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Fischbach A, Wiegand SB, Simons JA, Ammon L, Kopp R, Soccoro Matos GI, Baigorri JJ, Crowley JC, Bagchi A. The Ventilatory Ratio as a Predictor of Successful Weaning from a Veno-Venous Extracorporeal Membrane Oxygenator. J Clin Med 2024; 13:3758. [PMID: 38999326 PMCID: PMC11242634 DOI: 10.3390/jcm13133758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/11/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a critical intervention for patients with severe lung failure, especially acute respiratory distress syndrome (ARDS). The weaning process from ECMO relies largely on expert opinion due to a lack of evidence-based guidelines. The ventilatory ratio (VR), which correlates with dead space and mortality in ARDS, is calculated as [minute ventilation (mL/min) x arterial pCO2 (mmHg)]/[predicted body weight × 100 × 37.5]. Objectives: The aim of this study was to determine whether the VR alone can serve as a reliable predictor of safe or unsafe liberation from VV-ECMO in critically ill patients. Methods: A multicenter retrospective analysis was conducted, involving ARDS patients undergoing VV-ECMO weaning at Massachusetts General Hospital (January 2016 - December 2020) and at the University Hospital Aachen (January 2012-December 2021). Safe liberation was defined as no need for ECMO recannulation within 48 h after decannulation. Clinical parameters were obtained for both centers at the same time point: 30 min after the start of the SGOT (sweep gas off trial). Results: Of the patients studied, 83.3% (70/84) were successfully weaned from VV-ECMO. The VR emerged as a significant predictor of unsafe liberation (OR per unit increase: 0.38; CI: 0.17-0.81; p = 0.01). Patients who could not be safely liberated had longer ICU and hospital stays, with a trend towards higher mortality (38% vs. 13%; p = 0.05). Conclusions: The VR may be a valuable predictor for safe liberation from VV-ECMO in ARDS patients, with higher VR values associated with an elevated risk of unsuccessful weaning and adverse clinical outcomes.
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Affiliation(s)
- Anna Fischbach
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Steffen B. Wiegand
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Julia Alexandra Simons
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Liselotte Ammon
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Rüdger Kopp
- Department of Operative Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | | | | | - Jerome C. Crowley
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Aranya Bagchi
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA 02114, USA
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2
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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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3
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Tsiouris A, Protos AN, Saikus CE, Jeyakumar AKC. Fundamentals of weaning veno-arterial and veno-venous extracorporeal membrane oxygenation. Indian J Thorac Cardiovasc Surg 2023; 39:1-11. [PMID: 36820202 PMCID: PMC9932401 DOI: 10.1007/s12055-023-01474-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 02/18/2023] Open
Abstract
Recent advances in veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) technology and management have enabled us to support patients with cardiac and/or pulmonary failure, who may have previously been considered untreatable. VA ECMO and VV ECMO are by definition transient therapies and serve as a bridge to recovery, bridge to decision, bridge to transplant, or bridge to no recovery. Weaning ECMO should be considered for all patients once native cardiac and pulmonary function show signs of recovery. Currently, there are no universally accepted protocols for weaning VA and VV ECMO, and consequently, each individual center follows their own weaning protocols. The aim of this review article is to describe different approaches to safely wean from VA and VV ECMO.
