2019 年第 6 期 第 14 卷

心脏外科术后迟发性心源性休克患者行体外膜肺氧合辅助治疗的预后影响因素分析

Prognostic factors of delayed cardiogenic shock after cardiac surgery in patients undergoing extracorporeal membrane oxygenation

作者：崔永超杜中涛江春景王金宏邢智辰徐博杨峰郝星江瑜刘锋侯晓彤

英文作者：

单位：100029首都医科大学附属北京安贞医院成人心脏危重症中心北京市心肺血管疾病研究所

英文单位：

关键词：心源性休克；体外膜肺氧合；重症监护病房

英文关键词：

• 摘要：

• 【摘要】目的    探讨心脏外科术后迟发性心源性休克患者行体外膜肺氧合（ECMO）辅助的预后影响因素。方法    回顾性分析2006年1月至2016年12月在首都医科大学附属北京安贞医院行ECMO辅助的迟发性心脏外科术后心源性休克（PCCS）患者144例,根据预后分为出院存活组（52例）和住院死亡组（92例）,比较2组患者一般临床资料、合并疾病、外科手术操作情况、启动ECMO辅助时情况和ECMO辅助相关并发症发生率、血制品应用量和术后恢复情况，分析患者住院死亡的影响因素。结果    144例患者中92例（63.9%）患者成功脱机，最终52例（36.1%）患者存活出院。住院死亡组高龄（年龄≥65岁）和行瓣膜置换或成形术比例均高于出院存活组［30.4%(28/92)比15.4%（8/52）、38.0%(35/92)比19.2%（10/52）］，合并冠状动脉粥样硬化性心脏病和行冠状动脉旁路移植术比例低于出院存活组［42.4%(39/92)比59.6%（31/52）、32.6%(30/92)比50.0%（26/52）］，差异均有统计学意义（均P<0.05）。住院死亡组患者ECMO辅助期间下肢严重缺血、肾功能衰竭接受连续肾脏替代治疗、严重神经系统并发症和败血症发生率均高于出院存活组［14.1%(13/92)比0、79.3%(73/92)比15.4%（8/52）、28.3%(26/92)比3.8%（2/52）、31.5%(29/92)比15.4%（8/52）］，差异均有统计学意义（均P<0.05）。住院死亡组患者住院时间短于出院存活组［21(16,28)d比31(21,43)d］，差异有统计学意义（P<0.001）。多元Logistic回归分析结果显示肾功能衰竭需行连续肾脏替代治疗和严重神经系统并发症是成人迟发性PCCS行ECMO辅助患者住院死亡的影响因素（比值比=0.05、0.04，95%置信区间：0.01~0.22、0.01~0.28，均P<0.05）。结论    ECMO能够为成人迟发性PCCS患者提供有效循环辅助，肾功能衰竭和严重神经系统并发症为迟发性PCCS行ECMO辅助的预后影响因素，积极预防并发症可能是提高辅助效果的重要途径。

• 【Abstract】Objective    To analyze the prognostic factors of extracorporeal membrane oxygenation(ECMO) in patients with delayed post-cardiotomy cardiogenic shock(PCCS). Methods    A total of 144 adult patients with PCCS receiving ECMO in Beijing Anzhen Hospital, Capital Medical University from January 2006 to December 2016 were retrospectirely analyzed. According to the in-hospital outcomes, they were divided into survival group(n=52) and death group(n=92). Basic data, comorbidities, major surgical procedures, records of ECMO, complications, consumption of blood products and postoperative recovery were analyzed. Results    Among the 144 patients, 92 patients(63.9%) weaned from ECMO and 52 patients(36.1%) survived. Compared with survival group, the elderly（≥65 years old）, valve replacement and valvuloplasty took higher ratios in death group［30.4%(28/92) vs 15.4%（8/52）, 38.0%(35/92) vs 19.2%（10/52）］; patients with coronary heart disease and coronary artery bypass grafting took lower ratios in death group［42.4%(39/92) vs 59.6%（31/52）, 32.6%(30/92) vs 50.0%（26/52）］（all P<0.05）. Incidences of limb ischemia, renal function failure required continuous renal replacement therapy（CRRT）, severe neurological complication and sepsis in death group were higher than those in survival group［14.1%(13/92) vs 0, 79.3%(73/92) vs 15.4%（8/52）, 28.3%(26/92) vs 3.8%（2/52）, 31.5%(29/92) vs 15.4%（8/52）］（all P<0.05）. Length of hospital stay in death group was shorter than that in survival group［21(16,28)d vs 31(21,43)d， P<0.001］. Multivariate logistic regression analysis suggested that renal function failure required CRRT and severe neurological complication were risk factors of death in patients with PCCS undergoing ECMO（odds ratio=0.05, 0.04; 95% confidence interval： 0.01-0.22, 0.01-0.28, both P<0.05）. Conclusions    ECMO can provide effective circulation support for patients with PCCS. Renal failure and severe neurological complication are death factors in PCCS patients undergoing ECMO. Active prevention of complications during ECMO is an important measure to improve the clinical unit.