The ICM research agenda on extracorporeal life support

Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism

Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management.

Age and associated outcomes among patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory failure: analysis of the Extracorporeal Life Support Organization registry

PURPOSE

Venovenous extracorporeal membrane oxygenation (VV-ECMO) can be used to support patients with refractory acute respiratory failure, though guidance on patient selection is lacking. While age is commonly utilized as a factor in establishing the potential VV-ECMO candidacy of these patients, little is known regarding its association with outcome. We studied the association between increasing patient age and outcomes among patients with acute respiratory failure receiving VV-ECMO.

METHODS

In this registry-based cohort study, we used individual patient data from 144 centres. We included adult patients (≥ 18 years of age) receiving VV-ECMO from 2017 to 2022. The primary outcome was hospital mortality. Secondary outcomes included a composite of complications following initiation of VV-ECMO. We conducted Bayesian analyses to estimate the association between chronological age and outcomes.

RESULTS

We included 27,811 patients receiving VV-ECMO. Of these, 11,533 (41.5%) died in hospital. For the analysis conducted using weakly informed priors, and as compared to the reference category of age 18-29, the age brackets of 30-39 (odds ratio [OR] 1.17, 95% credible interval [CrI] 1.06-1.31), 40-49 (OR 1.65, 95% CrI 1.49-1.82), 50-59 (OR 2.39, 95% CrI 2.16-2.61), 60-69 (OR 3.29, 95% CrI 2.97-3.67), 70-79 (OR 4.57, 95% CrI 3.90-5.37), and ≥ 80 (OR 8.08, 95% CrI 4.85-13.74) were independently associated with increasing hospital mortality. Similar results were found between increasing age and post-ECMO complications.

CONCLUSIONS

Among patients receiving VV-ECMO for acute respiratory failure, increasing age is significantly associated with poorer outcomes, and this association emerges as early as 30 years of age.

Therapeutic drug monitoring of imipenem/cilastatin and meropenem in critically ill adult patients

OBJECTIVES

To investigate the factors influencing imipenem/cilastatin (IMI) and meropenem (MEM) concentrations in critically ill adult patients and the role of these concentrations in the clinical outcome.

METHODS

Plasma trough concentrations of IMI and MEM were detected by high-performance liquid chromatography. A target value of 100%-time above MIC was used for the drugs.

RESULTS

A total of 186 patients were included, with 87 receiving IMI and 99 receiving MEM. The percentages of patients reaching the target IMI and MEM concentrations were 44.8% and 38.4%, respectively. The proportions of patients infected with drug-resistant bacteria were 57.5% and 69.7% in the IMI group and MEM group, respectively. In the multivariate analysis, the risk factors for an IMI concentration that did not reach the target were infection with drug-resistant bacteria, and those for MEM were infection with drug-resistant bacteria, estimated glomerular filtration rate, and diabetes mellitus. A total of 47.1% of patients had good outcomes in the IMI cohort, and 38.1% of patients had good outcomes in the MEM cohort. The duration of mechanical ventilation and IMI concentration were associated with ICU stay in patients in the IMI cohort, while MEM concentration and severe pneumonia affected the clinical outcome of patients in the MEM cohort.

CONCLUSION

Infection with drug-resistant bacteria is an important factor influencing whether IMI and MEM concentrations reach the target. Furthermore, IMI and MEM concentrations are associated with the clinical outcome, and elevated doses of IMI and MEM should be given to patients who are infected with drug-resistant bacteria.

Anticoagulation and Bleeding during Veno-Venous Extracorporeal Membrane Oxygenation: Insights from the PROTECMO Study

Rationale: Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, whereas bleeding complications continue to pose major challenges. Objectives: To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO. Methods: This was an international prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality. Measurements and Main Results: The study cohort included 652 patients, and 8,471 days on ECMO were analyzed. Unfractionated heparin was the initial anticoagulant in 77% of patients, and the most frequently used anticoagulant during the ECMO course (6,221 d; 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (interquartile range, 39 to 61 s) but dropped by 5.3 seconds after the first bleeding event (95% confidence interval, -7.4 to -3.2; P < 0.01). Bleeding occurred on 1,202 days (16.5%). Overall, 342 patients (52.5%) experienced at least one bleeding event (one episode every 215 h on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20-s increase; hazard ratio, 1.07). Conclusions: Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.

Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury

Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.

Inadequate Energy Delivery Is Frequent among COVID-19 Patients Requiring ECMO Support and Associated with Increased ICU Mortality

BACKGROUND

Patients receiving extracorporeal membrane oxygenation (ECMO) support are at high risk for malnutrition. There are currently no general nutrition guidelines for coronavirus disease 2019 (COVID-19) patients during ECMO therapy.

METHODS

We conducted a retrospective analysis of COVID-19 patients requiring venovenous ECMO support at a large tertiary hospital center. Nutrition goals were calculated using 25 kcal/kg body weight (BW)/day. Associations between nutrition support and outcome were evaluated using Kaplan-Meier and multivariable Cox regression analyses.

RESULTS

Overall, 102 patients accounted for a total of 2344 nutrition support days during ECMO therapy. On 40.6% of these days, nutrition goals were met. Undernutrition was found in 40.8%. Mean daily calorie delivery was 73.7% of calculated requirements, mean daily protein delivery was 0.7 g/kg BW/d. Mean energy intake of ≥70% of calculated targets was associated with significantly lower ICU mortality independently of age, disease severity at ECMO start and body mass index (adjusted hazard ratio: 0.372, p = 0.007).

CONCLUSIONS

Patients with a mean energy delivery of ≥70% of calculated targets during ECMO therapy had a better ICU survival compared to patients with unmet energy goals. These results indicate that adequate nutritional support needs to be a major priority in the treatment of COVID-19 patients requiring ECMO support.

Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation

BACKGROUND

Outcomes of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) vary greatly by etiology, but large studies that incorporate the spectrum of shock supported with ECMO are rare.

OBJECTIVES

The purpose of this study was to describe the etiology-related outcome of patients with shock supported with peripheral VA-ECMO.

METHODS

All consecutive adults with peripheral VA-ECMO between January 2015 and August 2018 at Pitié-Salpêtrière Hospital (Paris, France) were included in this retrospective observational study. The indication for VA-ECMO was cardiogenic shock. Rates of hospital death and neurological, renal, and pulmonary complications were evaluated according to etiology.

RESULTS

Among 1,253 patients, hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown etiology, and 11.1% and 0.0% for refractory vasoplegia shock. Renal failure requiring hemodialysis developed in 50.0%, neurological complications in 16.0%, and hydrostatic pulmonary edema in 9.0%.

CONCLUSIONS

Although the outcome differs depending on etiology, this difference is related more to the severity of the situation associated with the cause rather than the cause of the shock per se. Survival to 5 years varied by cause, which may reflect the natural course of the chronic disease and illustrates the need for long-term follow-up.

The impact of preservation and recovery of renal function on survival after veno-arterial extracorporeal life support: A retrospective cohort study

BACKGROUND

Veno-arterial extracorporeal life support (V-A ECLS) has become a cornerstone in the management of critical cardiogenic shock, but it can also precipitate organ injury, e.g., acute kidney injury (AKI). Available studies highlight the effect of non-cardiac organ injury on patient outcomes. Only very little is known about the impact of non-cardiac organ recovery on patient survival. AKI occurs frequently during cardiogenic shock and carries a poor prognosis. We have developed descriptive models to hypothesize on the role of AKI severity versus that of recovery of renal function for patient survival.

