体外膜肺氧合治疗期间出血和血栓事件的危险因素分析  

Risk factors for bleeding and thrombotic events in critically ill patients undergoing extracorporeal membrane oxygenation

作　　者：周利平[1] 黄国庆[1] 李湘民[1] 杨宁[1] 伍平[1] 佘长寿 胡珊珊 徐吉[1] 李小刚[1] 莫晓叶[1] Zhou Liping;Huang Guoqing;Li Xiangmin;Yang Ning;Wu Ping;She Changshou;Hu Shanshan;Xu Ji;Li Xiaogang;Mo Xiaoye(Department of Emergency,Xiangya Hospital,Central South University,Changsha 410008,China)

机构地区：[1]中南大学湘雅医院急诊科,长沙410008

出　　处：《中华急诊医学杂志》2023年第9期1226-1234,共9页Chinese Journal of Emergency Medicine

基　　金：湖南省科技创新计划项目资助(2020SK53707)。

摘　　要：目的分析急危重症患者接受体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)治疗期间发生出血和血栓的危险因素,探讨预测出凝血相关并发症的更优方案。方法回顾性分析2020年1月至2022年12月中南大学湘雅医院收治的ECMO治疗患者,结局定义为ECMO置入后24 h至撤机前是否发生出血或血栓。比较各组患者的人口学特征、预后、血常规、脏器和凝血功能、血液制品输注的差异,采用Logistic回归评估ECMO转机期间出血和血栓的危险因素,ROC曲线分析上述危险因素预测出凝血并发症的能力。结果共纳入61例ECMO患者,ECMO期间发生出血21例,血栓14例。与未出血组相比,出血组患者的活化部分凝血活酶时间、凝血酶时间、冰冻血浆和浓缩红细胞输注量较高,差异具有统计学意义(均P<0.05)。与无血栓组相比,血栓组患者的体重、D二聚体、纤维蛋白原降解产物上机24 h内动脉氧分压上升幅度(ΔPO2)均较高,差异具有统计学意义(均P<0.05)。Logistic回归分析显示,凝血酶时间(OR=1.039,95%CI:1.006~1.072,P=0.018)和冰冻血浆输注量(OR=1.046,95%CI:1.010~1.083,P=0.012)是出血的危险因素,纤维蛋白原降解产物(OR=1.030,95%CI:1.009~1.051,P=0.005)、D二聚体(OR=1.181,95%CI:1.044~1.336,P=0.008)和ΔPO2(OR=1.007,95%CI:1.002~1.012,P=0.006)是血栓形成的危险因素。ROC曲线分析显示,凝血酶时间、冰冻血浆输注量以及联合两项指标预测出血的AUC分别为0.712、0.690和0.816,该联合指标的截断值为0.273,敏感度为75.61%,特异度为80.00%;纤维蛋白原降解产物、D二聚体、ΔPO2以及FDP和ΔPO2的联合指标预测血栓的AUC分别为0.778、0.748、0.786和0.868,该联合指标的截断值为0.157,敏感度和特异度分别为68.09%和92.86%。结论急危重症患者在ECMO期间,凝血酶时间联合冰冻血浆输注量预测出血发生最优,而FDP联合ΔPO2预测血栓发生更优。Objective To investigate the risk factors for bleeding and thrombosis during extracorporeal membrane oxygenation(ECMO)therapy in critically ill patients and determine the best predictors of coagulation-related complications.Methods A retrospective analysis was performed on patients who received ECMO for respiratory or circulatory failure at Xiangya Hospital of Central South University from January 2020 to December 2022.The outcome was whether bleeding or thrombosis occurred from 24 h after ECMO insertion to before weaning.The differences in demographic characteristics,weaning conditions,prognosis,routine blood tests,organ function,coagulation and blood product transfusion of each group were compared.Logistic regression analysis was used to evaluate the risk factors for bleeding and thrombosis,and ROC curve evaluation was used to assess their capacity to predict complications.Results A total of 61 patients with ECMO were enrolled,with 21 cases of bleeding and 14 cases of thrombosis during ECMO.Compared with the nonbleeding group,the activated partial thromboplastin time,thromboplastin time(TT),and transfusions of frozen plasma and red blood cells were higher in the bleeding group(all P<0.05).Compared with the nonthrombotic group,the increase in body weight,D-dimer(DD),fibrinogen degradation product(FDP),and improvement of arterial oxygen partial pressure(ΔPO2)within 24 h were significantly higher in the thrombotic group(all P<0.05).Logistic regression analysis revealed that TT(OR=1.039,95%CI:1.006~1.072,P=0.018)and frozen plasma transfusion volume(OR=1.046,95%CI:1.010-1.083,P=0.012)were risk factors for bleeding events.FDP(OR=1.030,95%CI:1.009-1.051,P=0.005),DD(OR=1.181,95%CI:1.044-1.336,P=0.008),andΔPO2(OR=1.007,95%CI:1.002-1.012,P=0.006)were risk factors for thrombosis.According to ROC curve analysis,the AUCs of TT,frozen plasma transfusion,and combined indexes for predicting bleeding were 0.712,0.690,and 0.816,respectively.The combined indices had a cut-off value of 0.273,a sensitivity of 75.61%,and a specifi

关 键 词：体外膜肺氧合 并发症 出血 血栓 凝血酶时间 动脉氧分压 

分 类 号：R459.7[医药卫生—急诊医学]