡率分别为60.5%(27/43)和69.8%(30/43)。ECMO患者院内死亡率为65.1%(28/43)。对出院患者进行门诊随访,ECMO患者1年生存率为30.2%(13/43)。Logistic回归分析发现患者应用ECMO后72 h左室射血分数(LVEF)≤30%和ECMO应用3 d内悬浮红细胞输入量是院内死亡率的重要预测因子(OR=14.76,95%CI=2.34-93.25,P=0.004;OR=0.60,95%CI=0.38-0.94,P=0.03)。结论 ECMO为心脏术后严重心源性休克患者提供了一个有效的临时心肺支持。辅助期间较低的LVEF和较多的悬浮红细胞输入量是影响死亡率的危险因素。在ECMO辅助支持期间,应该每日监测LVEF变化及悬浮红细胞的输入量。Objective Analysis of risk factors of early mortality and outcome during extracorporeal membrane oxygenation （ ECMO） support for those with refractory cardiogenic shock after cardiac surgery. Methods Between January 2012 and December 2012, 6986 patients underwent cardiac surgery in our adult cardiac critical care unit. Among those, 54 patients （0.77%） were supported with veno-arterial ECMO for cardiac support because of refractory postcardiotomy cardiogenic shock. Indications for ECMO support included：failure to wean from cardiopulmonary bypass, or refractory cardiogenic shock development despite adequate filling volumes, large-dose inotropes and/or intra-aortic balloon pump support. 11 patients （ 20%） were excluded because the support time was less than 24 hours. The short-term and medium-term results of these patients were analyzed, and in addition, the prognostic factors of survival were predicted. Results Patients＇average age was 59.0 ±12.2 years. There were 30 male and 13 female patients. Overall mean support time was 5.1±4.1 days. Thirty-one （72.1%） patients could be successfully weaned from ECMO. The 30-day and 1-year mortalities were 60.5% （27/43） and 69.8% （30/43）, respectively. The in-hospital mortality was 65.1% （28/43）. Thirteen （30.2%） patients were still alive at 1-year out-patient follow up. Stepwise logistic regression identified left-ventricular ejection fraction （ LVEF）≤30% at 72 h after ECMO initiation and number of packed red blood cells （ PRBCs） transfused during ECMO as significant predictors of mortality [ odds ratio （ OR）=14.76;95% confidence interval （ CI）=2.34-93.25;P =0.004 and OR=0.60;95% CI=0.38-0.94, P =0.03, respectively] . Conclusion ECMO provides a good temporary cardiopulmonary support in patients with postcardiotomy cardiogenic shock. The risk factor of mortality is poor LVEF after ECMO support, so the LVEF should be strictly monitored everyday during ECMO support.

关 键 词：机械循环辅助 体外生命支持 心脏外科 心源性休克 危险因素 

分 类 号：R654.2[医药卫生—外科学]