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中华危重症医学杂志(电子版) ›› 2022, Vol. 15 ›› Issue (01) : 28 -35. doi: 10.3877/cma.j.issn.1674-6880.2022.01.006

论著

体外膜肺氧合对心脏骤停患者神经功能预后的影响
金光勇1, 周梦露2, 刁孟元1, 席绍松1, 曾小康1, 顾乔1, 朱英1, 胡炜1,†()   
  1. 1. 310006　杭州，浙江大学医学院附属杭州市第一人民医院重症医学科
    2. 310015　杭州，杭州师范大学附属医院神经内科
  • 收稿日期:2021-07-28 出版日期:2022-02-28
  • 通信作者: 胡炜
  • 基金资助:
    浙江省医药卫生科技计划项目(2019KY481); 杭州市医学重点学科建设基金项目(OO20200485)

Effect of extracorporeal membrane oxygenation on the prognosis of neurological function in patients with cardiac arrest

Guangyong Jin1, Menglu Zhou2, Mengyuan Diao1, Shaosong Xi1, Xiaokang Zeng1, Qiao Gu1, Ying Zhu1, Wei Hu1,†()   

  1. 1. Department of Intensive Care Unit, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
    2. Department of Neurology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou 310015, China
  • Received:2021-07-28 Published:2022-02-28
  • Corresponding author: Wei Hu
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引用本文：

金光勇, 周梦露, 刁孟元, 席绍松, 曾小康, 顾乔, 朱英, 胡炜. 体外膜肺氧合对心脏骤停患者神经功能预后的影响[J]. 中华危重症医学杂志(电子版), 2022, 15(01): 28-35.

Guangyong Jin, Menglu Zhou, Mengyuan Diao, Shaosong Xi, Xiaokang Zeng, Qiao Gu, Ying Zhu, Wei Hu. Effect of extracorporeal membrane oxygenation on the prognosis of neurological function in patients with cardiac arrest[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2022, 15(01): 28-35.

目的

探讨体外膜肺氧合（ECMO）对心脏骤停患者神经功能预后的影响因素。

方法

纳入2012年1月至2020年6月因心脏骤停入住浙江大学医学院附属杭州市第一人民医院重症医学科且行ECMO治疗的22例患者。以脑功能分类（CPC）量表评价患者出院时神经功能情况，并将其分为CPC良好组（12例，CPC 1 ~ 2分）和CPC不佳组（10例，CPC 3 ~ 5分）。比较两组患者的一般资料、心脏骤停病因、基础疾病、疾病严重程度、心脏骤停相关情况、神经系统相关情况、ECMO相关情况及肌钙蛋白I、白蛋白等生化指标。采用二分类Logistic回归分析ECMO治疗心脏骤停患者对其神经功能预后的影响因素。

结果

22例接受ECMO治疗的心脏骤停患者中，14例存活出院且12例神经功能良好。CPC不佳组患者肌钙蛋白I[47.0（26.8，80.0）μg/L vs. 13.6（3.3，32.6）μg/L，U = 20.000，P = 0.017]水平较CPC良好组显著升高，白蛋白[（27 ± 7）g/L vs.（33 ± 6）g/L，t = 2.485，P = 0.022]水平较CPC良好组显著降低。此外，CPC不佳组患者第3天ECMO流量[（3.6 ± 0.8）L/min vs.（3.0 ± 0.7）L/min，t = 2.091，P = 0.050]高于CPC良好组，但两组比较差异无统计学意义。Logistic回归分析结果显示，较低的白蛋白浓度[优势比（OR）= 0.755，95%置信区间（CI）（0.576，0.990），P = 0.042]是ECMO治疗心脏骤停患者神经功能预后不佳的独立危险因素。

结论

较低的白蛋白浓度是ECMO治疗的心脏骤停患者神经功能预后不佳的独立危险因素。

关键词: 心脏骤停, 体外膜肺氧合, 白蛋白
Objective

To explore the influencing factors of extracorporeal membrane oxygenation (ECMO) on the prognosis of neurological function in patients with cardiac arrest (CA).

Methods

A total of 22 patients with CA who were treated with ECMO in the Department of Intensive Care Unit, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine from January 2012 to June 2020 were included. After evaluating the cerebral performance category (CPC) scale at discharge, we divided the participants into two groups: 12 cases in the good CPC group (CPC 1-2) and 10 cases in the poor CPC group (CPC 3-5). The general information, causes of CA, underlying diseases, disease severity, CA related conditions, nervous system related conditions, ECMO related conditions, troponin I, albumin and other biochemical indicators were compared between the two groups. Then with binary Logistic regression analysis, we assessed the possible influencing factors of ECMO on the prognosis of neurological function in participants.

Results

Of the 22 CA patients treated with ECMO, 14 were alive at discharge and among them 12 were alive with good neurological function. The poor CPC group has a significantly higher level of troponin I [47.0 (26.8, 80.0) μg/L vs. 13.6 (3.3, 32.6) μg/L, U = 20.000, P = 0.017], and a lower level of albumin [(27 ± 7) g/L vs. (33 ± 6) g/L, t = 2.485, P = 0.022] comparing with the good CPC group. Though the flow rate on the third day of ECMO was higher in the poor CPC group, there was no statistically significant difference between two groups [(3.6 ± 0.8) L/min vs. (3.0 ± 0.7) L/min, t = 2.091, P = 0.050]. In addition, the Logistic regression analysis showed that lower albumin concentration was an independent risk factor for poor neurological prognosis in patients with CA after ECMO treatment [odds ratio (OR) = 0.755, 95% confidence interval (CI) (0.576, 0.990), P = 0.042].