METHODS

Retrospective, observational study including 175 patients who were successfully decannulated from V-A ECLS. We assessed AKI severity using the "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria. We defined recovered or preserved renal function (RPRF) prior to decannulation from V-A ECLS as 0 (AKI with no improvement) or 1 (no AKI or AKI with improvement). We classified patient outcomes as alive or dead at hospital discharge.

RESULTS

78% (n = 138) of all patients survived hospital discharge of which 38% (n = 67) never developed AKI. After adjusting for shock severity and non-renal organ injury, RPRF emerged as an independent predictor of survival in both the overall cohort [OR (95% CI) - 4.11 (1.72-9.79)] and the AKI-only sub-cohort [OR (95% CI) - 5.18 (1.8-14.92)]. Neither maximum KDIGO stage nor KDIGO stage at the end of V-A ECLS was independently associated with survival.

CONCLUSIONS

Our model identifies RPRF, but not AKI severity, as an independent predictor of hospital survival in patients undergoing V-A ECLS for cardiogenic shock. We hypothesize that recovered or preserved non-cardiac organ function during V-A ECLS is crucial for patient survival.

Transfusion practice in patients receiving VV ECMO (PROTECMO): a prospective, multicentre, observational study

BACKGROUND

In patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) packed red blood cell (PRBC) transfusion thresholds are usually higher than in other patients who are critically ill. Available guidelines suggest a restrictive approach, but do not provide specific recommendations on the topic. The main aim of this study was, in a short timeframe, to describe the actual values of haemoglobin and the rate and the thresholds for transfusion of PRBC during VV ECMO.

METHODS

PROTECMO was a multicentre, prospective, cohort study done in 41 ECMO centres in Europe, North America, Asia, and Australia. Consecutive adult patients with acute respiratory distress syndrome (ARDS) who were receiving VV ECMO were eligible for inclusion. Patients younger than 18 years, those who were not able to provide informed consent when required, and patients with an ECMO stay of less than 24 h were excluded. Our main aim was to monitor the daily haemoglobin concentration and the value at the point of PRBC transfusion, as well as the rate of transfusions. The practice in different centres was stratified by continent location and case volume per year. Adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for baseline and time varying confounding.

FINDINGS

Between Dec 1, 2018, and Feb 22, 2021, 604 patients were enrolled (431 [71%] men, 173 [29%] women; mean age 50 years [SD 13·6]; and mean haemoglobin concentration at cannulation 10·9 g/dL [2·4]). Over 7944 ECMO days, mean haemoglobin concentration was 9·1 g/dL (1·2), with lower concentrations in North America and high-volume centres. PRBC were transfused on 2432 (31%) of days on ECMO, and 504 (83%) patients received at least one PRBC unit. Overall, mean pretransfusion haemoglobin concentration was 8·1 g/dL (1·1), but varied according to the clinical rationale for transfusion. In a time-dependent Cox model, haemoglobin concentration of less than 7 g/dL was consistently associated with higher risk of death in the intensive care unit compared with other higher haemoglobin concentrations (hazard ratio [HR] 2·99 [95% CI 1·95-4·60]); PRBC transfusion was associated with lower risk of death only when transfused when haemoglobin concentration was less than 7 g/dL (HR 0·15 [0·03-0·74]), although no significant effect in reducing mortality was reported for transfusions for other haemoglobin classes (7·0-7·9 g/dL, 8·0-9·9 g/dL, or higher than 10 g/dL).

INTERPRETATION

During VV ECMO, there was no universally accepted threshold for transfusion, but PRBC transfusion was invariably associated with lower mortality only when done with haemoglobin concentration of less than 7 g/dL.

FUNDING

Extracorporeal Life Support Organization.

Association of Extracorporeal Membrane Oxygenation With New Mental Health Diagnoses in Adult Survivors of Critical Illness

IMPORTANCE

Extracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in critically ill patients, but little is known regarding long-term psychiatric sequelae among survivors after ECMO.

OBJECTIVE

To investigate the association between ECMO survivorship and postdischarge mental health diagnoses among adult survivors of critical illness.

DESIGN, SETTING, AND PARTICIPANTS

Population-based retrospective cohort study in Ontario, Canada, from April 1, 2010, through March 31, 2020. Adult patients (N=4462; age ≥18 years) admitted to the intensive care unit (ICU), and surviving to hospital discharge were included.

EXPOSURES

Receipt of ECMO.

MAIN OUTCOMES AND MEASURES

The primary outcome was a new mental health diagnosis (a composite of mood disorders, anxiety disorders, posttraumatic stress disorder; schizophrenia, other psychotic disorders; other mental health disorders; and social problems) following discharge. There were 8 secondary outcomes including incidence of substance misuse, deliberate self-harm, death by suicide, and individual components of the composite primary outcome. Patients were compared with ICU survivors not receiving ECMO using overlap propensity score-weighted cause-specific proportional hazard models.

RESULTS

Among 642 survivors who received ECMO (mean age, 50.7 years; 40.7% female), median length of follow-up was 730 days; among 3820 matched ICU survivors who did not receive ECMO (mean age, 51.0 years; 40.0% female), median length of follow-up was 1390 days. Incidence of new mental health conditions among survivors who received ECMO was 22.1 per 100-person years (95% confidence interval [CI] 19.5-25.1), and 14.5 per 100-person years (95% CI, 13.8-15.2) among non-ECMO ICU survivors (absolute rate difference of 7.6 per 100-person years [95% CI, 4.7-10.5]). Following propensity weighting, ECMO survivorship was significantly associated with an increased risk of new mental health diagnosis (hazard ratio [HR] 1.24 [95% CI, 1.01-1.52]). There were no significant differences between survivors who received ECMO vs ICU survivors who did not receive ECMO in substance misuse (1.6 [95% CI, 1.1 to 2.4] per 100 person-years vs 1.4 [95% CI, 1.2 to 1.6] per 100 person-years; absolute rate difference, 0.2 per 100 person-years [95% CI, -0.4 to 0.8]; HR, 0.86 [95% CI, 0.48 to 1.53]) or deliberate self-harm (0.4 [95% CI, 0.2 to 0.9] per 100 person-years vs 0.3 [95% CI, 0.2 to 0.3] per 100 person-years; absolute rate difference, 0.1 per 100 person-years [95% CI, -0.2 to 0.4]; HR, 0.68 [95% CI, 0.21 to 2.23]). There were fewer than 5 total cases of death by suicide in the entire cohort.

CONCLUSIONS AND RELEVANCE

Among adult survivors of critical illness, receipt of ECMO, compared with ICU hospitalization without ECMO, was significantly associated with a modestly increased risk of new mental health diagnosis or social problem diagnosis after discharge. Further research is necessary to elucidate the potential mechanisms underlying this relationship.

A phased intervention bundle to decrease the mortality of patients with extracorporeal membrane oxygenation in intensive care unit

Aim

To evaluate whether a phased multidimensional intervention bundle would decrease the mortality of patients with extracorporeal membrane oxygenation (ECMO) and the complication incidence.

Materials and methods

We conducted a prospective observational study in comparison with a retrospective control group in six intensive care units (ICUs) in China. Patients older than 18 years supported with ECMO between March 2018 to March 2022 were included in the study. A phased intervention bundle to improve the outcome of patients with ECMO was developed and implemented. Multivariable logistic regression modeling was used to compare the mortality of patients with ECMO and the complication incidence before, during, and up to 18 months after implementation of the intervention bundle.

