Trends in and perspectives on extracorporeal membrane oxygenation for severe adult respiratory failure

Outcome of extracorporeal membrane oxygenation support in patients with liver cirrhosis: a nationwide population-based cohort study

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is used for life support in patients with liver cirrhosis (LC). However, there have been no studies evaluating the outcome of ECMO support in patients with LC.

METHODS

Using Taiwan's National Health Insurance (NHI) database, we retrospectively evaluated patients with LC who received veno-venous or veno-arterial ECMO between 1 January 2000 and 31 December 2013. The outcomes included ECMO-related complications, in-hospital mortality, all-cause mortality and long-term outcomes in patients with and without LC.

RESULTS

A total of 7003 patients who received ECMO, of whom 233 (3.3%) had LC, were eligible for analysis. The LC patients who received ECMO support had a significantly higher risk of in-hospital mortality than the non-LC group (76.4% vs 60.7%; odds ratio 1.97; 95% confidence interval 1.44-2.70). The LC group also had a higher risk of complications, including de novo dialysis and massive blood transfusion with >10 units of red blood cells. Patients ≥65 years of age, patients with respiratory disease, patients with hypoalbuminaemia and liver transplant patients had higher in-hospital and 1-year mortality. The mortality rates for patients with 2 or more risk factors were 90.3% and 95.8%, respectively. LC was associated with a higher incidence of all-cause mortality and liver-related outcomes during follow-up.

CONCLUSIONS

Our findings raise questions regarding the utility of ECMO for LC patients, especially when >2 risk factors have been identified. ECMO support for LC patients should be used with caution and with careful patient selection.

Extracorporeal membrane oxygenation use, expenditure, and outcomes in taiwan from 2000 to 2010

Background

No study to date has systematically examined use, expenditure, and outcomes associated with extracorporeal membrane oxygenation (ECMO) use in Taiwan. The aim of this study was to examine ECMO use, expenditure, and outcomes during an 11-year period in Taiwan.

Methods

Claims data were collected from the Taiwan National Health Insurance Research Database for patients who received ≥1 ECMO treatment between January 2000 and December 2010. Measurements included demographics, indications for ECMO use, length of hospital stay, outcome, and expenditure.

Results

A total of 3969 patients received ECMO during the study period (median age: 54.6 years). The number of patients receiving ECMO increased from 52 in 2000 to 1045 in 2010. The major indication for ECMO was cardiovascular disease (68.7%), followed by respiratory disease (17.9%). Median length of hospital stay was 13 days in 2000 and 17 days in 2010. Median expenditure (New Taiwan dollars) was $604 317 in 2000 and $673 888 in 2010. Some variables significantly differed by age, sex, hospital setting, calendar year, and indication for ECMO, and were associated with in-hospital and after-discharge mortality.

Conclusions

ECMO use has increased dramatically in Taiwan over the last decade. The high mortality rate of ECMO users suggested that ECMO may be being used in Taiwan for situations in which it provides no added benefit. This situation may be a reflection of the current reimbursement criteria for National Health Insurance in Taiwan. Refinement of the indications for use of ECMO is suggested.

Resource use trends in extracorporeal membrane oxygenation in adults: an analysis of the Nationwide Inpatient Sample 1998-2009

OBJECTIVE

The study objective was to determine whether significant trends over time have occurred in resource use associated with the use of extracorporeal membrane oxygenation in critically ill adults.

METHODS

All adult admissions involving extracorporeal membrane oxygenation were examined by using the Nationwide Inpatient Sample database (years 1998-2009). Trends in volume, outcome, and resource use (including hospital charges, length of stay, and charges per day) were analyzed.

RESULTS

An estimated total of 8753 admissions involved extracorporeal membrane oxygenation over the study period. Overall length of stay was 18.3 ± 1.3 days. Total hospital charges averaged $344,009 ± $30,707 per admission, with average charges per day of $40,588 ± $3099. Cumulative national charges for extracorporeal membrane oxygenation admissions increased significantly from $109.0 million in 1998 to $764.7 million in 2009 (P = .0016). Charges per patient and length of stay also increased significantly (P = .0032 and .0321, respectively). The increasing trend in the number of extracorporeal membrane oxygenation admissions during the study period was not statistically significant (P = .19). The post-cardiotomy group had more favorable outcomes and lower resource use. A shift was observed in the relative case-mix of extracorporeal membrane oxygenation admissions over the study period, with a relative decrease in the post-cardiotomy group and increases in the cardiogenic shock, respiratory failure, and lung transplant groups.

CONCLUSIONS

These results suggest that dramatic increases in resource use associated with extracorporeal membrane oxygenation are not solely the result of increased volume, but in part are due to a shift toward extracorporeal membrane oxygenation use in patient groups (other than in the post-cardiotomy setting) with greater resource use and worse outcomes.

Transesophageal echocardiography in noncardiac thoracic surgery

In high-risk surgeries with medically complicated patients, transesophageal echocardiography (TEE) adds an additional level of monitoring with which few can disagree. This article presents multiple applications of TEE that can assist both the anesthesiologist and the surgeon through major noncardiac thoracic surgery. It highlights how TEE can be used as an adjuvant to lung resection surgery; TEE as a monitor during lung transplantation; TEE to assess patients for extracorporeal membrane oxygenation; TEE for thoracic aortic surgery; and TEE in the assessment of patients with acute pulmonary hypertension undergoing noncardiac thoracic surgery.