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Affiliation(s)
- Athanasios Tsiouris
- Division of Cardiac Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 USA
| | - Adam Nicholas Protos
- Division of Cardiac Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 USA
| | - Christina Elena Saikus
- North Shore University Hospital, Northwell Health, 300 Community Dr, Manhasset, NY 11030 USA
| | - Ashok Kumar Coimbatore Jeyakumar
- Division of Cardiac Surgery, Department of Surgery, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 USA
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Collins PD, Giosa L, Camarda V, Camporota L. Physiological adaptations during weaning from veno-venous extracorporeal membrane oxygenation. Intensive Care Med Exp 2023; 11:7. [PMID: 36759388 PMCID: PMC9911184 DOI: 10.1186/s40635-023-00493-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) has an established evidence base in acute respiratory distress syndrome (ARDS) and has seen exponential growth in its use over the past decades. However, there is a paucity of evidence regarding the approach to weaning, with variation of practice and outcomes between centres. Preconditions for weaning, management of patients' sedation and mechanical ventilation during this phase, criteria defining success or failure, and the optimal duration of a trial prior to decannulation are all debated subjects. Moreover, there is no prospective evidence demonstrating the superiority of weaning the sweep gas flow (SGF), the extracorporeal blood flow (ECBF) or the fraction of oxygen of the SGF (FdO2), thereby a broad inter-centre variability exists in this regard. Accordingly, the aim of this review is to discuss the required physiological basis to interpret different weaning approaches: first, we will outline the physiological changes in blood gases which should be expected from manipulations of ECBF, SGF and FdO2. Subsequently, we will describe the resulting adaptation of patients' control of breathing, with special reference to the effects of weaning on respiratory effort. Finally, we will discuss pertinent elements of the monitoring and mechanical ventilation of passive and spontaneously breathing patients during a weaning trial. Indeed, to avoid lung injury, invasive monitoring is often required in patients making spontaneous effort, as pressures measured at the airway may not reflect the degree of lung strain. In the absence of evidence, our approach to weaning is driven largely by an understanding of physiology.
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Affiliation(s)
- Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, London, UK.
| | - Lorenzo Giosa
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, London, UK
| | - Valentina Camarda
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK
| | - Luigi Camporota
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, London, UK
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A Retrospective Analysis for Risk Factors and Early Prognosis of Delayed Withdrawal Extracorporeal Membrane Oxygenation After Lung Transplantation. Transplantation 2021; 105:867-875. [PMID: 32345865 DOI: 10.1097/tp.0000000000003290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is widely used for cardiopulmonary assistance during lung transplantation (LTx). However, the optimal timing for ECMO removal remains controversial. This study aimed to evaluate the risk factors and early prognosis of delayed withdrawal ECMO after LTx. METHODS Two hundred sixty-seven patients who underwent LTx supported by ECMO were included in this study. Based on whether or not ECMO was completely stopped in the operating room, patients were divided into early ECMO withdrawal group (group E, 107 cases) and delayed withdrawal group (group D, 160 cases). Perioperative data of the donors and recipients, including the suspected risk factors for delayed removal of ECMO, postoperative complications, and hospital survival rate, were retrospectively analyzed. RESULTS Preoperative New York Heart Association cardiac function for recipients and mechanical ventilation time for donors were independent risk factors for delayed weaning of ECMO in veno-arterial ECMO patients. Compared with group E, the odds of postoperative pulmonary infection, primary graft dysfunction, renal dysfunction, blood transfusion volume, and mechanical ventilation time were significantly higher in group D (all P < 0.05). Delayed withdrawal ECMO was decisive factor for early postoperative death, as the risk of early postoperative death in group D was 1.99 (95% confidence interval, 1.13-3.54) times as that in the group E. CONCLUSIONS During the period of LTx, New York Heart Association grade III/IV for recipients and mechanical ventilation time ≥5 days for donors are suggestive of delayed veno-arterial ECMO removal, and clinicians should minimize the postoperative bypass time of ECMO when conditions permit.
