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Recent advances in venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Curr Opin Crit Care 2020; 25:71-76. [PMID: 30516588 DOI: 10.1097/mcc.0000000000000567] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize results of the most recent trials on venovenous extracorporeal membrane oxygenation (VV-ECMO) in severe acute respiratory distress syndrome (ARDS) and to elaborate on the unmet needs regarding VV-ECMO management in this setting. RECENT FINDINGS Although it was terminated early for futility (i.e., failure to demonstrate a difference in 60-day mortality of 20%), the ECMO to Rescue Lung Injury in Severe ARDS trial of VV-ECMO for severe ARDS reported a nonsignificant, but clinically important, reduction in mortality (35 vs. 46%; relative risk 0.76; 95% confidence interval 0.55-1.04, P = 0.09). Refractory hypoxemia led to rescue ECMO in 28% of controls, who had more severe ARDS at inclusion, were extremely sick at the time of ECMO cannulation and for whom mortality was 57%. Beyond the rescue of patients dying of refractory hypoxemia, ECMO may now be used early in severe ARDS patients to reduce the intensity of mechanical ventilation and to minimize ventilator-induced lung injury. Future research in the field should focus on identification of patients who are more likely to benefit from this technique and the right timing for its initiation, optimization of daily management of patients under ECMO to further reduce complications, and selection of optimal ventilator management on ECMO. SUMMARY VV-ECMO is a reasonable therapeutic option for patients with severe ARDS and major hypoxemia or excessive pressures. Future trials should be designed to optimize patients' management while on VV-ECMO support.
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Bull T, Corley A, Lye I, Spooner AJ, Fraser JF. Cannula and circuit management in peripheral extracorporeal membrane oxygenation: An international survey of 45 countries. PLoS One 2019; 14:e0227248. [PMID: 31887197 PMCID: PMC6936833 DOI: 10.1371/journal.pone.0227248] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/15/2019] [Indexed: 01/05/2023] Open
Abstract
Effective and safe practices during extracorporeal membrane oxygenation (ECMO) including infection precautions and securement of lines (cannulas and circuits) are critical to prevent life-threatening patient complications, yet little is known about the practices of bedside clinicians and data to support best practice is lacking. Therefore, the aim of this study was to identify and describe common line-related practices for patients supported by peripheral ECMO worldwide and to highlight any gaps for further investigation. An electronic survey was conducted to examine common line practices for patients managed on peripheral ECMO. Responses were obtained from 45 countries with the majority from the United States (n = 181) and United Kingdom (n = 32). Standardised infection precautions including hand hygiene, maximal barrier precautions and skin antisepsis were commonplace for cannulation. The most common antisepsis strategies included alcohol-based chlorhexidine gluconate (CHG) for cannula insertion (53%) and maintenance (54%), isopropyl alcohol on circuit access ports (39%), and CHG-impregnated dressings to cover insertion sites (36%). Adverse patient events due to line malposition or dislodgement were reported by 34% of respondents with most attributable to ineffective securement. Centres 'always' suturing peripheral cannula sites were more likely to experience a cannula adverse event than centres that 'never' sutured (35% [95% CI 30, 41] vs 0% [95% CI 0, 28]; Chi-square 4.40; p = 0.04) but this did not meet the a priori significance level of <0.01. An evidence-based guideline would be beneficial to improve ECMO line management according to 78% of respondents. Evidence gaps were identified for antiseptic agents, dressing products and regimens, securement methods, and needleless valves. Future research addressing these areas may provide opportunities for consensus guideline development and practice improvement.
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Affiliation(s)
- Taressa Bull
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - India Lye
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - Amy J. Spooner
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - John F. Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
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Grasselli G, Scaravilli V, Alagna L, Bombino M, De Falco S, Bandera A, Abbruzzese C, Patroniti N, Gori A, Pesenti A. Gastrointestinal colonization with multidrug-resistant Gram-negative bacteria during extracorporeal membrane oxygenation: effect on the risk of subsequent infections and impact on patient outcome. Ann Intensive Care 2019; 9:141. [PMID: 31853672 PMCID: PMC6920277 DOI: 10.1186/s13613-019-0615-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/05/2019] [Indexed: 01/12/2023] Open
Abstract
Background In ICU patients, digestive tract colonization by multidrug-resistant (MDR) Gram-negative (G−) bacteria is a significant risk factor for the development of infections. In patients undergoing extracorporeal membrane oxygenation (ECMO), colonization by MDR bacteria and risk of subsequent nosocomial infections (NIs) have not been studied yet. The aim of this study is to evaluate the incidence, etiology, risk factors, impact on outcome of gastrointestinal colonization by MDR G− bacteria, and risk of subsequent infections in patients undergoing ECMO. Methods This is a retrospective analysis of prospectively collected data: 105 consecutive patients, treated with ECMO, were admitted to the ICU of an Italian tertiary referral center (San Gerardo Hospital, Monza, Italy) from January 2010 to November 2015. Rectal swabs for MDR G− bacteria were cultured at admission and twice a week. Only colonization and NIs by MDR G− bacteria were analyzed. Results Ninety-one included patients [48.5 (37–56) years old, 63% male, simplified acute physiology score II 37 (32–47)] underwent peripheral ECMO (87% veno-venous) for medical indications (79% ARDS). Nineteen (21%) patients were colonized by MDR G− bacteria. Male gender (OR 4.03, p = 0.029) and duration of mechanical ventilation (MV) before ECMO > 3 days (OR 3.57, p = 0.014) were associated with increased risk of colonization. Colonized patients had increased odds of infections by the colonizing germs (84% vs. 29%, p < 0.001, OR 12.9), longer ICU length of stay (LOS) (43 vs. 24 days, p = 0.002), MV (50 vs. 22 days, p < 0.001) and ECMO (28 vs. 12 days, p < 0.001), but did not have higher risk of death (survival rate 58% vs. 67%, p = 0.480, OR 0.68). Infected patients had almost halved ICU survival (46% vs. 78%, p < 0.001, OR 4.11). Conclusions In patients undergoing ECMO for respiratory and/or circulatory failure, colonization by MDR G− bacteria is frequent and associated with more the tenfold odds for subsequent infection. Those infections are associated with an increased risk of death.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, MI, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, MI, Italy.
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, MI, Italy
| | - Laura Alagna
- Infectious Diseases Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Michela Bombino
- Department of Anesthesia, Critical Care and Emergency, ASST Monza San Gerardo Hospital, Monza, MB, Italy
| | - Stefano De Falco
- Department of Pathophysiology and Transplantation, University of Milan, Milan, MI, Italy
| | - Alessandra Bandera
- Department of Pathophysiology and Transplantation, University of Milan, Milan, MI, Italy.,Infectious Diseases Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Chiara Abbruzzese
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, MI, Italy
| | - Nicolò Patroniti
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Andrea Gori
- Department of Pathophysiology and Transplantation, University of Milan, Milan, MI, Italy.,Infectious Diseases Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, MI, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, MI, Italy
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Marcus JE, Piper LC, Ainsworth CR, Sams VG, Batchinsky A, Okulicz JF, Barsoumian AE. Infections in patients with burn injuries receiving extracorporeal membrane oxygenation. Burns 2019; 45:1880-1887. [PMID: 31601427 DOI: 10.1016/j.burns.2019.04.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) has only recently been described in patients with burn injuries. We report the incidence and type of infections in critically ill burn and non-burn patients receiving ECMO. METHODS A retrospective chart review was performed on all patients at Brooke Army Medical Center who received ECMO between September 2012 and May 2018. RESULTS 78 patients underwent ECMO. Approximately half were men with a median age of 34 years with a median time on ECMO of 237 h (IQR 121-391). Compared to patients without burns (n = 58), patients with burns (n = 20) had no difference in time on ECMO, but had more overall infections (86 vs. 31 per 1000 days, p = 0.0002), respiratory infections (40 vs. 15 per 1000 days, p = 0.01), skin and soft tissue infections (21 vs. 5 per 1000 days, p = 0.02) and fungal infections (35% vs 10%, p = 0.02). Twenty percent of bacterial burn infections were due to drug resistant organisms. CONCLUSION This is the first study to describe the incidence of infection in burn injury patients who are undergoing ECMO. We observed an increase in infections in burn patients on ECMO compared to non-burn patients. ECMO remains a viable option for critically ill patients with burn injuries.