Results

The cohort included 297 patients in 6 ICUs, mostly VA ECMO (68.7%) with a median (25th–75th percentile) duration in ECMO of 9.0 (4.0–15.0) days. The mean (SD) APECHII score was 24.1 (7.5). Overall, the mortality of ECMO decreased from 57.1% at baseline to 21.8% at 13–18 months after implementation of the study intervention (P < 0.001). In multivariable analysis, even after excluding the confounding factors, such as age, APECHII score, pre-ECMO lactate, and incidence of CRRT during ECMO, the intervention bundle still can decrease the mortality independently, which also remained true in the statistical analysis of V-V and V-A ECMO separately. Among all the ECMO-related complications, the incidence of bloodstream infection and bleeding decreased significantly at 13–18 months after implementation compared with the baseline. The CUSUM analysis revealed a typical learning curve with a point of inflection during the implementation of the bundle.

Conclusion

A phased multidimensional intervention bundle resulted in a large and sustained reduction in the mortality of ECMO that was maintained throughout the 18-month study period.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT05024786].

Extracorporeal carbon dioxide removal for acute respiratory failure: a review of potential indications, clinical practice and open research questions

Extracorporeal carbon dioxide removal (ECCO₂R) is a form of extracorporeal life support (ECLS) largely aimed at removing carbon dioxide in patients with acute hypoxemic or acute hypercapnic respiratory failure, so as to minimize respiratory acidosis, allowing more lung protective ventilatory settings which should decrease ventilator-induced lung injury. ECCO₂R is increasingly being used despite the lack of high-quality evidence, while complications associated with the technique remain an issue of concern. This review explains the physiological basis underlying the use of ECCO₂R, reviews the evidence regarding indications and contraindications, patient management and complications, and addresses organizational and ethical considerations. The indications and the risk-to-benefit ratio of this technique should now be carefully evaluated using structured national or international registries and large randomized trials.

Venoarterial Extracorporeal Membrane Oxygenation in Severe Drug Intoxication: A Retrospective Comparison of Survivors and Nonsurvivors

Selecting patients most likely to benefit from venoarterial extracorporeal membrane oxygenation (V-A ECMO) to treat refractory drug-induced cardiovascular shock remains a difficult challenge for physicians. This study reported short-term survival outcomes and factors associated with mortality in V-A ECMO-treated patients for poisoning. Twenty-two patients placed on V-A ECMO after drug intoxication from January 2014 to December 2020 were retrospectively analyzed. The primary endpoint of this study was survival at hospital discharge. Univariate descriptive analysis was performed to compare survivors and nonsurvivors during hospitalization. The overall survival at hospital discharge was 45.4% (n = 10/22). Survival rate tended to be higher in patients treated for refractory shock (n = 7/10) compared with those treated for refractory cardiac arrest (n = 3/12, p = 0.08). Low-flow duration and time from admission to ECMO cannulation were shorter in survivors ( p = 0.02 and p = 0.03, respectively). Baseline characteristics before ECMO, including the class of drugs involved in the poisoning, between survivors and nonsurvivors were not statistically different except pH, bicarbonate, serum lactate, Sequential Organ Failure Assessment, and Survival After Veno-arterial-ECMO (SAVE) score. All patients with SAVE-score risk classes II/III survived whereas 85.7% (n = 12/14) of those with SAVE-score risk classes IV/V died. A lactic acid >9 mmol/L predicts mortality with a sensitivity/specificity ratio of 83.3%/100%. V-A ECMO for severe drug intoxication should be reserved for highly selected poisoned patients who do not respond to conventional therapies. Shortening the timing of V-A ECMO initiation should be a key priority in improving outcomes. Low-flow time >60min, lactic acid >9mmol/L, and SAVE-score may be good indicators of a worse prognosis.

A Narrative Review of Nutrition Therapy in Patients Receiving Extracorporeal Membrane Oxygenation

The use of extracorporeal membrane oxygenation (ECMO) in patients with severe cardiorespiratory failure has seen significant growth in the last decade. Despite this, there is paucity of data surrounding the optimum nutritional management for ECMO patients. This review aimed to describe current nutrition practices in patients receiving ECMO, critically appraise available studies and identify areas for future research. A literature search was conducted in PubMed, MEDLINE, and CINAHL Plus to identify all randomized trials and observational studies published between July 2000 and July 2020 investigating nutrition practices in critically ill adults receiving ECMO. The primary outcomes were nutritional adequacy, gastrointestinal complications, and physical function. Secondary outcomes included mortality, length of stay, and duration on ECMO support. From a total of 31 studies identified, 12 met the inclusion criteria. Nine observational studies were reviewed following eligibility assessment. Early enteral nutrition was deemed safe and feasible for ECMO patients; however, meeting nutritional targets was challenging. Utilizing alternative nutrition routes is an option, although risks and benefits should be taken into consideration. Data on gastrointestinal complications and other clinical outcomes were inconsistent, and no data were identified investigating the effects of nutrition on the physical and functional recovery of ECMO patients. Nutrition therapy in ECMO patients should be provided in line with current guidelines for nutrition in critical illness until further data are available. Further prospective, randomized studies investigating optimum nutrition practices and effects on clinical and functional outcomes are urgently required.

Direct Cardiac Compression Devices to Augment Heart Biomechanics and Function

The treatment of end-stage heart failure has evolved substantially with advances in medical treatment, cardiac transplantation, and mechanical circulatory support (MCS) devices such as left ventricular assist devices and total artificial hearts. However, current MCS devices are inherently blood contacting and can lead to potential complications including pump thrombosis, hemorrhage, stroke, and hemolysis. Attempts to address these issues and avoid blood contact led to the concept of compressing the failing heart from the epicardial surface and the design of direct cardiac compression (DCC) devices. We review the fundamental concepts related to DCC, present the foundational devices and recent devices in the research and commercialization stages, and discuss the milestones required for clinical translation and adoption of this technology. Expected final online publication date for the Annual Review of Biomedical Engineering, Volume 24 is June 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Extracorporeal Membrane Oxygenation in Infarct-Related Cardiogenic Shock

Mortality in infarct-related cardiogenic shock (CS) remains high, reaching 40–50%. In refractory CS, active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are rapidly evolving. However, supporting evidence of VA-ECMO therapy in infarct-related CS is low. The current review aims to give an overview on the basics of VA-ECMO therapy, current evidence, ongoing trials, patient selection and potential complications.

Veno-arteriovenous (V-AV) ECMO configuration: A single-center experience

BACKGROUND

With increasing extracorporeal membrane oxygenation (ECMO) utilization over the last decade, clinicians have developed "hybrid" configurations to meet complex perfusion requirements. In the setting of differential hypoxemia, a veno-arteriovenous (V-AV) configuration provides oxygenated cardiac preload and hemodynamic support to satisfy physiologic demands. We aim to further characterize the patient population, indications, and outcomes associated with this hybrid configuration.

METHODS

We retrospectively reviewed all adult patients placed on V-AV ECMO at our institution from June 2016 to December 2019. Through a review of the electronic medical records, data describing demographic features, comorbidities, and ECMO-specific information were analyzed systematically.

RESULTS

14 patients were placed on V-AV ECMO during the study period. Our cohort was 79% male with a median age of 54 and BMI of 30.3. These patients had a median SOFA-0 score of 15 and SAVE score of -12. Patients were treated with ECMO support for a median of 144.1 (IQR 98.5 - 183.1) hours, consisting of 0.2 (IQR 0 - 17.7) hours of VA and 92.4 (IQR 53.7 - 115.1) hours of V-AV followed by 67.4 (IQR 20.3 - 96.6) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%).

