心源性休克患者动脉-静脉体外膜肺氧合撤机后预后不良影响因素分析  

Influencing factors of poor prognosis in patients with cardiogenic shock after weaning from veno-arterial extracorporeal membrane oxygenation

作　　者：孟凡伟 李建朝 钱晓亮 刘礼平 屈永生 肖文涛 叶发民 郭素萍 张静 杨雷一 程兆云 MENG Fan-wei;LI Jian-chao;QIAN Xiao-liang;LIU Li-ping;QU Yong-sheng;XIAO Wen-tao;YE Fa-min;GU Su-ping;ZHANG Jing;YANG Lei-yi;CHENG Zhao-yun(Heart Centre,Henan Provincial People's Hospital,Fuwai Central China Cardiovascular Hospital,Zhengzhou,Henan 450003,China)

机构地区：[1]阜外华中心血管病医院河南省人民医院心脏中心,河南郑州450003

出　　处：《中华实用诊断与治疗杂志》2022年第10期985-988,共4页Journal of Chinese Practical Diagnosis and Therapy

基　　金：河南省医学科技攻关计划省部共建重大项目(SBGJ202101005)。

摘　　要：目的探讨心源性休克患者动脉-静脉体外膜肺氧合(veno-arterial extracorporeal membrane oxygenation,VA-ECMO)撤机后28d内死亡的影响因素。方法160例心源性休克患者均行VA-ECMO治疗,根据撤机后28d内生存情况分为死亡组84例和生存组76例,比较2组应用体外心肺复苏、主动脉内球囊反搏、连续性肾脏替代治疗比率及血肌酐、血乳酸、24h液体出入量等;采用多因素Cox回归分析心源性休克患者VA-ECMO撤机后28d内死亡的影响因素;绘制ROC曲线,评估血乳酸、24h液体出入量预测心源性休克患者VA-ECMO撤机后28d内死亡的效能。结果死亡组应用体外心肺复苏(26.2%)、主动脉内球囊反搏(71.4%)、连续性肾脏替代治疗(52.4%)比率及血肌酐[137.5(95.0,215.0)mmol/L]、血乳酸[6.1(2.9,10.8)mmol/L]、24h液体出入量[82.9(-681.0,810.0)mL]均高于生存组[6.6%、55.3%、19.7%、88.5(67.0,141.0)mmol/L、3.0(1.8,4.2)mmol/L、-822.0(-1130.0~10.0)mL](P<0.05),清醒比率(29.8%)低于生存组(51.3%)(χ2=7.723,P=0.005)。24h液体出入量(HR=6.983,95%CI:1.553~31.391,P=0.011)、连续性肾脏替代治疗(HR=2.349,95%CI:1.009~5.471,P=0.048)、血乳酸(HR=1.175,95%CI:1.054~1.309,P=0.004)是心源性休克患者VA-ECMO撤机后28d内死亡的影响因素。血乳酸、24h液体出入量分别以5.2mmol/L、22.25mL为最佳截断值,预测心源性休克患者VA-ECMO撤机后28d内死亡的AUC分别为0.741(95%CI:0.665~0.817,P<0.001)、0.687(95%CI:0.605~0.768,P<0.001),灵敏度分别为54.8%、52.4%,特异度分别为85.5%、81.6%。结论应用连续性肾脏替代治疗、高血乳酸水平、24h液体出入量增加的心源性休克患者VA-ECMO撤机后28d内死亡风险增大,血乳酸、24h液体出入量预测心源性休克患者VA-ECMO撤机后28d内死亡有一定价值。Objective To investigate the influencing factors of 28-d mortality in patients with cardiogenic shock after weaning from veno-arterial extracorporeal membrane oxygenation(VA-ECMO).Methods Totally 160patients with cardiogenic shock received VA-ECMO,and were divided into death group(n=84)and survival group(n=76)according to 28-d survival after weaning from VA-ECMO.The percentages of patients receiving cardiopulmonary resuscitation(CPR),intra-aortic balloon counter pulsation(IABP)and continuous renal replacement therapy(CRRT),the levels of serum creatinine and blood lactic acid,and 24-h fluid intake and output volume were compared between two groups.Multivariate Cox regression was used to analyze the influencing factors of 28-d mortality in patients with cardiogenic shock after weaning from VA-ECMO.ROC curve was drawn to evaluate the efficiencies of blood lactic acid and 24-h fluid intake and output volume on predicting the 28-d mortality in patients with cardiogenic shock after weaning from VA-ECMO.Results The percentages of patients receiving CPR,IABP and CRRT,the levels of blood creatinine and blood lactic acid and 24-h fluid intake and output volume were higher in death group[26.2%,71.4%,52.4%,137.5(95.0,215.0)mmol/L,6.1(2.9,10.8)mmol/L,82.9(-681.0,810.0)mL]than those in survival group[6.6%,55.3%,19.7%,88.5(67.0,141.0)mmol/L,3.0(1.8,4.2)mmol/L,-822.0(-1130.0-10.0)mL](P<0.05),and the awake rate was lower in death group(29.8%)than that in survival group(51.3%)(χ2=7.723,P=0.005).The 24-h fluid intake and output volume(HR=6.983,95%CI:1.553-31.391,P=0.011),CRRT(HR=2.349,95%CI:1.009-5.471,P=0.048),and blood lactic acid level(HR=1.175,95%CI:1.054-1.309,P=0.004)were the influencing factors of 28-d mortality in patients with cardiogenic shock after weaning from VA-ECMO.When the optimal cut-off values of blood lactic acid and 24-h liquid intake and output volume were 5.2mmol/L and 22.25mL,the AUCs for predicting 28-d mortality in patients with cardiogenic shock after weaning from VA-ECMO were 0.741(95%CI:0.665-0.817,P<0.

关 键 词：心源性休克 体外膜肺氧合 连续性肾脏替代治疗 乳酸 24h液体出入量 

分 类 号：R541.64[医药卫生—心血管疾病]