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Affiliation(s)
- Joseph E Marcus
- Department of Internal Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States.
| | - Lydia C Piper
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brook Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Craig R Ainsworth
- U.S. Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, United States
| | - Valerie G Sams
- Department of Surgery, Brooke Army Medical Center, 3551 Roger Brook Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Andriy Batchinsky
- U.S. Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, United States
| | - Jason F Okulicz
- Infectious Disease Service, MCHE-MDI, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
| | - Alice E Barsoumian
- Infectious Disease Service, MCHE-MDI, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States
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55
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Corley A, Lye I, Lavana JD, Ahuja A, Anstey CM, Jarrett P, Haisz E, Parke R, Pellegrino V, Buscher H, Fraser JF. Nosocomial infection prevalence in patients undergoing extracorporeal membrane oxygenation (ECMO): protocol for a point prevalence study across Australia and New Zealand. BMJ Open 2019; 9:e029293. [PMID: 31296512 PMCID: PMC6624104 DOI: 10.1136/bmjopen-2019-029293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) provides cardiac and/or respiratory support when other therapies fail. Nosocomial infection is reported in up to 64% of patients receiving ECMO and increases morbidity and mortality. These patients are at high risk of infection due, in part, to the multiple invasive devices required in their management, the largest being the cannulae through which ECMO is delivered. Prevalence of nosocomial infection in ECMO patients, including ECMO cannula-related infection, is not well described across Australia and New Zealand. METHODS AND ANALYSIS This is a prospective, observational point prevalence study of 12 months duration conducted at 11 ECMO centres across Australia and New Zealand. Data will be collected for every patient receiving ECMO during 12 predetermined data collection weeks. The primary outcome is the prevalence of laboratory-confirmed bloodstream infection, and suspected or probable nosocomial infections; and the secondary outcomes include describing ECMO cannula dressing and securement practices, and adherence to local dressing and securement guidelines. Data collection will be finalised by March 2019. ETHICS AND DISSEMINATION Relevant ethical and governance approvals have been received. Study results will describe the prevalence of suspected and confirmed nosocomial infection in adult, paediatric and neonatal patients receiving ECMO across Australia and New Zealand. It is expected that the results will be hypothesis generating and lead to interventional trials aimed at reducing the high infection rates seen in this cohort. Results will be published in peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER ANZCTRN12618001109291; Pre-results.
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Affiliation(s)
- Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - India Lye
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Jayshree D Lavana
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Abhilasha Ahuja
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Chris M Anstey
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- School of Medicine, Griffith University, Birtinya, Queensland, Australia
| | - Paul Jarrett
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Emma Haisz
- Paediatric Intensive Care Unit, Queensland Children’s Hospital, South Brisbane, Queensland, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Vincent Pellegrino
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Infections on Extracorporeal Life Support in Adults and Children-A Survey of International Practice on Prevention, Diagnosis, and Treatment. Pediatr Crit Care Med 2019; 20:667-671. [PMID: 31136375 DOI: 10.1097/pcc.0000000000001941] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess nosocomial infection management practices in pediatric and adult patients supported with extracorporeal life support. DESIGN A 23-question online survey was developed to assess practices related to infection prevention, surveillance, diagnosis, and treatment in patients managed on extracorporeal life support. The survey was distributed internationally to intensivists via online newsletters and e-mail from June to December 2017. SETTING Extracorporeal life support centers. SUBJECTS Intensivists working in extracorporeal life support centers. INTERVENTIONS None. RESULTS We analyzed 147 responses from 25 countries. Most centers have bundles implemented as standard of care to prevent against ventilator-associated pneumonia (77%) and central catheter-associated bloodstream infections (91%). Prophylactic antibiotics beyond cannulation are at least occasionally used by 61% of respondents. Daily C-reactive protein (35%) and white cell count (80%) are the most commonly used surveillance biomarkers, and 25% of respondents reported collecting daily surveillance cultures. Participants responded that new onset of hemodynamic instability and rising C-reactive protein (49%) or rising procalcitonin (30%) are the most common triggers to commence antibiotics. CONCLUSION There is considerable variability surrounding practices on prevention and diagnosis of infection in patients treated with extracorporeal life support. In view of the impact of infections acquired during extracorporeal life support, further research to inform recommendations on prevention, diagnosis, and management of infection on extracorporeal life support is urgently needed.
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57
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Ayyıldız P, Kasar T, Ozturk E, Yildiz O, Ozturk S, Ergul Y, Haydin S, Guzeltas A. The Evaluation of Nosocomial Infections in Pediatric Patients with Extracorporeal Membrane Oxygenation Support. Braz J Cardiovasc Surg 2019; 32:468-474. [PMID: 29267608 PMCID: PMC5731312 DOI: 10.21470/1678-9741-2017-0072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/07/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) has become a standard technique
over the past few decades in intensive care unit (ICU). Objective A review of pediatric patients who received ECMO support in the pediatric
cardiac ICU was conducted to determine the incidence, risk factors and
causal organisms related to acquired infections and assess the survival
rates of ECMO patients with nosocomial infections. Methods Sixty-six patients who received ECMO support in the pediatric cardiac ICU
between January 2011 and June 2014 were included in the study. Demographic,
echocardiographic, hemodynamic features and surgical procedures were
reviewed. Results Sixty-six patients received a total of 292.5 days of venoarterial ECMO
support. Sixty were postoperative patients. Forty-five patients were weaned
from ECMO support with an ECMO survival rate of 68.2%. The rate of infection
was 116.2/1000 ECMO days. Prolonged ICU stay, duration of ventilation and
ECMO were found associated with development of nosocomial infection and only
the duration of ECMO was an independent risk factor for nosocomial
infections in ECMO patients. Conclusion The correction of the underlying process leading to ECMO support and
shortening the length of ECMO duration together with stricter application of
ECMO indications would improve the infection incidence and hospital
surveillance of the patient group.
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Affiliation(s)
- Pelin Ayyıldız
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Taner Kasar
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Erkut Ozturk
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Okan Yildiz
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Serpil Ozturk
- Department of Infectious Diseases, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Yakup Ergul
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Sertac Haydin
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Alper Guzeltas
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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Silvetti S, Ranucci M, Pistuddi V, Isgrò G, Ballotta A, Ferraris L, Cotza M. Bloodstream infections during post-cardiotomy extracorporeal membrane oxygenation: Incidence, risk factors, and outcomes. Int J Artif Organs 2018; 42:299-306. [DOI: 10.1177/0391398818817325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Veno-arterial extracorporeal membrane oxygenation after heart surgery is a relatively common procedure. It is easily applicable but associated with a number of complications, including bloodstream infections. The aim of this study is to determine the current rate and the risk factors related to bloodstream infections acquired during post-cardiotomy veno-arterial extracorporeal membrane oxygenation. Methods: Single-center retrospective study. From the overall population receiving any kind of extracorporeal membrane oxygenation from March 2013 through December 2017, the post-cardiotomy patient population was extracted, with a final sample of 92 veno-arterial extracorporeal membrane oxygenations. The risk of developing bloodstream infections as a function of extracorporeal membrane oxygenation exposure was analyzed with appropriate statistical analyses, including a Kaplan–Meier analysis. Results: Overall, 14 (15.2%) patients developed a bloodstream infection during extracorporeal membrane oxygenation or within the first 48 h after extracorporeal membrane oxygenation removal. The total extracorporeal membrane oxygenation duration in the population was 567 days, and the incidence of bloodstream infections was 24.7 bloodstream infections/1000 extracorporeal membrane oxygenation days. There was a progressive increase in the cumulative hazard ratio during the first 7 days, reaching a value of 20% on day 7; from day 7 and day 15, the hazard ratio remained stable, with a second increase after day 15. The independent risk factors associated with bloodstream infections were adult age, pre-implantation serum total bilirubin level, and the amount of chest drain blood loss. Discussion: Infections acquired during veno-arterial extracorporeal membrane oxygenation are common. Identify the risk factors that may improve strategies for treatment and prevention.