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Swol J, Shekar K, Protti A, Tukacs M, Broman LM, Barrett NA, Mueller T, Peek GJ, Buscher H. Extubate Before Venovenous Extracorporeal Membranous Oxygenation Decannulation or Decannulate While Remaining on the Ventilator? The EuroELSO 2019 Weaning Survey. ASAIO J 2021; 67:e86-e89. [PMID: 32701622 DOI: 10.1097/mat.0000000000001237] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Justyna Swol
- From the Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University Nuremberg, General Hospital Nuremberg, Nuremberg, Germany
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane and Bond University, Gold Coast, Australia
| | - Alessandro Protti
- Department of Anesthesia and Intensive Care Units, Humanitas Research and Clinical Centre-IRCCS, Milan, Italy
| | - Monika Tukacs
- Department of Cardiothoracic Intensive Care Unit/Nursing, New York Presbyterian-Columbia University Irving Medical Center, New York
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Human & Applied Physiological Sciences (CHAPS), School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, United Kingdom
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Giles J Peek
- Congenital Heart Center, University of Florida, Shands Hospital for Children, Gainesville, Florida
| | - Hergen Buscher
- Department of Intensive Care Medicine, Centre of Applied Medical Research, St Vincent's Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
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Na SJ, Jeon K. Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome. Expert Rev Respir Med 2020; 14:511-519. [PMID: 32089016 DOI: 10.1080/17476348.2020.1734457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: The global number of patients receiving extracorporeal membrane oxygenation (ECMO) support has been growing after several studies highlighted the favorable results attained in cases of severe respiratory failure. However, evidence-based guidelines for optimal use of ECMO are lacking.Areas covered: This review covers optimal candidates, timing of initiation, strategies for patient management including mechanical ventilation, and decision-making regarding discontinuation of ECMO based on its potential role in treatment of patients with acute respiratory distress syndrome.Expert opinion: Early initiation of ECMO should be considered if hypoxemia and uncompensated hypercapnia do not respond to optimal conventional treatment. Use of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical during ECMO support to ensure the best outcome. The possibility of weaning from ECMO should be fully assessed by a multidisciplinary team during ECMO support. Futility should not be determined solely by duration of ECMO, and use of prolonged ECMO for lung recovery may be worthwhile.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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8
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Sawa Y, Matsumiya G, Matsuda K, Tatsumi E, Abe T, Fukunaga K, Ichiba S, Taguchi T, Kokubo K, Masuzawa T, Myoui A, Nishimura M, Nishimura T, Nishinaka T, Okamoto E, Tokunaga S, Tomo T, Tsukiya T, Yagi Y, Yamaoka T. Journal of Artificial Organs 2018: the year in review : Journal of Artificial Organs Editorial Committee. J Artif Organs 2019; 22:1-5. [PMID: 30796540 DOI: 10.1007/s10047-019-01094-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Y Sawa
- Division of Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - G Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - K Matsuda
- Emergency and Critical Care Medicine, University of Yamanashi Hospital, Yamanashi, Japan
| | - E Tatsumi
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - T Abe
- Department of Urology, Iwate Medical University School of Medicine, Iwate, Japan
| | - K Fukunaga
- Faculty of Health Sciences, Kyorin University, Tokyo, Japan
| | - S Ichiba
- Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - T Taguchi
- Biomaterial Unit, National Institute of Material Science, Ibaraki, Japan
| | - K Kokubo
- Department of Medical Engineering and Technology, Kitasato University School of Allied Health Science, Kanagawa, Japan
| | - T Masuzawa
- Department of Mechanical Engineering, Ibaraki University, Ibaraki, Japan
| | - A Myoui
- Medical Center for Translational Research, Osaka University Hospital, Osaka, Japan
| | - M Nishimura
- Division of Organ Regeneration Surgery, Tottori University Faculty of Medicine, Tottori, Japan
| | - T Nishimura
- Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - T Nishinaka
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - E Okamoto
- Department of Human Science and Informatics, School of Bioscience and Engineering, Tokai University, Sapporo, Japan
| | - S Tokunaga
- The Department of Cardiovascular Surgery, JCHO Kyushu Hospital, Fukuoka, Japan
| | - T Tomo
- Second Department of Internal Medicine, Faculty of Medicine, Oita University, Oita, Japan
| | - T Tsukiya
- Department of Artificial Organs, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Y Yagi
- Department of Clinical Engineering, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - T Yamaoka
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
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