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[Lancet发表论文]:VA-ECMO挽救脓毒症诱发心源性休克
2020年09月04日 时讯速递, 进展交流 暂无评论

ARTICLES| VOLUME 396, ISSUE 10250, P545-552, AUGUST 22, 2020

Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study

Nicolas Bréchot, David Hajage, Antoine Kimmoun, et al

Lancet 2020; 396: 545-552

Summary

Background 背景

Patients with sepsis-induced cardiomyopathy with cardiogenic shock have a high mortality. This study assessed venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for sepsis-induced cardiogenic shock refractory to conventional treatments.

脓毒症诱发心肌病合并心源性休克患者病死率很高。本研究评估脓毒症诱发心源性休克且传统治疗无效患者采用VA-ECMO的效果。

Methods 方法

In this retrospective, multicentre, international cohort study, we compared outcomes of 82 patients (aged ≥18 years) with septic shock who received VA-ECMO at five academic ECMO centres, with 130 controls (not receiving ECMO) obtained from three large databases of septic shock. All patients had severe myocardial dysfunction (cardiac index 3 L/min per m 2 or less or left ventricular ejection fraction [LVEF] 35% or less) and severe haemodynamic compromise (inotrope score at least 75 μg/kg per min or lactic acidaemia at least 4 mmol/L) at time of inclusion. The primary endpoint was survival at 90 days. A propensity score-weighted analysis was done to control for confounders.

这是一项回顾性多中心国际队列研究,我们比较了5个ECMO中心接受VA-ECMO的82名(年龄 ≥18 岁)感染性休克患者,以及从3个感染性休克数据库中挑选的130例对照(未使用ECMO)。所有患者在入选时均有严重的心肌功能障碍(心指数 3 L/min/m 2 或以下,或左室射血分数 [LVEF] 35% 或以下)和严重的血流动力学障碍(强心药物评分至少 75 μg/kg/min 或高乳酸血症至少 4 mmol/L)。主要预后终点为90天存活率。进行倾向性评分加权分析以校正混杂因素。

Findings 结果

At baseline, patients treated with VA-ECMO had more severe myocardial dysfunction (mean cardiac index 1·5 L/min per m 2vs 2·2 L/min per m 2, LVEF 17% vs 27%), more severe haemodynamic impairment (inotrope score 279 μg/kg per min vs 145 μg/kg per min, lactataemia 8·9 mmol/L vs 6·5 mmol/L), and more severe organ failure (Sequential Organ Failure Assessment score 17 vs 13) than did controls, with p<0·0001 for each comparison. Survival at 90 days for patients treated with VA-ECMO was significantly higher than for controls (60% vs 25%, risk ratio [RR] for mortality 0·54, 95% CI [0·40–0·70]; p<0·0001). After propensity score weighting, ECMO remained associated with improved survival (51% vs 14%, adjusted RR for mortality 0·57, 95% CI [0·35–0·93]; p=0·0029). Lactate and catecholamine clearance were also significantly enhanced in patients treated with ECMO. Among the 49 survivors treated with ECMO, 32 who had been treated at the largest centre reported satisfactory Short Form-36 evaluated health-related quality of life at 1-year follow-up.

在基线水平,与对照组相比,接受VA-ECMO治疗的患者心肌功能障碍更为严重(平均心指数 1·5 L/min per m 2vs 2·2 L/min per m 2, LVEF 17% vs 27%),血流动力学障碍更明显(强心药物评分279 μg/kg/min vs 145 μg/kg/min,乳酸 8·9 mmol/L vs 6·5 mmol/L),器官功能衰竭更严重(SOFA评分17 vs 13),所有比较 p<0·0001。接受VA-ECMO治疗的患者90天生存率显著高于对照组(60% vs 25%,病死率风险比[RR] 0·54, 95% CI [0·40–0·70]; p<0·0001)。经过倾向性评分加权后,ECMO仍然与生存率改善相关(51% vs 14%,病死率校正RR 0·57, 95% CI [0·35–0·93]; p=0·0029)。接受ECMO治疗的患者乳酸清除率及儿茶酚胺清除率显著增加。接受ECMO治疗的49名存活者中,32名患者在最大的医学中心接受治疗,1年随访时根据SF-36评估的健康相关生活质量满意。

Interpretation 结论

Patients with severe sepsis-induced cardiogenic shock treated with VA-ECMO had a large and significant improvement in survival compared with controls not receiving ECMO. However, despite the careful propensity-weighted analysis, we cannot rule out unmeasured confounders.

接受VA-ECMO治疗的脓毒症诱发心源性休克患者生存率较未接受ECMO治疗的患者显著改善。然而,尽管进行了仔细的倾向性评分加权分析,但我们仍无法排除未测定混杂因素的影响。

Funding 资助

None.

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