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Affiliation(s)
- Simona Silvetti
- Department of Cardiothoracic-Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic-Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
- ECMO Team, IRCCS Policlinico San Donato, Milan, Italy
| | - Valeria Pistuddi
- Department of Cardiothoracic-Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Giuseppe Isgrò
- Department of Cardiothoracic-Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Andrea Ballotta
- Department of Cardiothoracic-Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Mauro Cotza
- ECMO Team, IRCCS Policlinico San Donato, Milan, Italy
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Lo Coco V, Lorusso R, Raffa GM, Malvindi PG, Pilato M, Martucci G, Arcadipane A, Zieliński K, Suwalski P, Kowalewski M. Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille's heel. J Thorac Dis 2018; 10:6993-7004. [PMID: 30746245 DOI: 10.21037/jtd.2018.11.103] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is life-saving for potentially reversible heart failure and respiratory injuries not responsive to conventional therapies. Technological innovations have produced over the years significant improvements in ECMO devices (pump, cannula design and oxygenator) and have allowed a better risk/benefit profile. Alongside with recognized advantages in the treatment of very sick patients, ECMO remains an invasive procedure for mechanical circulatory support (MCS) and it is associated with complications that strongly influence the prognosis. Current review was designed to provide a comprehensive outline on ECMO complications, analyzing risk factors and strategies of management, focusing on adult population undergoing veno-arterial ECMO (VA-ECMO) therapy.
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Affiliation(s)
- Valeria Lo Coco
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe M Raffa
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | | | - Michele Pilato
- Department of the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Gennaro Martucci
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anaesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | | | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Clinical Department of Cardiac Surgery, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Poland.,Cardiothoracic Research Centre, Innovative Medical Forum, Bydgoszcz, Poland
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60
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Franchineau G, Luyt CE, Combes A, Schmidt M. Ventilator-associated pneumonia in extracorporeal membrane oxygenation-assisted patients. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:427. [PMID: 30581835 DOI: 10.21037/atm.2018.10.18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides a circulatory and/or respiratory assistance in case of refractory cardiogenic shock or acute respiratory distress syndrome (ARDS). Due to their extreme critical illness, these patients usually require prolonged mechanical ventilation, which is an inherent risk of ventilator-associated pneumonia (VAP). Although microorganisms responsible of VAP on ECMO are similar to those found in non-ECMO patients, classical suspicion criteria of VAP are no longer relevant on ECMO. Frequent severe chest X-Ray impairments, and poor specificity of the classical biomarkers on ECMO make VAP diagnosis challenging. In addition, significant drug pharmacokinetic modifications by the device may lead to low plasmatic antibiotic concentration and potential treatment failure. Consequently, rate of treatment failure and relapse appear high in that population (up to 30%), with significant impact on mortality and on the ECMO duration.
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Affiliation(s)
- Guillaume Franchineau
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Charles Edouard Luyt
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Alain Combes
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Matthieu Schmidt
- Sorbonne Universités, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
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Incidence of nosocomial infections in adult patients undergoing extracorporeal membrane oxygenation. Heart Lung 2018; 47:626-630. [PMID: 30166066 DOI: 10.1016/j.hrtlng.2018.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/21/2018] [Accepted: 07/11/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) are at increased risk for developing nosocomial infections owing to their underlying disease process along with numerous invasive monitoring devices. METHODS We retrospectively analyzed the rate, type, pathogens, outcomes, and risk factors of nosocomial infections that developed during adult patients on ECMO at our institution from 2012-2015. RESULTS Compared to current ELSO reported adult nosocomial infections rate of 20.5%, we report our rate of 26% (CI 17.2%-34.7%). No significant differences were observed in mortality (42.3% vs. 36.5%; p=0.598), and presence of either antibiotics prior to ECMO (57.7% vs. 56.7%; p=0.934) or culture-proven infection prior to ECMO (19.2% vs. 32.4%; p=0.201). Patients who developed nosocomial infections had longer duration of ECMO (13 vs. 5 days; p<0.001), longer length of stay (36.5 vs. 18.5 days; p=0.004), and more days on ventilator (29 vs. 12.5; p=0.002). Duration of ECMO (OR=1.20, 95% CI 1.02-1.39; p=0.020) and duration of ECMO greater than 10 days (OR=14.65, 95% CI 1.81-118.78; p=0.012) were independent risk factors for developing nosocomial infections. However, there was no difference in mortality when duration of ECMO >10 days was compared with ≤10 days (28.5% vs. 43.1%; p=0.154). CONCLUSION Nosocomial infections have no effect on survival in adult ECMO patients. Presence of either antibiotics or infection prior to ECMO has no effect on developing nosocomial infections while on ECMO. Duration of ECMO longer than 10 days is a major risk factor for developing nosocomial infection.
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Calderón Checa RM, Rojo Conejo P, González-Posada Flores AF, Llorente de la Fuente AM, Palacios Cuesta A, Aguilar JM, Belda Hofheinz S. Experience with infections in the use of extracorporeal membrane oxygenation. An Pediatr (Barc) 2018. [DOI: 10.1016/j.anpede.2017.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Calderón Checa RM, Rojo Conejo P, González-Posada Flores AF, Llorente de la Fuente AM, Palacios Cuesta A, Aguilar JM, Belda Hofheinz S. Infecciones durante oxigenación de membrana extracorpórea. An Pediatr (Barc) 2018; 89:86-91. [DOI: 10.1016/j.anpedi.2017.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/11/2017] [Accepted: 07/15/2017] [Indexed: 11/16/2022] Open
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Blood Stream Infection in Patients on Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure. Infect Control Hosp Epidemiol 2018; 39:871-874. [PMID: 29733005 DOI: 10.1017/ice.2018.90] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Bloodstream infection (BSI) occurred in 21 of 121 patients (17%) receiving venovenous extracorporeal membrane oxygenation within the median time of 6 days after initiation (interquartile range, 4-19 days). Longer duration of arterial catheterization and more blood transfusions were independently associated with BSI, which is associated with poor clinical outcomes.Infect Control Hosp Epidemiol 2018;1-4.
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Umei N, Ichiba S, Sakamoto A. Idiopathic pulmonary fibrosis patient supported with extracorporeal membrane oxygenation for 403 days while waiting for a lung transplant: A case report. Respir Med Case Rep 2018; 24:86-88. [PMID: 29977768 PMCID: PMC6010629 DOI: 10.1016/j.rmcr.2018.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 11/16/2022] Open
Abstract
According to the Extracorporeal Life Support Organization, the average duration of veno-venous extracorporeal membrane oxygenation (V-V ECMO) in adults with acute respiratory failure is 10.5-13.5 days. Some patients on V-V ECMO may not recover in such a short period of time, and recently, there have been more reports of prolonged V-V ECMO. However, we do not know how long it is feasible to wait for native lung recovery or lung transplant (LTx) with the use of ECMO. We describe a patient with acute exacerbation of idiopathic pulmonary fibrosis supported by ECMO for 403 days while waiting for a LTx. In this case, we kept the patient awake, and he was communicating frequently with his family. We changed the membrane oxygenator 23 times and the cannula 10 times without complication. However, we terminated the treatment on day 403 of ECMO because there was no access site for cannula insertion due to blockage by a venous thrombotic occlusion, making it impossible to continue this bridge to lung transplantation. It has become possible to maintain patients on ECMO for extended periods of time, but it is difficult to manage ECMO for more than one year without the development of a more durable lung support system.