CONCLUSION

ECMO patients with recovering left ventricular function and persistent gas exchange abnormalities are at risk for developing differential hypoxemia. We describe an approach to utilizing V-AV configuration when the likelihood of differential hypoxemia is extremely high, with a survival rate that compares favorably to Extracorporeal Life Support Organization statistics and published case series.

Extracorporeal cardiopulmonary resuscitation for refractory in-hospital cardiac arrest: A retrospective cohort study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is a rescue therapy for refractory cardiac arrest, but its high mortality has raised questions about patient selection. No selection criteria have been proposed for patients experiencing in-hospital cardiac arrest. We aimed to identify selection criteria available at the time ECPR was considered for patients with in-hospital cardiac arrest. We analyzed data of in-hospital cardiac arrest patients undergoing ECPR in our extracorporeal membrane oxygenation (ECMO) center (March 2007 to March 2019). Intensive care unit (ICU) and 1-year survival post-hospital discharge were assessed. Factors associated with ICU survival before ECPR were investigated. An external validation cohort from a previous multicenter study was used to validate our results.

RESULTS

Among the 137 patients (67.9% men; median [IQR] age, 54 [43-62] years; low-flow duration, 45 [30-70] min) requiring ECPR, 32.1% were weaned-off ECMO. Their respective ICU- and 1-year survival rates were 21.9% and 19%. Most 1-year survivors had favorable neurological outcomes (cerebral performance category score 1 or 2). ICU survivors compared to nonsurvivors, respectively, were more likely to have a shockable initial rhythm (53.3% versus 24.3%; P < 0.01), a shorter median (IQR) low-flow time (30 (25-53) versus 50 (35-80) min, P < 0.01) and they more frequently underwent a subsequent intervention (63.3% versus 26.2%, P < 0.01). The algorithm obtained by combining age, initial rhythm and low-flow duration discriminated between patient groups with very different survival probabilities in the derivation and validation cohorts.

CONCLUSION

Survival of ECPR-managed in-hospital cardiac arrest patients in this cohort was poor but hospital survivors' 1-year neurological outcomes were favorable. When deciding whether or not to use ECPR, the combination of age, initial rhythm and low-flow duration can improve patient selection.

Hospital Costs of Extracorporeal Membrane Oxygenation in Adults: A Systematic Review

BACKGROUND

Costs associated with extracorporeal membrane oxygenation (ECMO) are an important factor in establishing cost effectiveness. In this systematic review, we aimed to determine the total hospital costs of ECMO for adults.

METHODS

The literature was retrieved from the PubMed/MEDLINE, EMBASE, and Web of Science databases from inception to 4 March 2020 using the search terms 'extracorporeal membrane oxygenation' combined with 'costs'; similar terms or phrases were then added to the search, i.e. 'Extracorporeal Life Support' or 'ECMO' or 'ECLS' combined with 'costs'. We included any type of study (e.g. randomized trial or observational cohort) evaluating hospital costs of ECMO in adults (age ≥18 years).

RESULTS

A total of 1768 unique articles were retrieved during our search. We assessed 74 full-text articles for eligibility, of which 14 articles were selected for inclusion in this review; six papers were from the US, five were from Europe, and one each from Japan, Australia, and Taiwan. The sample sizes ranged from 16 to 18,684 patients. One paper exclusively used prospective cost data collection, while all other papers used retrospective data collection. Five papers reported charges instead of costs. There was large variation in hospital costs, ranging from US$22,305 to US$334,608 (2019 values), largely depending on the indication for ECMO support and location. The highest reported costs were for lung transplant recipients who were receiving ECMO support in the US, and the lowest reported costs were for extracorporeal cardiopulmonary resuscitation patients presenting with non-shockable rhythm in Japan. The additional costs of ECMO patients compared with non-ECMO patients varied between US$2518 and US$200,658. Personnel costs varied between 11 and 52% of the total amount.

CONCLUSIONS

ECMO therapy is an advanced and expensive technology, although reported costs differ considerably depending on ECMO indication and whether charges or costs are measured. Combined with the ongoing gathering of outcome data, cost effectiveness per ECMO indication could be determined in the future.

Effect of Body Mass Index on the Clinical Outcomes of Adult Patients Treated With Venoarterial ECMO for Cardiogenic Shock

OBJECTIVE

Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock.

DESIGN

This was a retrospective and observational study.

SETTING

University hospital.

PARTICIPANTS

The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI < 18.5 kg/m²), 62 were normal weight (BMI = 18.5-24.9 kg/m²), 34 were overweight (BMI = 25.0-29.9 kg/m²), 34 were obese class I (BMI = 30.0-34.9 kg/m²), and 10 were obese class II (BMI = 35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p = 0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p = 0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p = 0.07). No statistically significant differences were found among BMI categories in the incidences of complications.

CONCLUSION

The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.

Severe thrombocytopenia in adults undergoing extracorporeal membrane oxygenation is predictive of thrombosis

Extracorporeal membrane oxygenation (ECMO) provides lifesaving circulatory support and gas exchange, although hematologic complications are frequent. The relationship between ECMO and severe thrombocytopenia (platelet count <50 × 10⁹/L) remains ill-defined. We performed a cohort study of 67 patients who received ECMO between 2016 and 2019, of which 65.7% received veno-arterial (VA) ECMO and 34.3% received veno-venous (VV) ECMO. All patients received heparin and 25.4% received antiplatelet therapy. In total, 23.9% of patients had a thrombotic event and 67.2% had a hemorrhagic event. 38.8% of patients developed severe thrombocytopenia. Severe thrombocytopenia was more common in patients with lower baseline platelet counts and increased the likelihood of thrombosis by 365% (OR 3.65, 95% CI 1.13-11.8, P = .031), while the type of ECMO (VA or VV) was not predictive of severe thrombocytopenia (P = .764). Multivariate logistic regression controlling for additional clinical variables found that severe thrombocytopenia predicted thrombosis (OR 3.65, CI 1.13-11.78, P = .031). Over a quarter of patients requiring ECMO developed severe thrombocytopenia in our cohort, which was associated with an increased risk of thrombosis and in-hospital mortality. Additional prospective observation is required to clarify the clinical implications of severe thrombocytopenia in the ECMO patient population.

Monocyte Dysfunction Detected by the Designed Ankyrin Repeat Protein F7 Predicts Mortality in Patients Receiving Veno-Arterial Extracorporeal Membrane Oxygenation

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used for critically ill patients requiring hemodynamic support but has been shown to induce an inflammatory response syndrome potentially leading to severe complications and poor outcome. Monocytes are comprised of different subsets and play a central role in the innate immune system. The unique small binding proteins, Designed Ankyrin Repeat Protein “F7” and single chain variable fragment “MAN-1,” specifically detect the activated conformation of the leukocyte integrin Mac-1 enabling the highly sensitive detection of monocyte activation status. The aim of this study was to characterize monocyte function and heterogeneity and their association with outcome in VA-ECMO patients.

Methods: VA-ECMO patients were recruited from the ICUs of the University Hospital in Freiburg, Germany. Blood was sampled on day 0 and day 3 after VA-ECMO placement, after VA-ECMO explantation and from healthy controls. Monocyte subset distribution, baseline activation and stimulability were analyzed by flow cytometry using the unique small binding proteins F7 and MAN-1 and the conventional activation markers CD163, CD86, CD69, and CX3CR1. Furthermore, expression of monocyte activation markers in survivors and non-survivors on day 0 was compared. Simple logistic regression was conducted to determine the association of monocyte activation markers with mortality.

