Complications of Extracorporeal Membrane Oxygenation for Treatment of Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis of 1,866 Adult Patients
Complications of Extracorporeal Membrane Oxygenation for Treatment of Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis of 1,866 Adult Patients
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DOI：
10.1016/j.athoracsur.2013.09.008
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发表时间：
2014-02-01
影响因子：
4.6
通讯作者：
Azarbal, Babak
中科院分区：
文献类型：
--
作者：
Cheng, Richard;Hachamovitch, Rory;Azarbal, Babak
背景静脉动脉体外膜肺氧合（ECMO）已成功用于治疗心源性休克或心脏骤停。确切的并发症发生率尚不清楚，部分原因是研究规模较小。在缺乏大型临床试验的情况下，汇总分析的性能代表了确定ECMO并发症发生率的最佳方法。对ECMO进行了系统性PubMed检索，仅用于治疗成人患者的心源性休克或心脏骤停，更新至2012年11月。纳入了2000年或之后发表的报告ECMO并发症发生率的10例以上患者的研究。分析的特定并发症包括下肢缺血、筋膜切开术或筋膜室综合征、截肢、卒中、神经系统并发症、急性肾损伤、肾脏替代治疗、大出血或显著出血、因出血或填塞而再次开胸术和显著感染。对于包含重叠患者的研究，纳入最大的研究，排除其他研究。计算Cochran's Q和I平方。所有分析均采用保守的随机效应模型。20项研究被纳入分析，涵盖1，866例患者。17项研究报告了出院生存率，1,529例患者中有534例的累积生存率，范围为20.8%至65.4%。根据分析的具体并发症，分析包括192至1，452例患者。合并估计并发症发生率及其95%置信区间如下：下肢缺血，16.9%筋膜切开术或筋膜室综合征，10.3%（7.3%至14.5%）;下肢截肢，4.7%（2.3%至9.3%）;中风，5.9%（4.2%-8.3%）;神经系统并发症，13.3%（9.9%-17.7%）;急性肾损伤，55.6%（35.5%至74.0%）;肾脏替代治疗，46.0%（36.7%至55.5%）;严重或显著出血，40.8%（26.8%至56.6%）;心脏切开术后患者因出血或填塞而再次开胸，41.9%严重感染占30.4%（19.5%~ 44.0%）。尽管ECMO可以提高晚期心脏病患者的生存率，但这种干预措施的执行与发病率显著相关。当考虑开始ECMO治疗心源性休克时，应将这些发现纳入风险-获益分析。(C)2014年由胸外科医师协会
Background. Venoarterial extracorporeal membrane oxygenation (ECMO) has been used successfully for treatment of cardiogenic shock or cardiac arrest. The exact complication rate is not well understood, in part because of small study sizes. In the absence of large clinical trials, performance of pooled analysis represents the best method for ascertaining complication rates for ECMO.Methods. A systematic PubMed search was conducted on ECMO for treatment of cardiogenic shock or cardiac arrest in adult patients only, updated to November 2012. Studies with more than 10 patients published in the year 2000 or later that reported complication rates for ECMO were included. Specific complications analyzed included lower extremity ischemia, fasciotomy or compartment syndrome, amputation, stroke, neurologic complications, acute kidney injury, renal replacement therapy, major or significant bleeding, rethoracotomy for bleeding or tamponade, and significant infection. For studies that included overlapping patients, the largest study was included and the others excluded. Cochran's Q and I-squared were calculated. A more conservative randomeffects model was chosen for all analyses.Results. Twenty studies were included in the analyses encompassing 1,866 patients. Seventeen studies reported survival to hospital discharge, with a cumulative survival rate of 534 of 1,529, and a range of 20.8% to 65.4%. Analyses encompassed 192 to 1,452 patients depending on the specific complication analyzed. The pooled estimate rates of complications with 95% confidence intervals were as follows: lower extremity ischemia, 16.9% (12.5% to 22.6%); fasciotomy or compartment syndrome, 10.3% (7.3% to 14.5%); lower extremity amputation, 4.7% (2.3% to 9.3%); stroke, 5.9% (4.2% to 8.3%); neurologic complications, 13.3% (9.9% to 17.7%); acute kidney injury, 55.6% (35.5% to 74.0%); renal replacement therapy, 46.0% (36.7% to 55.5%); major or significant bleeding, 40.8% (26.8% to 56.6%); rethoracotomy for bleeding or tamponade in postcardiotomy patients, 41.9% (24.3% to 61.8%); and significant infection, 30.4% (19.5% to 44.0%).Conclusions. Although ECMO can improve survival of patients with advanced heart disease, there is significant associated morbidity with performance of this intervention. These findings should be incorporated in the risk-benefit analysis when initiation of ECMO for cardiogenic shock is being considered. (C) 2014 by The Society of Thoracic Surgeons