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Affiliation(s)
- Nao Umei
- Department of Anesthesiology, Nippon Medical School Hospital, Japan
- Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Shingo Ichiba
- Department of Anesthesiology, Nippon Medical School Hospital, Japan
- Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Atsuhiro Sakamoto
- Department of Anesthesiology, Nippon Medical School Hospital, Japan
- Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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Bull T, Corley A, Smyth DJ, McMillan DJ, Dunster KR, Fraser JF. Extracorporeal membrane oxygenation line-associated complications: in vitro testing of cyanoacrylate tissue adhesive and securement devices to prevent infection and dislodgement. Intensive Care Med Exp 2018. [PMID: 29532189 PMCID: PMC5847637 DOI: 10.1186/s40635-018-0171-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) delivers cardiac and/or respiratory support to critically ill patients who have failed conventional medical therapies. If the large-bore cannulas used to deliver ECMO become infected or dislodged, the patient consequences can be catastrophic. ECMO cannula-related infection has been reported to be double the rate of other vascular devices (7.1 vs 3.4 episodes/1000 ECMO days respectively). The aim of this study was to assess the ability of cyanoacrylate tissue adhesive (TA) to inhibit bacterial growth at the ECMO cannulation site, and the effectiveness of TA and securement devices in securing ECMO cannulas and tubing. Methods This in vitro study tested the (1) antimicrobial qualities of TA against standard transparent dressing with ECMO cannula; (2) chemical compatibility between cannula, TA and removal agent; (3) pull-out strength of transparent dressing and TA at the cannula insertion site; and (4) pull-out strength of adhesive bandage and commercial sutureless securement devices (SSDs) on circuit tubing. Fisher’s exact test was used to evaluate differences in bacterial growth observed between the transparent dressing and TA groups. Data from mechanical testing were analysed using one-way ANOVA, followed by Tukey’s multiple comparison test or t test as appropriate. Statistical significance was defined as p < 0.05. Results No bacterial growth occurred under TA-covered cannulas compared with transparent dressing-covered cannulas (p = 0.002). Compared to plates lacking TA or transparent dressing, growth was observed at the insertion point and under the dressing in the transparent dressing group; however, no growth was observed in the TA group (p = 0.019). TA did not weaken the cannulas; however, the TA removal agent did after 60 min of exposure, compared with control (p < 0.01). Compared with transparent dressing, TA increased the pull-out force required for cannula dislodgement from the insertion point (p < 0.0001). SSDs significantly increased the force required to remove the tubing from the fixation points compared with adhesive bandage (p < 0.01). Conclusions Our findings suggest that the combined use of TA at the cannula insertion site with a commercial device for tubing securement could provide an effective bedside strategy to prevent or minimise infection and line dislodgement.
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Affiliation(s)
- Taressa Bull
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Level 3 Clinical Sciences Building, Rode Rd, Chermside, 4032, Queensland, Australia.
| | - Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Level 3 Clinical Sciences Building, Rode Rd, Chermside, 4032, Queensland, Australia
| | - Danielle J Smyth
- Bacterial Pathogenesis Laboratory, Queensland Institute of Medical Research, Herston Rd, Herston, 4006, Queensland, Australia
| | - David J McMillan
- Inflammation and Healing Research Cluster, Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, 90 Sippy Downs Dr, Sippy Downs, 4556, Queensland, Australia
| | - Kimble R Dunster
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Level 3 Clinical Sciences Building, Rode Rd, Chermside, 4032, Queensland, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Level 3 Clinical Sciences Building, Rode Rd, Chermside, 4032, Queensland, Australia
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Santiago-Lozano MJ, Barquín-Conde ML, Fuentes-Moreno L, León-Vela RM, Madrid-Vázquez L, Sánchez-Galindo A, López-Herce Cid J. Infectious complications in paediatric patients treated with extracorporeal membrane oxygenation. Enferm Infecc Microbiol Clin 2017; 36:563-567. [PMID: 29203305 DOI: 10.1016/j.eimc.2017.10.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/22/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The aim of this study was to analyse the incidence, treatment and evolution of infections in children treated with ECMO. METHODS A retrospective study based on a prospective database was performed. Children under the age of 18 years treated with ECMO from September 2006 to November 2015 were included. The patients' clinical characteristics were collected, together with ECMO technique, cultures and treatment of infection. RESULTS One hundred patients with a median age of 11 months were analysed. Heart disease was diagnosed in 94 patients. An infection was suspected and antibiotic treatment was initiated in 51 patients, although only 22 of them were microbiologically confirmed. The most common infection was sepsis (49%), followed by pneumonia (35.3%) and urinary tract infection (9.8%). There were no differences in haematological parameters and acute phase reactants between children with infection and those without. Children who died had a higher incidence of infection during ECMO (60.4%) than the survivors (40.3%), but the difference did not reach statistical significance (P=.07). The duration of admission in the PICU was 57 days in patients with infection vs 37 days in patients without infection but the difference was not statistically significant (P=.067). CONCLUSIONS Infection in children with ECMO is common. There are no specific infection parameters and less than half of the clinical infections are confirmed microbiologically. There was no statistically significant correlation between infection and mortality or duration of PICU stay.
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Affiliation(s)
- Maria José Santiago-Lozano
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007
| | | | - Lucía Fuentes-Moreno
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Roberto Manuel León-Vela
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Lucas Madrid-Vázquez
- Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Amelia Sánchez-Galindo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007
| | - Jesús López-Herce Cid
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Madrid, España; Instituto de Investigación Sanitaria, Hospital Gregorio Marañón, Madrid, España; Red de Salud Maternoinfantil y del Desarrollo (Red SAMID) RD16/0022/0007; Departamento de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España.
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Sun G, Li B, Lan H, Wang J, Lu L, Feng X, Luo X, Yan H, Mu Y. Factores de riesgo de las infecciones nosocomiales en pacientes que reciben oxigenación por membrana extracorpórea. Med Clin (Barc) 2017. [DOI: 10.1016/j.medcli.2017.03.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nosocomial Infections During Extracorporeal Membrane Oxygenation: Incidence, Etiology, and Impact on Patients' Outcome. Crit Care Med 2017; 45:1726-1733. [PMID: 28777198 DOI: 10.1097/ccm.0000000000002652] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To study incidence, type, etiology, risk factors, and impact on outcome of nosocomial infections during extracorporeal membrane oxygenation. DESIGN Retrospective analysis of prospectively collected data. SETTING Italian tertiary referral center medical-surgical ICU. PATIENTS One hundred five consecutive patients who were treated with extracorporeal membrane oxygenation from January 2010 to November 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ninety-two patients were included in the analysis (48.5 [37-56] years old, simplified acute physiology score II 37 [32-47]) who underwent peripheral extracorporeal membrane oxygenation (87% veno-venous) for medical indications (78% acute respiratory distress syndrome). Fifty-two patients (55%) were infected (50.4 infections/1,000 person-days of extracorporeal membrane oxygenation). We identified 32 ventilator-associated pneumonia, eight urinary tract infections, five blood stream infections, three catheter-related blood stream infections, two colitis, one extracorporeal membrane oxygenation cannula infection, and one pulmonary-catheter infection. G+ infections (35%) occurred earlier compared with G- (48%) (4 [2-10] vs. 13 [7-23] days from extracorporeal membrane oxygenation initiation; p < 0.001). Multidrug-resistant organisms caused 56% of bacterial infections. Younger age (2-35 years old) was independently associated with higher risk for nosocomial infections. Twenty-nine patients (31.5%) died (13.0 deaths/1,000 person-days of extracorporeal membrane oxygenation). Infected patients had higher risk for death (18 vs. 8 deaths/1,000 person-days of extracorporeal membrane oxygenation; p = 0.037) and longer ICU stay (32.5 [19.5-78] vs. 19 [10.5-27.5] days; p = 0.003), mechanical ventilation (36.5 [20-80.5] vs. 16.5 [9-25.5] days; p < 0.001), and extracorporeal membrane oxygenation (25.5 [10.75-54] vs. 10 [5-13] days; p < 0.001). Older age (> 50 years old), reason for connection different from acute respiratory distress syndrome, higher simplified acute physiology score II, diagnosis of ventilator-associated pneumonia, and infection by multidrug-resistant bacteria were independently associated to increased death rate. CONCLUSIONS Infections (especially ventilator-associated pneumonia) during extracorporeal membrane oxygenation therapy are common and frequently involve multidrug-resistant organisms. In addition, they have a negative impact on patients' outcomes.
