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体外膜式氧合治疗重度急性呼吸窘迫综合征
Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome


Alain Combes ... 呼吸系统疾病 • 2018.05.24
相关阅读
• 体外膜氧合治疗重度急性呼吸窘迫综合征 • 急性呼吸窘迫综合征

摘要


背景

静脉-静脉体外膜式氧合(ECMO)对重度急性呼吸窘迫综合征(ARDS)患者的疗效仍有争议。

 

方法

在一项国际性临床试验中,我们将患极重度ARDS(根据以下三项标准之一确定:动脉血氧分压[Pao2]与吸入氧浓度[Fio2]的比值小于50 mmHg持续超过3小时;Pao2∶Fio2小于80 mmHg持续超过6小时;或动脉血pH低于7.25并且动脉二氧化碳分压至少为60 mmHg持续超过6小时)的患者随机分组,一组立即接受静脉-静脉ECMO(ECMO组)治疗,另外一组继续接受常规治疗(对照组)。对于患难治性低氧血症的对照组患者,可能交叉到ECMO组。主要终点为60日时的死亡率。

 

结果

60日时,ECMO组124例患者中的44例(35%)和对照组125例患者中的57例(46%)死亡(相对危险度,0.76;95%置信区间[CI],0.55~1.04;P=0.09)。对照组的35例患者(28%)在随机分组后平均(±SD)6.5日±9.7日交叉后接受ECMO治疗,其中20例患者(57%)死亡。与对照组相比,在ECMO组中,导致输血的出血事件较多(46%的患者 vs. 28%的患者;绝对危险度差异,18个百分点;95% CI,6~30)、重度血小板减少病例较多(27% vs. 16%;绝对危险度差异,11个百分点;95% CI,0~21)、缺血性卒中病例较少(0例患者vs. 5%;绝对危险度差异,-5个百分点;95% CI,-10~-2),除此之外两组的并发症发生率无显著差异。

 

结论

在极重度ARDS患者中,与使用ECMO作为补救治疗的常规机械通气策略相比,采用ECMO治疗时,60日死亡率未显著降低(由临床研发部[Direction de la Recherche Clinique et du Développement]和法国卫生部资助;EOLIA在ClinicalTrials.gov注册号为NCT01470703)。





作者信息

Alain Combes, M.D., Ph.D., David Hajage, M.D., Ph.D., Gilles Capellier, M.D., Ph.D., Alexandre Demoule, M.D., Ph.D., Sylvain Lavoué, M.D., Christophe Guervilly, M.D., Daniel Da Silva, M.D., Lara Zafrani, M.D., Ph.D., Patrice Tirot, M.D., Benoit Veber, M.D., Ph.D., Eric Maury, M.D., Ph.D., Bruno Levy, M.D., Ph.D., Yves Cohen, M.D., Ph.D., Christian Richard, M.D., Ph.D., Pierre Kalfon, M.D., Ph.D., Lila Bouadma, M.D., Ph.D., Hossein Mehdaoui, M.D., Gaëtan Beduneau, M.D., Ph.D., Guillaume Lebreton, M.D., Ph.D., Laurent Brochard, M.D., Ph.D., Niall D. Ferguson, M.D., Eddy Fan, M.D., Ph.D., Arthur S. Slutsky, M.D., Daniel Brodie, M.D., and Alain Mercat, M.D., Ph.D. for the EOLIA Trial Group, REVA, and ECMONet*
From Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition (A.C., G.L.), Service de Médecine Intensive–Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris (APHP) Hôpital Pitié–Salpêtrière (A.C.), Département de Biostatistiques, Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie, APHP Hôpital Pitié–Salpêtrière (D.H.), Sorbonne Université, Unité de Recherche Clinique Pitié–Salpêtrière (D.H.), Sorbonne Université INSERM UMRS 1158 (A.D.), Service de Médecine Intensive–Réanimation et Pneumologie, APHP Hôpital Pitié–Salpêtrière (A.D.), Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire (CHU) Saint Louis (L.Z.), Service de Médecine Intensive et Réanimation, CHU Saint Antoine (E.M.), Service de Médecine Intensive et Réanimation, APHP Bichat Hospital, Diderot University (L. Bouadma), and Service de Chirurgie Thoracique et Cardiovasculaire, APHP Hôpital Pitié–Salpêtrière, Institut de Cardiologie (G.L.), Paris, Service de Médecine Intensive et Réanimation, Besançon University Hospital, and Research Unit Equipe Avenir 3920 and Structure Fédérative de Recherche 4234, University of Franche Comté, Besançon (G.C.), Service de Médecine Intensive et Réanimation, CHU Pontchaillou, Rennes (S.L.), Service de Médecine Intensive et Réanimation, CHU Hôpital Nord, APHM, Marseille (C.G.), Service de Médecine Intensive et Réanimation, CHU Saint Denis, Saint Denis (D.D.S.), Service de Médecine Intensive et Réanimation, CHU Le Mans, Le Mans (P.T.), Département d’Anesthésie et Réanimation, CHU de Rouen (B.V.), Service de Médecine Intensive et Réanimation, Rouen University Hospital (G.B.), and Normandie University, Université de Rouen, Equipe Avenir 3830, Rouen University Hospital (G.B.), Rouen, Service de Médecine Intensive et Réanimation, CHU Nancy and INSERM Unité 1116, Université de Lorraine, Nancy (B.L.), Service de Médecine Intensive et Réanimation, CHU Avicenne, Bobigny (Y.C.), Service de Médecine Intensive et Réanimation, CHU Kremlin Bicêtre, Le Kremlin Bicêtre (C.R.), Service de Réanimation Polyvalente, Hôpital de Chartres, Chartres (P.K.), CHU Martinique, Fort-de-France (H.M.), and Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire d’Angers, Université d’Angers, Angers (A.M.) — all in France; the Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Management, Policy, and Evaluation, University of Toronto (L. Brochard, N.D.F., E.F.), Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael’s Hospital (L. Brochard, A.S.S.), and the Department of Medicine, Division of Respirology, University Health Network and Sinai Health System, Toronto General Hospital (N.D.F., E.F.), Toronto; and the Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, and New York–Presbyterian Hospital, Columbia University, New York (D.B.). Address reprint requests to Dr. Combes at Service de Médecine Intensive–Réanimation, Hôpital Pitié–Salpêtrière, Assistance Publique–Hôpitaux de Paris, Sorbonne Université INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition 47, Boulevard de l’Hôpital, F-75013 Paris, France, or at alain.combes@aphp.fr. *A list of the investigators in the ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) Trial Group, the Réseau Européen en Ventilation Artificielle (REVA), and the International ECMO Network (ECMONet) is provided in the Supplementary Appendix, available at NEJM.org.

 

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