背景:接受股静脉-动脉体外生命支持(VA-ECLS)的患者存在下肢远端灌注不足和插管腿部缺血的风险。本研究旨在评估使用近红外反射光谱(NIRS)连续无创下肢血氧饱和度检测组织缺氧并指导远端灌注导管(DPC)放置对需要手术干预的腿部缺血率的影响。
方法:我们对2010-2014年(NIRS前时代)和2017-2021年(NIRS时代)在我们机构接受股骨VA-ECLS治疗的患者进行了回顾性分析。在2015-2016年过渡期内插管的患者被排除在外。基线特征,短期结果,和需要手术干预的缺血性并发症(筋膜切开术,血栓切除术,截肢,探索)在两个队列中进行了比较。
结果:在纳入研究的490名患者中,在常规使用NIRS以直接放置DPC之前和之后,分别对141(28.8%)和349(71.2%)进行了插管,分别。NIRS队列患者的高脂血症发生率更高(53.7%vs41.1%,P=0.015)和高血压(71.4%vs60%,P=0.020)在基线时,尽管在ECLS插管之前,他们不太可能得到主动脉内球囊泵的支持(26.9%对37.6%,P=0.026)。这些患者也更有可能发生心脏骤停(22.9%vs7.8%,P=<0.001)和肺部原因(5.2%vs0.7%,P=0.04)作为ECLS的适应症,急性心肌梗死的ECLS发生率较低(15.8%vs34%,P=<0.001)。NIRS队列患者的动脉插管尺寸较小(P=<0.001),ECLS支持持续时间较长(5天vs3.25天,P=<0.001),但手术干预肢体缺血的发生率显着降低(2.6%vs8.5%,P=0.007)尽管DPC放置率相当(49.1%vs44.7%,P=0.427),只有2例患者(1.1%)未通过NIRS鉴定,最终需要手术干预。
结论:使用较小的动脉插管(≤15Fr)和持续的NIRS监测来指导DPC的选择性插入可能是一种有效的策略,与减少需要手术干预的缺血性事件的发生率相关。
Patients requiring femoral venoarterial (VA) extracorporeal life support (ECLS) are at risk of distal lower limb hypoperfusion and ischemia of the cannulated leg. In the present study, we evaluated the effect of using continuous noninvasive lower limb oximetry with near-infrared reflectance spectroscopy (NIRS) to detect tissue hypoxia and guide distal perfusion catheter (DPC) placement on the rates of leg ischemia requiring surgical intervention.
We performed a retrospective analysis of patients who had undergone femoral VA-ECLS at our institution from 2010 to 2014 (pre-NIRS era) and 2017 to 2021 (NIRS era). Patients who had undergone cannulation during the 2015 to 2016 transition era were excluded. The baseline characteristics, short-term outcomes, and ischemic complications requiring surgical intervention (eg, fasciotomy, thrombectomy, amputation, exploration) were compared across the two cohorts.
Of the 490 patients included in the present study, 141 (28.8%) and 349 (71.2%) had undergone cannulation before and after the routine use of NIRS to direct DPC placement, respectively. The patients in the NIRS cohort had had a greater incidence of hyperlipidemia (53.7% vs 41.1%; P = .015) and hypertension (71.4% vs 60%; P = .020) at baseline, although they were less likely to have been supported with an intra-aortic balloon pump before ECLS cannulation (26.9% vs 37.6%; P = .026). These patients were also more likely to have experienced cardiac arrest (22.9% vs 7.8%; P ≤ .001) and a pulmonary cause (5.2% vs 0.7%; P = .04) as an indication for ECLS, with ECLS initiated less often for acute myocardial infarction (15.8% vs 34%; P ≤ .001). The patients in the NIRS cohort had had a smaller arterial cannula size (P ≤ .001) and a longer duration of ECLS support (5 vs 3.25 days; P ≤ .001) but significantly lower rates of surgical intervention for limb ischemia (2.6% vs 8.5%; P = .007) despite comparable rates of DPC placement (49.1% vs 44.7%; P = .427), with only two patients (1.1%) not identified by NIRS ultimately requiring surgical intervention.
The use of a smaller arterial cannula (≤15F) and continuous NIRS monitoring to guide selective insertion of DPCs could be a valid and effective strategy associated with a reduced incidence of ischemic events requiring surgical intervention.