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Population Pharmacokinetics and Dose Optimization of Teicoplanin during Venoarterial Extracorporeal Membrane Oxygenation. Antimicrob Agents Chemother 2017; 61:AAC.01015-17. [PMID: 28674057 DOI: 10.1128/aac.01015-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 06/24/2017] [Indexed: 12/14/2022] Open
Abstract
The pharmacokinetics (PK) of drugs are known to be significantly altered in patients receiving extracorporeal membrane oxygenation (ECMO). However, clinical studies of the PK of drugs administered during ECMO are scarce, and the proper dosing adjustment has yet to be established. We developed a population PK model for teicoplanin, investigated covariates influencing teicoplanin exposure, and suggested an optimal dosing regimen for ECMO patients. Samples for PK analysis were collected from 10 adult patients, and a population PK analysis and simulations were performed to identify an optimal teicoplanin dose needed to provide a >50% probability of target attainment at 72 h using a trough concentration target of >10 μg/ml for mild to moderate infections and a trough concentration target of >15 μg/ml for severe infections. Teicoplanin was well described by a two-compartment PK model with first-order elimination. The presence of ECMO was associated with a lower central volume of distribution, and continuous renal replacement therapy (CRRT) was associated with a higher peripheral volume of distribution. For mild to moderate infections, an optimal dose was a loading dose (LD) of 600 mg and a maintenance dose (MD) of 400 mg for ECMO patients not receiving CRRT and an LD of 800 mg and an MD of 600 mg for those receiving CRRT. For severe infections, an optimal dose was an LD of 1,000 mg and an MD of 800 mg for ECMO patients not receiving CRRT and an LD of 1,200 mg and an MD of 1,000 mg for those receiving CRRT. In conclusion, doses higher than the standard doses are needed to achieve fast and appropriate teicoplanin exposure during ECMO. (This study has been registered at ClinicalTrials.gov under identifier NCT02581280.).
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Biffi S, Di Bella S, Scaravilli V, Peri AM, Grasselli G, Alagna L, Pesenti A, Gori A. Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention. Int J Antimicrob Agents 2017; 50:9-16. [DOI: 10.1016/j.ijantimicag.2017.02.025] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 11/27/2022]
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Burns S, Constantin N, Robles P. Understanding the long-term sequelae of ECMO survivors. Intensive Care Med 2017; 44:1144-1147. [PMID: 28210774 DOI: 10.1007/s00134-017-4714-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 02/04/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Stacey Burns
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
| | - Natalie Constantin
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Priscila Robles
- Department of Medicine, Interdepartmental Division of Critical Care Medicine, Toronto General Research Institute, Institute of Medical Science, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.,Graduate Department of Rehabilitation Science, University of Toronto, Toronto, Canada
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Rozencwajg S, Pilcher D, Combes A, Schmidt M. Outcomes and survival prediction models for severe adult acute respiratory distress syndrome treated with extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:392. [PMID: 27919283 PMCID: PMC5139100 DOI: 10.1186/s13054-016-1568-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) has known a growing interest over the last decades with promising results during the 2009 A(H1N1) influenza epidemic. Targeting populations that can most benefit from this therapy is now of major importance. Survival has steadily improved for a decade, reaching up to 65% at hospital discharge in the most recent cohorts. However, ECMO is still marred by frequent and significant complications such as bleeding and nosocomial infections. In addition, physiological and psychological symptoms are commonly described in long-term follow-up of ECMO-treated ARDS survivors. Because this therapy is costly and exposes patients to significant complications, seven prediction models have been developed recently to help clinicians identify patients most likely to survive once ECMO has been initiated and to facilitate appropriate comparison of risk-adjusted outcomes between centres and over time. Higher age, immunocompromised status, associated extra-pulmonary organ dysfunction, low respiratory compliance and non-influenzae diagnosis seem to be the main determinants of poorer outcome.
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Affiliation(s)
- Sacha Rozencwajg
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, Australia.,Intensive Care Department, Alfred Hospital, Melbourne, Australia
| | - Alain Combes
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France
| | - Matthieu Schmidt
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France. .,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651, Paris Cedex 13, France.
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The Evidence Base for Prophylactic Antibiotics in Patients Receiving Extracorporeal Membrane Oxygenation. ASAIO J 2016; 62:6-10. [DOI: 10.1097/mat.0000000000000287] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Impact of bloodstream infections on catheter colonization during extracorporeal membrane oxygenation. J Artif Organs 2015; 19:128-33. [DOI: 10.1007/s10047-015-0882-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/18/2015] [Indexed: 01/07/2023]
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Schmidt M, Combes A. Complications infectieuses sous ECMO. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE There are limited data on the outcomes of children receiving delayed (≥7 days) extracorporeal membrane oxygenation after cardiac surgery. The primary aim of this project is to identify the aetiology and outcomes of extracorporeal membrane oxygenation in children receiving delayed (≥7 days) extracorporeal membrane oxygenation after cardiac surgery. PATIENTS AND METHODS We conducted a retrospective review of all children ≤18 years supported with delayed extracorporeal membrane oxygenation after cardiac surgery between the period January, 2001 and March, 2012 at the Arkansas Children's Hospital, United States of America, and Royal Children's Hospital, Australia. The data collected in our study included patient demographic information, diagnoses, extracorporeal membrane oxygenation indication, extracorporeal membrane oxygenation support details, medical and surgical history, laboratory, microbiological, and radiographic data, information on organ dysfunction, complications, and patient outcomes. The outcome variables evaluated in this report included: survival to hospital discharge and current survival with emphasis on neurological, renal, pulmonary, and other end-organ function. RESULTS During the study period, 423 patients undergoing cardiac surgery were supported with extracorporeal membrane oxygenation at two institutions, with a survival of 232 patients (55%). Of these, 371 patients received extracorporeal membrane oxygenation <7 days after cardiac surgery, with a survival of 205 (55%) patients, and 52 patients received extracorporeal membrane oxygenation ≥7 days after cardiac surgery, with a survival of 27 (52%) patients. The median duration of extracorporeal membrane oxygenation run for the study cohort was 5 days (interquartile range: 3, 10). In all, 14 patients (25%) received extracorporeal membrane oxygenation during active cardiopulmonary resuscitation with chest compressions. There were 24 patients (44%) who received dialysis while being on extracorporeal membrane oxygenation. There were eight patients (15%) who had positive blood cultures and four patients (7%) who had positive urine cultures while being on extracorporeal membrane oxygenation. There were nine patients (16%) who had bleeding complications associated with extracorporeal membrane oxygenation runs. There were 10 patients (18%) who had cerebrovascular thromboembolic events associated with extracorporeal membrane oxygenation runs. Of these, 19 patients are still alive with significant comorbidities. CONCLUSIONS This study demonstrates that mortality outcomes are comparable among children receiving extracorporeal membrane oxygenation ≥7 days and <7 days after cardiac surgery. The proportion of patients receiving extracorporeal membrane oxygenation ≥7 days is small and the aetiology diverse.