Conclusion

In present study, we found lower albumin concentration was an independent risk factor for poor neurological prognosis in patients with CA after ECMO treatment.

Key words: Cardiac arrest, Extracorporeal membrane oxygenation, Albumin
表1 两组心脏骤停患者一般资料比较（ ± s）
组别 例数 年龄[岁，M（P25，P75）] 性别（例，男/女） 心脏骤停病因（例） 基础情况（例） 病情严重程度（分）
急性心肌梗死 爆发性心肌炎 其他病因 高血压 糖尿病 CHD 慢性肾病 抽烟 APACHE Ⅱ评分 SOFA评分
CPC良好组 12 37.5（27.0，40.0） 5/7 5 6 1 3 2 1 0 1 21 ± 10 11.5 ± 2.5
CPC不佳组 10 62.5（28.0，67.8） 7/3 7 3 0 5 2 2 1 1 25 ± 10 13.8 ± 5.0
t/χ2/U值   45.000 - 2.169 - - - - - 0.829 1.390
P值   0.339 0.231 0.338 0.378 1.000 0.571 0.455 1.000 0.417 0.180
表2 两组心脏骤停患者临床资料比较[M（P25，P75）]
组别 例数 心脏骤停相关情况（例） 神经系统相关情况（例）
发生在医院内 发生在医院外 旁观者心肺复苏 可电击心律 ECMO前ROSC ROSC后再次心脏骤停 0 h意识-昏迷 72 h意识-昏迷 0 h瞳孔直径（mm） 72 h瞳孔直径（mm）
CPC良好组 12 11 1 12 11 9 11 9 5 2.5（1.6，4.8） 2.0（1.5，2.0）
CPC不佳组 10 8 2 7 9 8 6 8 7 2.3（1.4，3.9） 2.0（1.4，2.9）
t/χ2/U值   - - - - - - - 50.000 56.000
P值   0.571 0.078 1.000 1.000 0.135 1.000 0.231 0.525 0.811
组别 例数 ECMO相关情况
建立ECMO耗时（min） ECMO后体温（℃） ECMO后脉搏（次/min） ECMO后呼吸频率（次/min） ECMO后平均动脉压（mmHg） 初始流量（L/min） 第1天流量（L/min） 第2天流量（L/min） 第3天流量（L/min） ECMO运行时间（d）
CPC良好组 12 55.0（42.5，69.8） 36.1（35.6，36.6） 83 ± 34 15.0（15.0，16.0） 94.5（69.0，99.8） 3.4 ± 0.8 3.3（3.0，3.8） 3.4 ± 0.8 3.0 ± 0.7 6.0（5.0，8.0）
CPC不佳组 10 49.0（43.8，71.5） 36.0（35.7，36.8） 110 ± 58 15.0（12.8，16.0） 85.5（70.8，100.0） 3.5 ± 0.8 3.2（3.0，3.7） 3.6 ± 0.9 3.6 ± 0.8 7.0（5.8，11.8）
t/χ2/U值   56.500 56.500 1.296 54.500 56.500 0.203 55.500 0.629 2.091 41.000
P值   0.843 0.842 0.218 0.731 0.843 0.840 0.792 0.536 0.050 0.217
组别 例数 并发症情况（例） 其他相关情况 检验指标
腹腔/消化道出血 下肢缺血 脓毒症 使用CRRT（例） 使用IABP（例） 有创机械通气时间（d） 使用去甲肾上腺素（例） pH值 乳酸（mmol/L） 24 h乳酸清除率（%）
CPC良好组 12 1 0 0 8 5 9±6 9 7.34（7.22，7.50） 9 ± 6 59 ± 28
CPC不佳组 10 3 3 2 9 6 14 ± 6 7 7.41（7.29，7.45） 8 ± 6 38 ± 43
t/χ2/U值   - - - - - 2.041 - 57.000 0.294 1.390
P值   0.293 0.078 0.195 0.323 0.670 0.054 1.000 0.869 0.772 0.180
组别 例数 检验指标
肌钙蛋白I（μg/L） 总胆红素（μmol/L） 肌酐（μmol/L） 白蛋白（g/L） 血糖（mmol/L） 血钠（mmol/L） 白细胞计数（× 109/L） 血红蛋白（g/L） 血小板计数（× 109/L） 凝血酶原时间（s）
CPC良好组 12 13.6（3.3，32.6） 18.8（13.2，33.0） 117.5（107.0，169.8） 33 ± 6 13.4（8.3，14.6） 144 ± 6 17 ± 6 109 ± 24 176±87 16.4（15.2，21.7）
CPC不佳组 10 47.0（26.8，80.0） 17.8（11.9，26.7） 112.5（102.3，193.3） 27 ± 7 12.4（10.6，16.1） 146 ± 5 15 ± 6 106 ± 28 169±91 24.9（14.6，41.3）
t/χ2/U值   20.000 55.000 58.000 2.485 59.000 0.738 0.756 0.187 0.171 37.000
P值   0.017 0.767 0.921 0.022 0.974 0.469 0.459 0.854 0.865 0.138
表3 影响ECMO治疗心脏骤停患者神经功能预后的Logistic回归分析
变量 回归系数 标准误 Wald值 P值 OR值 95%CI
肌钙蛋白I（μg/L） 0.005 0.012 0.149 0.700 1.005 0.982 ~ 1.028
白蛋白（g/L） -0.281 0.138 4.132 0.042 0.755 0.576 ~ 0.990
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