Results: Twenty two patients on VA-ECMO and 15 healthy controls were recruited. Eleven patients survived until discharge from the ICU. Compared to controls, baseline monocyte activation was significantly increased, whereas stimulability was decreased. The percentage of classical monocytes increased after explantation, while the percentage of intermediate monocytes decreased. Total, classical, and intermediate monocyte counts were significantly elevated compared to controls. On day 0, baseline binding of F7 was significantly lower in non-survivors than survivors. The area under the ROC curve associated with mortality on day 0 was 0.802 (p = 0.02).

Conclusions: Distribution of monocyte subsets changes during VA-ECMO and absolute classical and intermediate monocyte counts are significantly elevated compared to controls. Monocytes from VA-ECMO patients showed signs of dysfunction. Monocyte dysfunction, as determined by the unique tool F7, could be valuable for predicting mortality in patients receiving VA-ECMO and may be used as a novel biomarker guiding early clinical decision making in the future.

Annexin V positive microvesicles are elevated and correlate with flow rate in patients receiving veno-arterial extracorporeal membrane oxygenation

OBJECTIVES

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used in critically ill patients requiring haemodynamic support. Microvesicles (MV) are released by activated blood cells acting as mediators of intercellular communication. We aimed to determine MV count and composition over time in patients with VA-ECMO and explore what drives MV formation.

METHODS

VA-ECMO patients and healthy controls were recruited prospectively, and blood was taken at different time points (day 0, 1, 3 after ECMO placement and after explantation) for MV analysis.

RESULTS

Annexin V positive MV were increased in patients (n = 14, mean age = 61.4 ± 9.0 years, 11 males, 3 females) compared to healthy controls (n = 6, Annexin V positive MV count per millilitre day 1 versus healthy controls: 2.3 × 106 vs 1.3 × 105, P < 0.001). Furthermore, patients had higher proportions of endothelial and leukocyte MV [leukocyte MV day 1 versus healthy controls (%): 32.8 vs 17.5, P = 0.001; endothelial MV day 1 versus healthy controls (%): 10.5 vs 5.5, P = 0.01]. Annexin V positive and leucocyte MV correlated with the flow rate (r = 0.46, P = 0.01).

CONCLUSIONS

Patients on VA-ECMO have increased levels of circulating MV and a changed MV composition. Our data support the hypothesis that MV release may be driven by higher flow rate and cellular activation in the extracorporeal circuit leading to poor outcomes in these patients.

CLINICAL TRIAL REGISTRATION NUMBER

German Clinical Trials Register-ID: DRKS00011106.

Impact of early nutrition route in patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

BACKGROUND

Early nutrition management in patients receiving extracorporeal membrane oxygenation (ECMO) remains controversial. Despite its potentially beneficial effect, enteral nutrition (EN) could be associated with gastrointestinal (GI) complications. Total daily energy requirements remain difficult to achieve with ECMO support. Analysis of nutrition practices could improve nutrition management of this particular population.

METHODS

A monocentric retrospective study of patients requiring ECMO in a cardiac surgery intensive care unit (ICU) between 2010 and 2014 with follow-up ≥6 days. Nutrition support was monitored daily until ECMO weaning. We compared patients exposed (EN group, n = 49) and unexposed (No EN group (NEN), n = 63) with EN, as well as the energy and protein intakes within 4 days after initiation of ECMO. Vital status and nosocomial infections were followed up until ICU discharge. Primary outcome was the incidence of GI intolerance and risk-factor identification. Secondary outcomes included impact of nutrition inadequacy and clinical outcome.

RESULTS

A total 112 patients were analyzed, representing 969 nutrition days. Median ratio of energy and protein prescribed/required daily was 81% (58-113) and 56% (36-86), respectively. GI intolerance was experienced by 53% (26 of 49) of patients in the EN group and was only associated with ECMO duration (odds ratio, 1.14: 95% CI, 1.00-1.31; P = .05). Low-energy and protein days were not associated with clinical outcomes such as nosocomial infections.

CONCLUSION

EN is associated with almost 50% GI intolerance without clinical benefit for patients receiving ECMO. Adequacy in energy and protein amounts did not affect clinical outcome.

Estimating cardiac output based on gas exchange during veno-arterial extracorporeal membrane oxygenation in a simulation study using paediatric oxygenators

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Cognitive, Psychiatric, and Quality of Life Outcomes in Adult Survivors of Extracorporeal Membrane Oxygenation Therapy: A Scoping Review of the Literature

OBJECTIVES

To perform a scoping literature review of cognitive, psychiatric, and quality of life outcomes in adults undergoing extracorporeal membrane oxygenation for any indication.

DATA SOURCES

We searched PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, and PsycINFO from inception to June 2019.

STUDY SELECTION

Observational studies, clinical trials, qualitative studies, and case series with at least 10 adult subjects were included for analysis. Outcomes of interest consisted of general or domain-specific cognition, psychiatric illness, and quality of life measures that included both mental and physical health.

DATA EXTRACTION

Study selection, data quality assessment, and interpretation of results were performed by two independent investigators in accordance with the PRISMA statement.

DATA SYNTHESIS

Twenty-two articles were included in this review. Six described cognitive outcomes, 12 described psychiatric outcomes of which two were qualitative studies, and 16 described quality of life outcomes. Cognitive impairment was detected in varying degrees in every study that measured it. Three studies examined neuroimaging results and found neurologic injury to be more frequent in venoarterial versus venovenous extracorporeal membrane oxygenation, but described a variable correlation with cognitive impairment. Rates of depression, anxiety, and post-traumatic stress disorder were similar to other critically ill populations and were related to physical disability after extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survivors' physical quality of life was worse than population norms but tended to improve with time, while mental quality of life did not differ significantly from the general population. Most studies did not include matched controls and instead compared outcomes to previously published values.

CONCLUSIONS

Extracorporeal membrane oxygenation survivors experience cognitive impairment, psychiatric morbidity, and worse quality of life compared with the general population and similar to other survivors of critical illness. Physical disability in extracorporeal membrane oxygenation patients plays a significant role in psychiatric morbidity. However, it remains unclear if structural brain injury plays a role in these outcomes and whether extracorporeal membrane oxygenation causes secondary brain injury.

Obesity as a Risk Factor for Failure to Wean from ECMO: A Systematic Review and Meta-Analysis

Purpose

Obesity has been associated with an increased risk of respiratory complications and other systemic illnesses. Respiratory dynamics in an obese patient, combined with modified lung physiology of ARDS, present a significant challenge in managing obese patients with ARDS. Many physicians think of obesity as a relative contraindication to ECMO. We performed a meta-analysis to see the effect of obesity on weaning from ECMO and survival to hospital discharge.

Methods

We searched online databases for studies on ECMO and obesity. The search yielded 49 citations in total; after extensive review, six studies were assessed and qualified to be included in the final analysis. Patients were stratified into BMI >30 kg/m2 (obese) and BMI < 30 kg/m2 (nonobese).

Results

In meta-analysis, there was a total sample population of 1285 patients, with 466 in the obese group and 819 in the nonobese group. There was no significant difference in weaning from ECMO when compared between obese and nonobese patients, with a risk ratio of 1.03 and 95% confidence interval (CI) of 0.94-1.13 (heterogeneity: chi2 = 7.44, df = 4 (p=0.11), I 2 = 46%). There was no significant difference in survival rates between obese and nonobese patients who were treated with ECMO during hospitalization, with a risk ratio of 1.04 and 95% CI of 0.86-1.25 (heterogeneity: Tau2 0.03, chi2 = 14.61, df = 5 (p=0.01), I 2 = 66%).

Conclusion

Our findings show no significant difference in survival and weaning from ECMO in obese vs. nonobese patients. ECMO therapy should not be withheld from obese patients, as obesity is not a contraindication to ECMO.