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Influence of different oxygenator types on changing frequency, infection incidence, and mortality in ARDS patients on veno-venous ECMO. Int J Artif Organs 2014; 37:839-46. [PMID: 25362902 DOI: 10.5301/ijao.5000360] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2014] [Indexed: 01/19/2023]
Abstract
PURPOSE Veno-venous extracorporeal membrane oxygenation (vv-ECMO) is pivotal in the treatment of patients suffering from acute respiratory distress syndrome (ARDS). Comparative data with different oxygenator models have not yet been reported. The aim of this retrospective investigation was therefore to assess whether different oxygenator types might influence changing frequency, infection incidence, and mortality in patients on vv-ECMO. METHODS 42 patients undergoing vv-ECMO between 1998 and 2009 were identified. In 20 out of these patients, a polypropylene (PP) microporous hollow fiber membrane oxygenator, and in 22 patients a nonmicroporous polymethylpentene (PMP) diffusion membrane oxygenator was used. Infection incidence, changing frequency, and mortality were documented. RESULTS In the PMP group, an oxygenator change was necessary less often than in the PP group (p<0.001). The incidence of bacterial, viral, or fungal growth was similar in the groups, thus independent of the frequency of oxygenator change. Irrespective of the groups, the occurrence of Candida sp. tended to correlate with death (p = 0.06). In general, there was a trend towards a higher infection incidence in the subgroup with pulmonary ARDS (p = 0.07). Moreover, infection incidence was associated with a longer ICU stay (p = 0.03) and longer ECMO therapy (p = 0.03). ICU mortality was lower in the PMP group than in the PP group, although not statistically significant (p = 0.10). CONCLUSIONS The PMP oxygenator membranes showed benefits with regards to changing frequency, but not infection incidence, length of ICU stay, and length of ECMO therapy. There was a trend towards a lower ICU mortality in patients with PMP oxygenators.
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Papadopoulos N, Marinos S, El-Sayed Ahmad A, Keller H, Meybohm P, Zacharowski K, Moritz A, Zierer A. Risk factors associated with adverse outcome following extracorporeal life support: analysis from 360 consecutive patients. Perfusion 2014; 30:284-90. [PMID: 25049285 DOI: 10.1177/0267659114542458] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Risk factors for adverse outcome after extracorporeal life support (ECLS) are yet to be defined. For this purpose, we reviewed our institutional data from more than a decade, focusing on patients with ECLS. METHODS Between December 2001 and June 2013, 360 consecutive cardiac surgical patients received ECLS for post-cardiotomy cardiogenic shock, with high mortality risk despite optimal conventional therapy. Patient demographics, clinical characteristics, ECLS-related morbidity, as well as in-hospital and long-term mortality were analysed. Multivariate logistic regression analysis was performed to identify independent predictors of adverse outcome (failed ECLS weaning, in-hospital mortality). RESULTS The mean age was 62±17 years, 76% were male and the mean preoperative ejection fraction was 35±16%. ECLS was established through peripheral (90%) or central thoracic cannulation. The mean duration of ECLS was 7±1 days. Intra-aortic balloon pumps were implanted in 22% of the patients. ECLS weaning was successful in 58% and 30% could be discharged from hospital. The main cause of death was sepsis (69%). Overall, major cerebrovascular events occurred in 12% (bleeding 3%, embolic 9%), limb ischaemia in 13%, gastrointestinal complications in 16% and renal replacement therapy in 61%. Independent risk factors for adverse outcome were prior cardiorespiratory resuscitation (OR: 4.1, 95%CI: 0.34-4.21, p=0.04), pH <7.1 (OR: 2.8, 95%CI: 0.45-3.28, p=0.01), serum lactate >120 mg/dL (OR: 2.6, 95%CI: 0.75-2.96, p< 0.01), norepinephrine dosage >0.5 µg/kg/min (OR: 2.4, 95%CI: 0.35-2.92, p=0.02) and age >75 years (OR: 2.0, 95%CI: 0.41-2.88, p=0.02). Kaplan Meier estimates for long-term survival were 26±3% at one year and 22±2% at five years. CONCLUSION ECLS therapy offers one-year survival to one quarter of patients with an otherwise fatal prognosis. Procedural mortality is low and morbidity at the implantation site typically moderate. Thus, prolonged metabolic deterioration in combination with high-dose vasopressor support prior to ECLS therapy should be avoided, particularly in younger patients.
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Affiliation(s)
- N Papadopoulos
- Division of Thoracic and Cardiovascular Surgery, University Frankfurt/Main, Germany
| | - S Marinos
- Division of Thoracic and Cardiovascular Surgery, University Frankfurt/Main, Germany
| | - A El-Sayed Ahmad
- Division of Thoracic and Cardiovascular Surgery, University Frankfurt/Main, Germany
| | - H Keller
- Division of Thoracic and Cardiovascular Surgery, University Frankfurt/Main, Germany
| | - P Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt/Main, Germany
| | - K Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt/Main, Germany
| | - A Moritz
- Division of Thoracic and Cardiovascular Surgery, University Frankfurt/Main, Germany
| | - A Zierer
- Division of Thoracic and Cardiovascular Surgery, University Frankfurt/Main, Germany
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Invasive pulmonary aspergillosis post extracorporeal membrane oxygenation support and literature review. Med Mycol Case Rep 2014; 4:12-5. [PMID: 24624325 DOI: 10.1016/j.mmcr.2014.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/30/2014] [Indexed: 01/24/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for reversible pulmonary failure in critically ill patients has increased over the last few decades. Nosocomial infections are a major complication of ECMO and fungi have been found to be a common cause. Herein, we describe a case of invasive pulmonary aspergillosis following ECMO, which was successfully treated with combination antifungal therapy and interferon-gamma.
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81
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Aubron C, Cheng AC, Pilcher D, Leong T, Magrin G, Cooper DJ, Scheinkestel C, Pellegrino V. Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R73. [PMID: 23594433 PMCID: PMC4056036 DOI: 10.1186/cc12681] [Citation(s) in RCA: 240] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 04/16/2013] [Indexed: 12/12/2022]
Abstract
Introduction Mortality of patients on extracorporeal membrane oxygenation (ECMO) remains high. The objectives of this study were to assess the factors associated with outcome of patients undergoing ECMO in a large ECMO referral centre and to compare veno-arterial ECMO (VA ECMO) with veno-venous ECMO (VV ECMO). Methods We reviewed a prospectively obtained ECMO database and patients' medical records between January 2005 and June 2011. Demographic characteristics, illness severity at admission, ECMO indication, organ failure scores before ECMO and the ECMO mode and configuration were recorded. Bleeding, neurological, vascular and infectious complications that occurred on ECMO were also collected. Demographic, illness, ECMO support descriptors and complications associated with hospital mortality were analysed. Results ECMO was initiated 158 times in 151 patients. VA ECMO (66.5%) was twice as common as VV ECMO (33.5%) with a median duration significantly shorter than for VV ECMO (7 days (first and third quartiles: 5; 10 days) versus 10 days (first and third quartiles: 6; 16 days)). The most frequent complications during ECMO support were bleeding and bloodstream infections regardless of ECMO type. More than 70% of the ECMO episodes were successfully weaned in each ECMO group. The overall mortality was 37.3% (37.1% for the patients who underwent VA ECMO, and 37.7% for the patients who underwent VV ECMO). Haemorrhagic events, assessed by the total of red blood cell units received during ECMO, were associated with hospital mortality for both ECMO types. Conclusions Among neurologic, vascular, infectious and bleeding events that occurred on ECMO, bleeding was the most frequent and had a significant impact on mortality. Further studies are needed to better investigate bleeding and coagulopathy in these patients. Interventions that reduce these complications may improve outcome.
