Décubitus ventral au cours du SDRA : revue des effets physiologiques, cliniques et des techniques d'oxygénation extracorporelle

Abstract : Introduction: Early, prolonged and repeated sessions of prone positioning (PP) have proven substantial outcome benefit in ARDS patients. In the most severe forms of ARDS, veno venous extracorporeal membrane oxygenation (vvECMO) is considered as a therapeutic option performed on a case by case. About 50% of patients treated with vvECMO have previously been turned prone. However, only few studies have evaluated the interest of maintaining PP during ECMO. Therefore, the objective of this study was to compare the 90-day survival rate of patients supported by vvECMO with concomitant PP (prone ECMO group) to those not turned prone during the ECMO period (ECMO alone group). Methods: We included all adults treated with vvECMO for ARDS between January 2012 and April 2017 in a university teaching hospital in Marseille, France. Patients were either cannulated in our ICU or in a referring hospital then transported by the ECMO mobile team. Before considering patients for ECMO, a PP session was systematically performed in our center if feasible, and strongly encouraged for patients from referral centers. Criteria for vvECMO have been previously published. During ECMO, patients were considered for prone position in case of 1/ persistent hypoxemia defined by SpO2 < 88 % or PaO2 < 55 mmHg despite a 100% FdO2 and FiO2 with a maximal ECMO blood flow, 2/ failure of attempt to wean ECMO after at least 10 days of ECMO and the presence of lung consolidations on chest X-ray or ultrasounds echography, 3/ according to the physician in charge. Technical issues have been previously described. We compared the prone ECMO group to the ECMO alone group. We performed Kaplan-Meier 90-day survival curves and Coxmodel for 90-day mortality. Results: 169 patients were included in the analysis, 92 in the prone group and 77 in the ECMO alone group. The prone group has a 57.6% 90-day survival rate as compared with a 37.7% 90-day survival rate of the ECMO alone group, p=0.01. SAPS2 [HR =1.040 (95% CI 1.024-1.056) and use of iNO before ECMO [HR = 1.86 (95% CI 1.156-2.992)] were independently associated with increase in 90-day mortality whereas the use of PP during ECMO was independently associated with decrease in 90-day mortality [HR=0.439 (95% CI 0.270-0.714)] Conclusion: The continuation of PP during vvECMO could be of clinical interest. Further prospective controlled study is warranted.
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Eloi Prud'Homme. Décubitus ventral au cours du SDRA : revue des effets physiologiques, cliniques et des techniques d'oxygénation extracorporelle. Sciences du Vivant [q-bio]. 2018. ⟨dumas-02094909⟩

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