Referral to an Extracorporeal Membrane Oxygenation Center and Mortality Among Patients With Severe 2009 Influenza A(H1N1)
Referral to an Extracorporeal Membrane Oxygenation Center and Mortality Among Patients With Severe 2009 Influenza A(H1N1)
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DOI：
10.1001/jama.2011.1471
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发表时间：
2011-10-19
影响因子：
120.7
通讯作者：
Rowan, Kathryn M.
中科院分区：
文献类型：
--
作者：
Noah, Moronke A.;Peek, Giles J.;Rowan, Kathryn M.
背景体外膜肺氧合（ECMO）可以支持严重急性呼吸窘迫综合征（ARDS）患者的气体交换，但其作用仍存在争议。 ECMO 曾在 2009 年甲型 H1N1 流感大流行期间用于治疗 ARDS 患者。 目的 比较转诊、接受和转诊至 ECMO 的 H1N1 相关 ARDS 患者与未转诊至 ECMO 的匹配患者的医院死亡率。 设计、设置和患者 一项队列研究，其中 ECMO 转诊患者定义为所有 H1N1 相关 ARDS 患者 2009-2010 年冬季 H1N1 流感大流行期间，他们被转诊、接受并转移到英国 4 个成人 ECMO 中心之一。使用 ECMO 转诊患者和非 ECMO 转诊患者的数据进行匹配，这些数据来自一项针对疑似或确诊 H1N1 危重患者的同期纵向队列研究（猪流感分类研究）。详细的人口统计学、生理学和合并症数据采用 3 种不同的匹配技术（个体匹配、倾向评分匹配和 GenMatch 匹配）。主要结果指标根据意向治疗原则分析出院生存率。结果 在 80 名 ECMO 转诊患者中，69 名接受了 ECMO（86.3%），22 名在出院前死亡（27.5%）。从 1756 名患者中，通过个体匹配识别出 59 对 ECMO 转诊患者和非 ECMO 转诊患者，通过倾向评分匹配识别出 75 对匹配，通过 GenMatch 匹配识别出 75 对匹配。使用个体匹配时，ECMO 转诊患者的医院死亡率为 23.7%，而非 ECMO 转诊患者为 52.5%（相对风险 [RR]，0.45 [95% CI，0.26-0.79]；P=.006）；使用倾向评分匹配时，分别为 24.0% 和 46.7%（RR，0.51 [95% CI，0.31-0.81]；P=.008）；使用 GenMatch 匹配时，分别为 24.0% 和 50.7%（RR，0.47 [95% CI，0.31-0.72]；P=.001）。结果对敏感性分析来说是稳健的，包括修改纳入标准和限制非 ECMO 转诊患者的治疗地点。结论 对于 H1N1 相关 ARDS 患者，与匹配的非 ECMO 转诊患者相比，转诊和转移到 ECMO 中心与较低的医院死亡率相关。贾马。 2011;306(15):1659-1668 2011 年 10 月 5 日在线发布。doi:10.1001/jama.2011.1471 www.jama.com
Context Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients with severe acute respiratory distress syndrome (ARDS), but its role has remained controversial. ECMO was used to treat patients with ARDS during the 2009 influenza A(H1N1) pandemic.Objective To compare the hospital mortality of patients with H1N1-related ARDS referred, accepted, and transferred for ECMO with matched patients who were not referred for ECMO.Design, Setting, and Patients A cohort study in which ECMO-referred patients were defined as all patients with H1N1-related ARDS who were referred, accepted, and transferred to 1 of the 4 adult ECMO centers in the United Kingdom during the H1N1 pandemic in winter 2009-2010. The ECMO-referred patients and the non-ECMO-referred patients were matched using data from a concurrent, longitudinal cohort study (Swine Flu Triage study) of critically ill patients with suspected or confirmed H1N1. Detailed demographic, physiological, and comorbidity data were used in 3 different matching techniques (individual matching, propensity score matching, and GenMatch matching).Main Outcome Measure Survival to hospital discharge analyzed according to the intention-to-treat principle.Results Of 80 ECMO-referred patients, 69 received ECMO (86.3%) and 22 died (27.5%) prior to discharge from the hospital. From a pool of 1756 patients, there were 59 matched pairs of ECMO-referred patients and non-ECMO-referred patients identified using individual matching, 75 matched pairs identified using propensity score matching, and 75 matched pairs identified using GenMatch matching. The hospital mortality rate was 23.7% for ECMO-referred patients vs 52.5% for non-ECMO-referred patients (relative risk [RR], 0.45 [95% CI, 0.26-0.79]; P=.006) when individual matching was used; 24.0% vs 46.7%, respectively (RR, 0.51 [95% CI, 0.31-0.81]; P=.008) when propensity score matching was used; and 24.0% vs 50.7%, respectively (RR, 0.47 [95% CI, 0.31-0.72]; P=.001) when GenMatch matching was used. The results were robust to sensitivity analyses, including amending the inclusion criteria and restricting the location where the non-ECMO-referred patients were treated.Conclusion For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non-ECMO-referred patients. JAMA. 2011;306(15):1659-1668 Published online October 5, 2011. doi:10.1001/jama.2011.1471 www.jama.com