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82
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Aubron C, Cheng AC, Pilcher D, Leong T, Magrin G, Cooper DJ, Scheinkestel C, Pellegrino V. Infections acquired by adults who receive extracorporeal membrane oxygenation: risk factors and outcome. Infect Control Hosp Epidemiol 2012; 34:24-30. [PMID: 23221189 DOI: 10.1086/668439] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To analyze infectious complications that occur in patients who receive extracorporeal membrane oxygenation (ECMO), associated risk factors, and consequences on patient outcome. DESIGN Retrospective observational survey from 2005 through 2011. PARTICIPANTS AND SETTING Patients who required ECMO in an Australian referral center. METHODS Cases of bloodstream infection (BSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP) that occurred in patients who received ECMO were analyzed. RESULTS A total of 146 ECMO procedures were performed for more than 48 hours in 139 patients, and 36 patients had a total of 46 infections (30.1 infectious episodes per 1,000 days of ECMO). They included 24 cases of BSI, 6 of them secondary to VAP; 23 cases of VAP; and 5 cases of CAUTI. The most frequent pathogens were Enterobacteriaceae (found in 16 of 46 cases), and Candida was the most common cause of BSI (in 9 of 24 cases). The Sequential Organ Failure Assessment score before ECMO initiation and the number of days of support were independently associated with a risk of BSI, with odds ratios of 1.23 (95% confidence interval [CI], 1.03-1.47; [Formula: see text]) and 1.08 (95% CI, 1.03-1.19]; [Formula: see text]), respectively. Infected patients did not have a significantly higher mortality compared with uninfected patients (41.7% vs 32%; [Formula: see text]), but intensive care unit length of stay (16 days [interquartile range, 8-26 days] vs 11 days [IQR, 4-19 days]; [Formula: see text]) and hospital length of stay (33.5 days [interquartile range, 15.5-55.5] vs 24 days [interquartile range, 9-42 days]; [Formula: see text]) were longer. CONCLUSION The probability of infection increased with the duration of support and the severity of illness before initiation of ECMO. Infections affected length of stay but did not have an impact on mortality.
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Affiliation(s)
- Cecile Aubron
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia.
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83
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Schmidt M, Bréchot N, Hariri S, Guiguet M, Luyt CE, Makri R, Leprince P, Trouillet JL, Pavie A, Chastre J, Combes A. Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation. Clin Infect Dis 2012; 55:1633-41. [PMID: 22990851 DOI: 10.1093/cid/cis783] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Incidence and impact on adult patients' outcomes of nosocomial infections (NIs) occurring during venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for refractory cardiogenic shock have rarely been described. METHODS We retrospectively reviewed the charts of a large series of patients who received VA-ECMO in our intensive care unit (ICU) from January 2003 through December 2009. Incidence, types, risk factors, and impact on outcomes of NIs occurring during ECMO support were analyzed. RESULTS Among 220 patients (49 ± 16 years old, simplified acute physiology score (SAPS) II 61 ± 20) who underwent ECMO support for >48 hours for a total of 2942 ECMO days, 142 (64%) developed NIs. Ventilator-associated pneumonia (VAP), bloodstream infections, cannula infections, and mediastinitis infections occurred in 55%, 18%, 10% and 11% of the patients, respectively. More critical condition at ICU admission, but not antibiotics at the time of ECMO cannulation, was associated with subsequently developing NIs (hazard ratio, 0.73; 95% confidence interval [CI], .50-1.05; P = .09). Infected patients had longer durations of mechanical ventilation, ECMO support, and hospital stays. Independent predictors of death were infection with severe sepsis or septic shock (odds ratio, 1.93; 95% CI, 1.26-2.94; P = .002) and SAPS II, whereas immunosuppression and myocarditis as the reason for ECMO support were associated with better outcomes. CONCLUSIONS Cardiogenic shock patients who received the latest generation VA-ECMO still had a high risk of developing NIs, particularly VAP. Strategies aimed at preventing these infections may improve the outcomes of these critically ill patients.
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Affiliation(s)
- Matthieu Schmidt
- Service de Réanimation Médicale, Institut de Cardiologie, Paris Cedex 13, France
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84
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Sadahiro T, Oda S, Nakamura M, Hirayama Y, Watanabe E, Tateishi Y, Shinozaki K. Trends in and perspectives on extracorporeal membrane oxygenation for severe adult respiratory failure. Gen Thorac Cardiovasc Surg 2012; 60:192-201. [PMID: 22451141 DOI: 10.1007/s11748-011-0868-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Indexed: 10/28/2022]
Abstract
Various approaches such as ventilator management involving lung-protective ventilation, corticosteroids, prone positioning, and nitric oxide have failed to maintain sufficient lung oxygenation or appropriate ventilation competence in very severe acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) has been aggressively introduced for such patients, although in only a few institutions. The clinical usefulness of ECMO in a large-scale multicenter study (CESAR trial, 2009) and continued development/improvement of ECMO devices have facilitated performance of ECMO, with further increase in the number of institutions adopting ECMO therapy. Clinical usefulness of ECMO was documented in many cases of severe ARDS secondary to influenza A (H1N1) 2009 infection. ECMO requires establishment of an appropriate management system to minimize fatal complications (e.g., hemorrhage), which requires a multidisciplinary team. This, in combination with a new technique, interventional lung assist, will further extend the indications for ECMO. ECMO can be expected to gain importance as a respiratory support technique.
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Affiliation(s)
- Tomohito Sadahiro
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuoku, Chiba, 260-8677, Japan.
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85
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20-year experience of prolonged extracorporeal membrane oxygenation in critically ill children with cardiac or pulmonary failure. Ann Thorac Surg 2012; 93:1584-90. [PMID: 22421589 DOI: 10.1016/j.athoracsur.2012.01.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 01/03/2012] [Accepted: 01/06/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for life-threatening respiratory or circulatory failure. Although outcomes are favorable with short-term ECMO therapy, data on the outcomes of prolonged ECMO therapy in children are very limited. This study aimed to study morbidity and mortality associated with prolonged ECMO therapy (≥28 days) in children with refractory cardiac or pulmonary failure. METHODS We conducted a retrospective review of all children≤18 years supported with ECMO for ≥28 days between January 1991 and September 2011 at the Arkansas Children's Hospital. The data collected in our study included patient demographic information; diagnosis; indication for ECMO; ECMO support details; medical and surgical history; laboratory, microbiologic, and radiographic data; information on organ dysfunction; complications; and patient outcomes. The outcome variables evaluated in this report included survival to ECMO decannulation, survival to hospital discharge, and current survival with emphasis on neurologic, renal, pulmonary, and other end organ function. RESULTS During the study period, 984 events in 951 patients were supported with ECMO with a 30-day survival of 666 events (68%). Only 22 ECMO runs were ≥28 days and were eligible for inclusion in this report. The longest ECMO run in our series was 1,206 hours (50 days). The average length of ECMO run in this cohort was 855±133 hours, with a mean intensive care unit length of stay of 56±27 days. Ten patients (45%) were successfully decannulated from ECMO. Six patients (27%) were alive 30 days after decannulation, and only 4 patients (19%) survived to hospital discharge. Of the 4 survivors, only 3 patients (14%) are living to date. Of the 3 living children, 2 have significant neurologic issues with brain atrophy and developmental delay, and 1 is awaiting renal transplant; all 3 survivors have chronic lung disease. CONCLUSIONS This case series highlights that the prolonged use of ECMO in children with refractory cardiac failure, respiratory failure, or both is associated with low survival. Furthermore, it suggests that the survivors of prolonged ECMO runs have significant long-term sequelae.