Tissue adhesives for bacterial inhibition in extracorporeal membrane oxygenation cannulae

BACKGROUND

One of the most serious complications of extracorporeal membrane oxygenation (ECMO) therapy is ECMO cannulae infection, which can occur at quadruple the rate of central venous catheter infections, and significantly impact morbidity and paediatric mortality. The objective of this in vitro observational study was to assess antimicrobial properties of two n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) formulations for bacterial inhibition at peripheral ECMO cannulae insertion sites.

METHODS

Antimicrobial properties were assessed using modified agar disk-diffusion (n = 3) and simulated agar cannulation insertion site (n = 20) models. Both assays used Staphylococcus epidermidis which was seeded at the edge of the TA or dressing. Microorganism inhibition was visually inspected and evidenced by the presence or absence of a TA bacterial inhibition zone at 24 and 72 h.

RESULTS

Both TAs provided effective barriers to bacterial migration under cannula dressings, to cannula insertion sites and down cannula tunnels. Additionally, both TAs demonstrated distinct zones of inhibition produced when left to polymerise onto agar plates seeded with S. epidermidis.

CONCLUSIONS

N-Butyl-2-octyl cyanoacrylate TA appears to inhibit bacterial growth and migration of S. epidermidis. Application of TA to cannulae insertion sites may therefore be a potential bedside strategy for infection prevention in ECMO cannulae, but requires further testing before being used clinically for this purpose.

The effectiveness of vitamin C for patients with severe viral pneumonia in respiratory failure

Background

Vitamin C is a well-known antioxidant and essential cofactor for numerous biological reactions. Several studies reported that vitamin C can improve the symptoms and prognosis of patients with sepsis and respiratory infection. We aimed to examine the effect of vitamin C when used in viral pneumonia patients with severe respiratory failure.

Methods

Total 201 patients with viral pneumonia were included, of them 35 patients used vitamin C. We performed a statistical analysis through a propensity score matching of the age and baseline characteristics of these patients.

Results

There were differences between the vitamin C group and non-vitamin C group in terms of age (60±15 vs. 66±14, P=0.03), extracorporeal membrane oxygenation (28.6% vs. 5.4%, P<0.001), and procalcitonin (3±8 vs. 9±23, P=0.02). The 28-day mortality was not different between the two groups (20.0% vs. 24.7%, P=0.33). In the propensity-matched group, the 28-day mortality was not significantly different between the two groups (20.0% vs. 37.1%, P=0.07). Moreover, no difference was observed in shock reversal within 14 days (45.7% vs. 25.7%, P=0.08) and recovery after acute kidney injury (52.9% vs. 66.7%, P=0.41) between the two groups. Vitamin C was not a prognostic factor for 28-day mortality (P=0.33).

Conclusions

In this study adjunctive intravenous vitamin C therapy alone was not associated with improvement of the 28-day mortality and prognosis in patients with severe viral pneumonia with respiratory failure.

Trends in Extracorporeal Membrane Oxygenation Application and Outcomes in Korea

The use of extracorporeal membrane oxygenation (ECMO) is increasing despite the limited evidence in survival benefit. This study aimed to analyze the changes of in-hospital mortality, medical costs, and other outcomes in ECMO therapy. We used 2004-2017 data from a nationwide healthcare administrative claims database in Korea. Overall, 14,775 ECMO procedures were performed in 14,689 patients at 112 hospitals. We found a 170-fold and a 334-fold increase in the number of ECMO procedures and related costs, respectively. For indications, the performance of ECMO for heart or lung transplantation and respiratory failure increased, whereas that for cardiovascular surgery decreased. The duration of ECMO increased from a median of 3 days (IQR, 2-5 days) in 2004 to 4 days (IQR, 2-9 days) in 2017. The overall in-hospital mortality rate was 68.6%, and this improved over time, especially for lung transplantation and respiratory failure patients. Bleeding-related complications and the transfusion amount also decreased. Hospitals with higher case volume showed better survival outcomes. The median cost per procedure and per day was 26,538 USD (IQR, 14,646-47,862 USD) and 1,560 USD (IQR, 903-2,929 USD), respectively, and increased with time. A trend toward greater resource use and better outcomes requires additional cost-effective analysis based on indications.

Post-resuscitation shock: recent advances in pathophysiology and treatment

A post-resuscitation shock occurs in 50–70% of patients who had a cardiac arrest. It is an early and transient complication of the post-resuscitation phase, which frequently leads to multiple-organ failure and high mortality. The pathophysiology of post-resuscitation shock is complex and results from the whole-body ischemia–reperfusion process provoked by the sequence of circulatory arrest, resuscitation manoeuvers and return of spontaneous circulation, combining a myocardial dysfunction and sepsis features, such as vasoplegia, hypovolemia and endothelial dysfunction. Similarly to septic shock, the hemodynamic management of post-resuscitation shock is based on an early and aggressive hemodynamic management, including fluid administration, vasopressors and/or inotropes. Norepinephrine should be considered as the first-line vasopressor in order to avoid arrhythmogenic effects of other catecholamines and dobutamine is the most established inotrope in this situation. Importantly, the optimal mean arterial pressure target during the post-resuscitation shock still remains unknown and may probably vary according to patients. Mechanical circulatory support by extracorporeal membrane oxygenation can be necessary in the most severe patients, when the neurological prognosis is assumed to be favourable. Other symptomatic treatments include protective lung ventilation with a target of normoxia and normocapnia and targeted temperature management by avoiding the lowest temperature targets. Early coronary angiogram and coronary reperfusion must be considered in ST-elevation myocardial infarction (STEMI) patients with preserved neurological prognosis although the timing of coronary angiogram in non-STEMI patients is still a matter of debate. Further clinical research is needed in order to explore new therapeutic opportunities regarding inflammatory, hormonal and vascular dysfunction.

Predicting Parameters for Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock

Aims

Percutaneous veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is utilized for patients with cardiogenic shock or cardiac arrest. However, the procedure protocol for weaning from VA‐ECMO has not been well established. The present study aimed to determine the usefulness of echocardiographic and pulmonary artery catheter parameters for predicting successful weaning from VA‐ECMO in patients with refractory cardiogenic shock.

Methods and results

We retrospectively studied 50 patients who were hospitalized and supported by VA‐ECMO for >48 h between January 2013 and March 2017. Patients successfully weaned from VA‐ECMO without reintroduction of VA‐ECMO or left ventricular assist device implantation were defined as 30 day survivors. Echocardiographic and pulmonary artery catheter parameters were evaluated when ECMO flow was limited to a maximum of 1.5–2.0 L/min. Twenty‐four patients were successfully weaned from VA‐ECMO, whereas 26 were not. Fractional shortening, corrected left ventricular ejection time (LVETc, defined as LVET divided by the square root of heart rate), left ventricular outflow tract velocity time integral, and LVETc divided by pulmonary artery wedge pressure (PAWP) were significantly larger in the 30 day survivor groups. Multivariable analysis revealed LVETc∕PAWP as a significant independent predictor of successful weaning (LVETc∕PAWP, odds ratio 0.82, 95% confidence interval 0.71–0.94, P = 0.005). Receiver operating characteristic curve analysis revealed 15.9 as the optimal LVETc∕PAWP for predicting successful weaning (area under the curve 0.82).

Conclusions

The present findings indicate that LVETc∕PAWP is a potential predictor of successful weaning from VA‐ECMO.

