OBJECTIVES: 

Although patients on venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock are usually supported with mechanical ventilation, it is not clear whether sedation cessation and extubation might improve outcomes.

DESIGN: 

Retrospective cohort study with propensity score overlap weighting analysis.

SETTING: 

Three ICUs in a 1,500-bed tertiary university hospital.

PATIENTS: 

From an overall cohort of 641 patients with venoarterial-extracorporeal membrane oxygenation support, the primary analysis was performed in 344 patients who had been successfully decannulated in order to reduce immortal time bias.

MEASUREMENTS AND MAIN RESULTS: 

Seventy-five patients (22%) were extubated during extracorporeal membrane oxygenation support and were subsequently decannulated alive. Forty-nine percent received noninvasive ventilation, and 25% had emergency reintubation for respiratory, neurologic, or hemodynamic reasons. Higher Simplified Acute Physiology Score II at admission (odds ratio, 0.97; 95% CI [0.95–0.99]; p = 0.008) was associated with a lower probability of extubation, whereas cannulation in cardiac surgery ICU (odds ratio, 3.14; 95% CI [1.21–8.14]; p = 0.018) was associated with an increased probability. Baseline characteristics were well balanced after propensity score overlap weighting. The number of ICU-free days within 30 days of extracorporeal membrane oxygenation decannulation was significantly higher among extubated patients compared with nonextubated patients (22 d [11–26 d] vs 18 d [7–25 d], respectively; p = 0.036). There were no differences in other outcomes including ventilator-associated pneumonia (odds ratio, 0.96; 95% CI [0.51–1.82]; p = 0.90) and all-cause mortality within 30 days of extracorporeal membrane oxygenation decannulation (5% vs 17%; hazard ratio, 0.54; 95% CI [0.19–1.59]; p = 0.27).

As a secondary analysis, outcomes were compared in the overall cohort of 641 venoarterial extracorporeal membrane oxygenation–supported patients. Results were consistent with the primary analysis as extubated patients had a higher number of ICU-free days (18 d [0–24 d] vs 0 d [0–18 d], respectively; < 0.001) and a lower risk of death within 30 days of extracorporeal membrane oxygenation cannulation (hazard ratio, 0.45; 95% CI [0.29–0.71]; p = 0.001).

CONCLUSIONS: 

Extubation during venoarterial-extracorporeal membrane oxygenation support is safe, feasible, and associated with greater ICU-free days.

中文翻译：

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静脉动脉体外膜氧合患者拔管的临床益处

 目标：

尽管接受静脉动脉体外膜肺氧合治疗难治性心源性休克的患者通常得到机械通气支持，但尚不清楚停止镇静和拔管是否可以改善预后。

 设计：

回顾性队列研究与倾向评分重叠加权分析。

 环境：

一家拥有 1,500 个床位的三级大学医院设有三个 ICU。

 患者：

在 641 名接受静脉动脉体外膜氧合支持的患者的总体队列中，对 344 名已成功拔管的患者进行了初步分析，以减少永生时间偏差。

测量和主要结果：

75 名患者 (22%) 在体外膜氧合支持期间拔管，随后活着拔管。 49% 接受无创通气，25% 因呼吸、神经或血流动力学原因紧急重新插管。入院时较高的简化急性生理学评分 II（比值比，0.97；95% CI [0.95–0.99]； p = 0.008）与较低的拔管概率相关，而在心脏手术 ICU 中插管（比值比，3.14；95%） CI [1.21–8.14]； p = 0.018）与概率增加相关。倾向得分重叠加权后基线特征得到了很好的平衡。与未拔管的患者相比，体外膜肺氧合拔管后 30 天内无需 ICU 的天数显着增加（分别为 22 天 [11-26 天] 和 18 天 [7-25 天]； p = 0.036） 。其他结果没有差异，包括呼吸机相关性肺炎（比值比，0.96；95% CI [0.51–1.82]； p = 0.90）和体外膜肺氧合拔管后 30 天内的全因死亡率（5% vs 17%） ；风险比， 0.54；95% CI [0.19–1.59]；

作为二次分析，对 641 名接受静脉动脉体外膜氧合支持的患者的整个队列的结果进行了比较。结果与主要分析一致，因为拔管患者的无 ICU 天数较高（分别为 18 天 [0-24 天] 与 0 天 [0-18 天]；< 0.001），且死亡风险较低体外膜肺氧合插管 30 天（风险比，0.45；95% CI [0.29–0.71]； p = 0.001）。

 结论：

在静脉动脉-体外膜氧合支持期间拔管是安全、可行的，并且与更长的无 ICU 天数相关。