经皮氧分压监测对行体外膜氧合治疗的心源性休克患者预后评估的价值

摘要

目的 探讨经皮氧分压监测对行体外膜氧合(ECMO)治疗的心源性休克患者预后评估的价值.方法 选取2012-06~2015-05南京医科大学附属无锡人民医院重症医学科(ICU)收治的因心源性休克而接受静脉-动脉(V-A) ECMO治疗的患者共41例.在接受ECMO治疗后6 h进行经皮氧分压监测和氧负荷试验,计算6 h的10 min氧负荷值(10 min OCT)及氧负荷指数(OCI),并收集ECMO治疗首日患者的一般资料、血常规生化指标、APACHEⅡ评分.依据ECMO治疗后60 d生存情况将患者分为存活组和死亡组,比较两组患者10 min OCT、OCI及APACHEⅡ评分.采用受试者工作特征(ROC)曲线分析10 min OCT、OCI值及APACHEⅡ评分对患者预后的判断价值,采用Kaplan-Meier法绘制患者的生存曲线,Log-rank法分析患者生存情况,多因素Logistic回归分析筛选患者预后相关危险因素.结果 存活组和死亡组分别纳入19例及22例患者,存活组10 min OCT[(78.00±19.15)mm Hg vs.(55.41±15.68)mm Hg,P<0.05]及OCI[(0.75±0.15) vs.(0.61±0.15),P<0.05]均高于死亡组,存活组 APACHE Ⅱ评分[(11.37±5.54) vs.(19.45±6.47),P<0.05]低于死亡组.10 min OCT预测患者60 d死亡的ROC曲线下面积为0.82±0.07(95%CI 0.67~0.92,P<0.05). OCI值预测患者60 d死亡的ROC曲线下面积为0.75±0.08(95%CI 0.59~0.87,P<0.05).Kaplan-Meier生存曲线分析显示,分别以10 min OCT=72.00 mm Hg(66.7% vs.25.0%)和OCI=0.70(77.8% vs.21.7%)为最佳界值分组患者60 d生存率差异有统计学意义(均P<0.05).多因素Logistic回归分析显示APACHEⅡ评分(OR=1.21,95%CI 1.08~1.36,P<0.05)、6 h 10 min OCT (OR=0.93,95%CI 0.89~0.97,P<0.05)、OCI(OR=0.002,95%CI 0.001~0.223,P<0.05)均是患者死亡的相关因素.结论 经皮氧分压监测是早期预测行ECMO治疗的心源性休克患者预后的可靠指标.%Objective To evaluate effect of transcutaneous oximetry on prognosis of patients with cardiogenic shock receiving extracorporeal membrane oxygenation (ECMO).Methods Forty-one patients with cardiogenic shock supported by Veno-Arterial (V-A) ECMO were prospectively enrolled from June 2012 to May 2015.10 min oxygen challenge test were measured using transcutaneous oximetry at 6 hours after ECMO initiation respectively, 10 min OCT value (10 min OCT) and oxygen challenge index(OCI) were then calculated.Patients were divided into the survival group and the death group based on the 60 days survival status.10 min OCT, OCI and APACHEⅡ score were compared between groups.The effect of 10 min OCT, OCI and APACHEⅡ score for predicting death was evaluated by receiver operating characteristic (ROC) curves.The surviving curve was created using the Kaplan-Meier method, and the survival of the patients was analyzed by the Log-rank test.Risk factors associated with the prognosis were analyzed using the multiple logistic regression analysis.Results There were 19 patients and 22 patients in survival group and death group respectively.10 min OCT[(78.00±19.15) mm Hg vs.(55.41±15.68) mm Hg], OCI[(0.75±0.15) vs.(0.61±0.15)]at 6 h and APACHE Ⅱ score[(11.37±5.54) vs.(19.45±6.47)]were all significantly different between survivors and nonsurvivors (P<0.05).The area under the ROC curve of 10 min OCT and OCI for predicting death were[(0.82±0.07)95%CI 0.67~0.92]and[(0.75±0.08)95%CI 0.59~0.87], respectively.The best cutoff point for 10 min OCT was 72.0 mm Hg with a sensitivity of 86.4%and specificity of 73.7%.The best cutoff point for OCI was 0.70 with a sensitivity of 81.8%and specificity of 70.0%.Kaplan-Meier survival analysis indicated that 60 days survival rate of high 10 min OCT and high OCI group were significantly higher than those of low 10 min OCT (66.7% vs.25.0%, P<0.05) and low OCI (77.8% vs.21.7%, P<0.05) group.Multivariate logistic regression analysis showed that APACHEⅡ score (OR=1.21, 95%CI 1.08~1.36, P<0.05), 10 min OCT (OR=0.93, 95%CI 0.89~0.97, P<0.05) and OCI (OR=0.002, 95%CI 0.001~0.223, P<0.05) at 6 h were both independent risk factors associated with mortality of cardiogenic shock patients with ECMO.Conclusion Early 10 min OCT and OCI could be used as important indicator for predicting the prognosis of cardiogenic shock patients with ECMO.