Antibiotic therapeutic drug monitoring in intensive care patients treated with different modalities of extracorporeal membrane oxygenation (ECMO) and renal replacement therapy: a prospective, observational single-center study

BACKGROUND

Effective antimicrobial treatment is key to reduce mortality associated with bacterial sepsis in patients on intensive care units (ICUs). Dose adjustments are often necessary to account for pathophysiological changes or renal replacement therapy. Extracorporeal membrane oxygenation (ECMO) is increasingly being used for the treatment of respiratory and/or cardiac failure. However, it remains unclear whether dose adjustments are necessary to avoid subtherapeutic drug levels in septic patients on ECMO support. Here, we aimed to evaluate and comparatively assess serum concentrations of continuously applied antibiotics in intensive care patients being treated with and without ECMO.

METHODS

Between October 2018 and December 2019, we prospectively enrolled patients on a pneumological ICU in southwest Germany who received antibiotic treatment with piperacillin/tazobactam, ceftazidime, meropenem, or linezolid. All antibiotics were applied using continuous infusion, and therapeutic drug monitoring of serum concentrations (expressed as mg/L) was carried out using high-performance liquid chromatography. Target concentrations were defined as fourfold above the minimal inhibitory concentration (MIC) of susceptible bacterial isolates, according to EUCAST breakpoints.

RESULTS

The final cohort comprised 105 ICU patients, of whom 30 were treated with ECMO. ECMO patients were significantly younger (mean age: 47.7 vs. 61.2 years; p < 0.001), required renal replacement therapy more frequently (53.3% vs. 32.0%; p = 0.048) and had an elevated ICU mortality (60.0% vs. 22.7%; p < 0.001). Data on antibiotic serum concentrations derived from 112 measurements among ECMO and 186 measurements from non-ECMO patients showed significantly lower median serum concentrations for piperacillin (32.3 vs. 52.9; p = 0.029) and standard-dose meropenem (15.0 vs. 17.8; p = 0.020) in the ECMO group. We found high rates of insufficient antibiotic serum concentrations below the pre-specified MIC target among ECMO patients (piperacillin: 48% vs. 13% in non-ECMO; linezolid: 35% vs. 15% in non-ECMO), whereas no such difference was observed for ceftazidime and meropenem.

CONCLUSIONS

ECMO treatment was associated with significantly reduced serum concentrations of specific antibiotics. Future studies are needed to assess the pharmacokinetic characteristics of antibiotics in ICU patients on ECMO support.

Acute mesenteric ischaemia in refractory shock on veno-arterial extracorporeal membrane oxygenation

BACKGROUND

Acute mesenteric ischaemia is a severe complication in critically ill patients, but has never been evaluated in patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). This study was designed to determine the prevalence of mesenteric ischaemia in patients supported by V-A ECMO and to evaluate its risk factors, as well as to appreciate therapeutic modalities and outcome.

METHODS

In a retrospective single centre study (January 2013 to January 2017), all consecutive adult patients who underwent V-A ECMO were included, with exclusion of those dying in the first 24 hours. Diagnosis of mesenteric ischaemia was performed using digestive endoscopy, computed tomography scan or first-line laparotomy.

RESULTS

One hundred and fifty V-A ECMOs were implanted (65 for post-cardiotomy shock, 85 for acute cardiogenic shock, including 39 patients after refractory cardiac arrest). Overall, median age was 58 (48-69) years and mortality 56%. Acute mesenteric ischaemia was suspected in 38 patients, with a delay of four (2-7) days after ECMO implantation, and confirmed in 14 patients, that is, a prevalence of 9%. Exploratory laparotomy was performed in six out of 14 patients, the others being too unstable to undergo surgery. All patients with mesenteric ischaemia died. Independent risk factors for developing mesenteric ischaemia were renal replacement therapy (odds ratio (OR) 4.5, 95% confidence interval (CI) 1.3-15.7, p=0.02) and onset of a second shock within the first five days (OR 7.8, 95% CI 1.5-41.3, p=0.02). Conversely, early initiation of enteral nutrition was negatively associated with mesenteric ischaemia (OR 0.15, 95% CI 0.03-0.69, p=0.02).

CONCLUSIONS

Acute mesenteric ischaemia is a relatively frequent but dramatic complication among patients on V-A ECMO.

Effects of levosimendan on weaning and survival in adult cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation: systematic review and meta-analysis

Introduction:

Veno-arterial extracorporeal membrane oxygenation may be used to support patients with refractory cardiogenic shock. Many patients can be successfully weaned, the ability of some medications to facilitate weaning from veno-arterial extracorporeal membrane oxygenation were reported. To date, there are limited studies investigating the impact of levosimendan on veno-arterial extracorporeal membrane oxygenation weaning. The objective of this systematic review and meta-analysis was to assess the effects of levosimendan on successful weaning from veno-arterial extracorporeal membrane oxygenation and survival in adult patients with cardiogenic shock.

Methods:

We performed a systematic review and meta-analysis (PubMed, the Cochrane Library, and the International Clinical Trials Registry Platform published from the year 2000 onwards) investigating whether levosimendan offers advantages compared to standard therapy or placebo, in cardiogenic shock adult patients treated with veno-arterial extracorporeal membrane oxygenation. The primary outcome was veno-arterial extracorporeal membrane oxygenation successful weaning, whereas secondary outcome was all-cause mortality at the longest follow-up available. We pooled risk ratio and 95% confidence interval using fixed and random effects models according to the heterogeneity.

Results:

A total of five non-randomized clinical trials comprising 557 patients were included, 299 patients for levosimendan and 258 patients for control groups. The pooled prevalence of veno-arterial extracorporeal membrane oxygenation successful weaning was 61.4% (95% confidence interval 39.8-82.9%), and all-cause mortality was 36% (95% confidence interval 29.6-48.8%). There was a significant increase in veno-arterial extracorporeal membrane oxygenation successful weaning with levosimendan compared to the controls (risk ratio = 1.42 (95% confidence interval 1.12-1.8), p for effect = 0.004, I2 = 71%). A decrease risk of all-cause mortality in the levosimendan group was also observed, risk ratio = 0.62 (95% confidence interval 0.44-0.88), p for effect = 0.007, I2 = 36%.

Conclusion:

The use of levosimendan on adult patients with cardiogenic shock may facilitate the veno-arterial extracorporeal membrane oxygenation weaning and reduce all-cause mortality. Few articles of this topic are available, and prospective, randomized multi-center trials are warranted to conclude decisively on the benefits of levosimendan in this setting.

Gas exchange calculation may estimate changes in pulmonary blood flow during veno-arterial extracorporeal membrane oxygenation in a porcine model

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is used as rescue therapy for severe cardiopulmonary failure. We tested whether the ratio of CO₂ elimination at the lung and the V-A ECMO (V̇co_2ECMO/V̇co_2Lung) would reflect the ratio of respective blood flows and could be used to estimate changes in pulmonary blood flow (Q̇_Lung), i.e., native cardiac output. Four healthy pigs were centrally cannulated for V-A ECMO. We measured blood flows with an ultrasonic flow probe. V̇co_2ECMO and V̇co_2Lung were calculated from sidestream capnographs under constant pulmonary ventilation during V-A ECMO weaning with changing sweep gas and/or V-A ECMO blood flow. If ventilation-to-perfusion ratio (V̇/Q̇) of V-A ECMO was not 1, the V̇co_2ECMO was normalized to V̇/Q̇ = 1 (V̇co_2ECMONorm). Changes in pulmonary blood flow were calculated using the relationship between changes in CO₂ elimination and V-A ECMO blood flow (Q̇_ECMO). Q̇_ECMO correlated strongly with V̇co_2ECMONorm (r² 0.95–0.99). Q̇_Lung correlated well with V̇co_2Lung (r² 0.65–0.89, P < = 0.002). Absolute Q̇_Lung could not be calculated in a nonsteady state. Calculated pulmonary blood flow changes had a bias of 76 (−266 to 418) mL/min and correlated with measured Q̇_Lung (r² 0.974–1.000, P = 0.1 to 0.006) for cumulative ECMO flow reductions. In conclusion, V̇co₂ of the lung correlated strongly with pulmonary blood flow. Our model could predict pulmonary blood flow changes within clinically acceptable margins of error. The prediction is made possible with normalization to a V̇/Q̇ of 1 for ECMO. This approach depends on measurements readily available and may allow immediate assessment of the cardiac output response.

