Timing of Initiation of Extracorporeal Membrane Oxygenation Support and Outcomes Among Patients With Cardiogenic Shock.
Timing of Initiation of Extracorporeal Membrane Oxygenation Support and Outcomes Among Patients With Cardiogenic Shock.
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DOI：
10.1161/jaha.123.032288
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发表时间：
2024-01
影响因子：
5.4
通讯作者：
J. Jentzer;S. Drakos;C. Selzman;Clark G Owyang;Felipe Teran;J. Tonna
中科院分区：
文献类型：
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作者：
J. Jentzer;S. Drakos;C. Selzman;Clark G Owyang;Felipe Teran;J. Tonna
背景：静脉动脉体外膜肺氧合（ECMO）为心源性休克患者提供了充分的血流动力学支持，但ECMO启动的最佳时机仍不确定。我们试图确定早期开始ECMO是否与改善心源性休克患者的生存率相关。方法和结果我们分析了2009年至2019年期间从国际体外生命支持组织（ELSO）登记中心接受静脉动脉ECMO的心源性休克成人患者，不包括手术后插管的患者。多变量logistic回归分析评估了从入院到ECMO启动的时间与院内死亡之间的关系。在8619例患者中（中位数，56.7 [范围，44.8-65.6]岁; 33.5%为女性），从入院到ECMO启动的中位持续时间为14（5-32）小时。24小时内开始ECMO的患者（n=5882 [68.2%]）与24小时后开始ECMO的患者不同，年龄更小，心脏骤停前更多，酸中毒更严重。多变量校正后，入院后>24小时开始ECMO的患者院内死亡风险较高（校正比值比，1.20 [95%CI，1.06-1.36]; P=0.004）。从入院到开始ECMO的时间每增加12小时，与更高的调整后院内死亡率递增相关（调整后比值比，1.06 [95%CI，1.03-1.10]; P<0.001）。在休克严重程度较低的患者中，ECMO时间较长与预后较差之间的相关性似乎更强。结论：在一项大规模的国际登记研究中，从入院到ECMO启动的延迟时间越长，死亡率越高。我们的分析支持优化上门支持时间和避免不适当地延迟ECMO启动。
BACKGROUND Venoarterial extracorporeal membrane oxygenation (ECMO) provides full hemodynamic support for patients with cardiogenic shock, but optimal timing of ECMO initiation remains uncertain. We sought to determine whether earlier initiation of ECMO is associated with improved survival in cardiogenic shock. METHODS AND RESULTS We analyzed adult patients with cardiogenic shock who received venoarterial ECMO from the international Extracorporeal Life Support Organization (ELSO) registry from 2009 to 2019, excluding those cannulated following an operation. Multivariable logistic regression evaluated the association between time from admission to ECMO initiation and in-hospital death. Among 8619 patients (median, 56.7 [range, 44.8-65.6] years; 33.5% women), the median duration from admission to ECMO initiation was 14 (5-32) hours. Patients who had ECMO initiated within 24 hours (n=5882 [68.2%]) differed from those who had ECMO initiated after 24 hours, with younger age, more preceding cardiac arrest, and worse acidosis. After multivariable adjustment, patients with ECMO initiated >24 hours after admission had higher risk of in-hospital death (adjusted odds ratio, 1.20 [95% CI, 1.06-1.36]; P=0.004). Each 12-hour increase in the time from admission to ECMO initiation was incrementally associated with higher adjusted in-hospital mortality rate (adjusted odds ratio, 1.06 [95% CI, 1.03-1.10]; P<0.001). The association between longer time to ECMO and worse outcomes appeared stronger in patients with lower shock severity. CONCLUSIONS Longer delays from admission to ECMO initiation were associated with higher a mortality rate in a large-scale, international registry. Our analysis supports optimization of door-to-support time and the avoidance of inappropriately delayed ECMO initiation.