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86
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Vogel AM, Lew DF, Kao LS, Lally KP. Defining risk for infectious complications on extracorporeal life support. J Pediatr Surg 2011; 46:2260-4. [PMID: 22152861 DOI: 10.1016/j.jpedsurg.2011.09.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 09/03/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND/PURPOSE Little is known about potentially modifiable risk factors associated with infectious complications (IC) acquired during extracorporeal life support (ECLS). PATIENTS AND METHODS The Extracorporeal Life Support Organization registry was accessed, and data on patient demographics, run characteristics, infections, and outcomes were collected. Patients who developed IC while on ECLS were compared to those that did not. Regression analysis was performed. Results are expressed as odds ratios, with P < .05 considered significant. RESULTS Infectious complications developed in 10.2% of 38,661 patients and was associated with increased odds of death. Risk factors for IC included increasing age, diagnosis, more remote decade, complications, presence of multiple complications, and ECLS mode. The risk of IC increased with the number of complications (P < .001). Patients with positive cultures before ECLS also had increased odds of IC (OR 2.12, 95% CI 1.92-2.34, P < .001). Those with IC were more likely to have cultures grow aggressive organisms (non-lactose fermenting gram negative rods, methicillin resistant Staphylococcus aureus, and fungi). CONCLUSIONS Strategies to reduce IC while on ECLS should be aimed at prevention of complications and treatment of pre-existing infections. Future studies should address whether broader spectrum antibiotic prophylaxis and/or empiric coverage for suspected sepsis is indicated in ECLS patients.
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Affiliation(s)
- Adam M Vogel
- Department of Pediatric Surgery, The University of Texas Health Science Center, Houston, TX 77030, USA.
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87
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Prolonged venovenous extracorporeal membrane oxygenation in a child with leukemia and persistent bacteremia. Pediatr Crit Care Med 2011; 12:e395-7. [PMID: 21116210 DOI: 10.1097/pcc.0b013e3181fe25ce] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In patients who require extracorporeal membrane oxygenation for prolonged periods, it is uncertain whether nosocomial bacteremia that persists throughout an entire extracorporeal membrane oxygenation run can be associated with good outcomes. DESIGN Case report. SETTING Tertiary pediatric intensive care unit. PATIENT A 6-yr-old boy with acute myeloid leukemia and prolonged mechanical ventilatory support. INTERVENTIONS Venovenous extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS The patient required extracorporeal membrane oxygenation for refractory hypoxia secondary to nosocomial pneumonia. On day 2 of the extracorporeal membrane oxygenation run and every day thereafter, blood cultures were consistently positive for Stenotrophomonas maltophilia despite combination therapy with intravenous polymyxin B and cotrimoxazole. Excluding the cannulae, the extracorporeal membrane oxygenation circuit was electively changed once during the run but without any effect on bacteremia. After 38 days of extracorporeal membrane oxygenation, the patient was successfully decannulated and the bacteremia ceased. He remains completely well and disease-free at 6-month follow-up. CONCLUSIONS Sustained bacteremia during an extracorporeal membrane oxygenation run should not be regarded as a reason to withdraw extracorporeal support, although efforts are clearly warranted to identify possible sources of sepsis and wean off extracorporeal membrane oxygenation at the earliest opportunity.
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Köck R, Siam K, Al-Malat S, Christmann J, Schaumburg F, Becker K, Friedrich AW. Characteristics of hospital patients colonized with livestock-associated meticillin-resistant Staphylococcus aureus (MRSA) CC398 versus other MRSA clones. J Hosp Infect 2011; 79:292-6. [PMID: 22024921 DOI: 10.1016/j.jhin.2011.08.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 08/22/2011] [Indexed: 01/24/2023]
Abstract
Meticillin-resistant Staphylococcus aureus (MRSA) associated with the clonal complex (CC) 398 has emerged among livestock and humans exposed to these animals. MRSA CC398 has so far contributed relatively little to spread of MRSA and the burden of disease in the healthcare setting. This study aimed to assess whether demographic and clinical differences in patients colonized with MRSA CC398 and those carrying other MRSA clones contribute to the observed differences in transmission and infection rates. Age, sex, length of stay (LOS), diagnoses and medical procedures were assessed in all patients with MRSA admitted to a university hospital in 2008 and 2009. S. aureus protein A gene (spa) typing was performed on the first MRSA isolate from each patient. Patients colonized or infected with MRSA that had spa types indicative of CC398 (MRSA CC398) were compared with patients who had other MRSA clones (MRSA non-CC398). Age (53 vs 59 years), mean LOS (8 vs 13 days) and percentage of patients admitted to an intensive care unit (12% vs 17%) differed significantly between MRSA CC398 and MRSA non-CC398 patients, respectively. The mean numbers and types of diagnoses and medical procedures performed for patients in these two groups also differed significantly. The differences in patient characteristics could explain, at least in part, the relatively low rates of transmission and infection associated with MRSA CC398 in the healthcare setting.
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Affiliation(s)
- R Köck
- Institute of Hygiene, University Hospital Münster, Münster, Germany
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Antimicrobial Prophylaxis and Infection Surveillance in Extracorporeal Membrane Oxygenation Patients: A Multi-Institutional Survey of Practice Patterns. ASAIO J 2011; 57:231-8. [DOI: 10.1097/mat.0b013e31820d19ab] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Pharmacokinetics of cefotaxime and desacetylcefotaxime in infants during extracorporeal membrane oxygenation. Antimicrob Agents Chemother 2010; 54:1734-41. [PMID: 20176908 DOI: 10.1128/aac.01696-09] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to temporarily sustain cardiac and respiratory function in critically ill infants but can cause pharmacokinetic changes necessitating dose modifications. Cefotaxime (CTX) is used to prevent and treat infections during ECMO, but the current dose regimen is based on pharmacokinetic data obtained for non-ECMO patients. The objective of this study was to validate the standard dose regimen of 50 mg/kg of body weight twice a day (postnatal age [PNA], <1 week), 50 mg/kg three times a day (PNA, 1 to 4 weeks), or 37.5 mg/kg four times a day (PNA, >4 weeks). We included 37 neonates on ECMO, with a median (range) PNA of 3.3 (0.67 to 199) days and a median (range) body weight of 3.5 (2.0 to 6.2) kg at the onset of ECMO. Median (range) ECMO duration was 108 (16 to 374) h. Plasma samples were taken during routine care, and pharmacokinetic analysis of CTX and its active metabolite, desacetylcefotaxime (DACT), was done using nonlinear mixed-effects modeling (NONMEM). A one-compartment pharmacokinetic model for CTX and DACT adequately described the data. During ECMO, CTX clearance (CL(CTX)) was 0.36 liter/h (range, 0.19 to 0.75 liter/h), the volume of distribution of CTX (V(CTX)) was 1.82 liters (0.73 to 3.02 liters), CL(DACT) was 1.46 liters/h (0.48 to 5.93 liters/h), and V(DACT) was 11.0 liters (2.32 to 28.0 liters). Elimination half-lives for CTX and DACT were 3.5 h (1.6 to 6.8 h) and 5.4 h (0.8 to 14 h). Peak CTX concentration was 98.0 mg/liter (33.2 to 286 mg/liter). DACT concentration varied between 0 and 38.2 mg/liter, with a median of 10 mg/liter in the first 12 h postdose. Overall, CTX concentrations were above the MIC of 8 mg/liter over the entire dose interval. Only 1 of the 37 patients had a sub-MIC concentration for over 50% of the dose interval. In conclusion, the standard cefotaxime dose regimen provides sufficiently long periods of supra-MIC concentrations to provide adequate treatment of infants on ECMO.
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