Long-term survival and costs following extracorporeal membrane oxygenation in critically ill children-a population-based cohort study

Background

Extracorporeal membrane oxygenation (ECMO) is used to provide temporary cardiorespiratory support to critically ill children. While short-term outcomes and costs have been evaluated in this population, less is known regarding long-term survival and costs.

Methods

Population-based cohort study from Ontario, Canada (October 1, 2009 to March 31, 2017), of pediatric patients (< 18 years of age) receiving ECMO, identified through the use of an ECMO procedural code. Outcomes were identified through linkage to provincial health databases. Primary outcome was survival, measured to hospital discharge, as well as at 1 year, 2 years, and 5 years following ECMO initiation. We evaluated total patient costs in the first year following ECMO.

Results

We analyzed 342 pediatric patients. Mean age at ECMO initiation was 2.9 years (standard deviation [SD] = 5.0). Median time from hospital admission to ECMO initiation was 5 days (interquartile range [IQR] = 1–13 days). Overall survival to hospital discharge was 56.4%. Survival at 1 year, 2 years, and 5 years was 51.5%, 50.0%, and 42.1%, respectively. Among survivors, 99.5% were discharged home. Median total costs among all patients in the year following hospital admission were $147,957 (IQR $70,571–$300,295). Of these costs, the large proportion were attributable to the inpatient cost from the index admission (median $119,197, IQR $57,839–$250,675).

Conclusions

Children requiring ECMO continue to have a significant in-hospital mortality, but reassuringly, there is little decrease in long-term survival at 1 year. Median costs among all patients were substantial, but largely reflect inpatient hospital costs, rather than post-discharge outpatient costs. This information provides value to providers and health systems, allowing for prognostication of short- and long-term outcomes, as well as long-term healthcare-related expenses for pediatric ECMO survivors.

Low molecular weight heparin versus unfractioned heparin for anticoagulation during perioperative extracorporeal membrane oxygenation: A single center experience in 102 lung transplant patients

Extracorporeal membrane oxygenation (ECMO) is gaining importance in the perioperative management of lung transplant patients. To date, the ideal substance for anticoagulation of ECMO patients is still a matter of debate. In this study, we describe our experience with the use of low molecular weight heparin (LMWH) in comparison with unfractioned heparin (UFH) in lung transplant patients undergoing perioperative ECMO support. We retrospectively analyzed data from all lung transplant patients who underwent perioperative ECMO support at our institution between 2013 and 2017. Bleeding events served as primary outcome parameter. Secondary outcome parameters consisted of thromboembolic events. 102 patients were included in this study, of which 22 (21.6%) received UFH for anticoagulation, and 80 (78.4%) received LMWH. There was no difference between the two groups in regard to serious bleeding events (22.7% in the UFH group vs 12.5% in the LMWH group, P = .31). However, the proportion of patients experiencing thromboembolic events was significantly higher in the UFH group than in the LMWH group (50% vs 20%, P = .01). After adjusting for baseline differences between the two groups, we still observed a difference with respect to thromboembolic events. These data remain to be validated in future prospective, randomized trials.

Predictors for unsuccessful weaning from venoarterial extracorporeal membrane oxygenation in patients undergoing coronary artery bypass grafting

Background:

Studies reporting risk factors associated with unsuccessful weaning for coronary artery bypass grafting patients on venoarterial extracorporeal membrane oxygenation are scarce. This study was designed to identify factors associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation.

Methods:

Data from 166 coronary artery bypass grafting patients supported with venoarterial extracorporeal membrane oxygenation at the Beijing Anzhen Hospital between February 2004 and March 2017 were retrospectively analyzed. Multivariable logistic regression was performed using bootstrapping methodology to identify factors independently associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation.

Results:

A total of 106 patients (64%) could be weaned from venoarterial extracorporeal membrane oxygenation, and 74 patients (45%) were alive at hospital discharge. The 30-day and 60-day survival rates after ECMO weaning were 72% and 70%, respectively. Pre-existing hypertension (odds ratio, 2.54; 95% confidence interval, 1.16-5.56; p = 0.02), serum creatinine (+1 μmol/L; odds ratio, 1.008; 95% confidence interval, 1.003-1.013; p = 0.001), and serum lactate (+1 mmol/L; odds ratio, 1.17; 95% confidence interval, 1.08-1.26; p = 0.001) were independent risk factors associated with unsuccessful weaning from venoarterial extracorporeal membrane oxygenation. Higher platelet count was protective (+1 × 109/L; odds ratio, 0.992; 95% confidence interval, 0.986-0.998; p = 0.011). The area under the receiver operating characteristic curve 0.81 (95% confidence interval, 0.75-0.88) for the logistic regression model was better than those for the survival after VA-ECMO score (p = 0.002), EuroSCORE (p < 0.001), and the prEdictioN of Cardiogenic shock OUtcome foR Acute myocardial infarction patients salvaGed by VA-ECMO scores (p = 0.02) in this population. The pRedicting mortality in patients undergoing venoarterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (0.76; 95% confidence interval, 0.68-0.83; p = 0.29) and sepsis-related organ failure assessment score (0.77; 95% confidence interval, 0.70-0.85; p = 0.46) exhibited good performances similar to the logistic regression model.

Conclusion:

Pre-existing hypertension, serum creatinine, serum lactate, and low platelet count were independent predictors for unsuccessful weaning from venoarterial extracorporeal membrane oxygenation in patients undergoing coronary artery bypass grafting.

Management of Acute Heart Failure during an Early Phase

Acute heart failure (AHF), a global pandemic with high morbidity and mortality, exerts a considerable economic burden. AHF includes a broad spectrum of clinical presentations ranging from new-onset heart failure to cardiogenic shock. Key elements of the management rely on the clinical diagnosis confirmed on, both, increased natriuretic peptides and echocardiography, and on the prompt initiation of oxygen therapy, including non-invasive positive pressure ventilation, vasodilators, and diuretics. A care pathway is essential, specifically when an acute coronary syndrome is suspected or in the case of cardiogenic shock. Association or increasing doses of vasopressors despite an adequate volume status are markers of progression toward a refractory cardiogenic shock state. For the latter, mechanical circulatory support should be initiated early, optimally before the onset of renal or liver failure. Thus, a tertiary care center is recommended for the management of patients with AHF who require percutaneous coronary intervention or mechanical circulatory support. This narrative review provides multidisciplinary guidance for the management of AHF and cardiogenic shock from pre-hospital to intensive care unit/cardiac care unit, based on contemporary evidence and expert opinion.

Cannula and circuit management in peripheral extracorporeal membrane oxygenation: An international survey of 45 countries

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.

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

Nosocomial infection prevalence in patients undergoing extracorporeal membrane oxygenation (ECMO): protocol for a point prevalence study across Australia and New Zealand

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.