Position article for the use of extracorporeal life support in adult patients

[The Role of the Percutaneous Impella Pump in Anesthesia and Intensive Care]

The use of temporary mechanical circulatory support (tMCS) devices and in particular the increasing use of the Impella device family has gained significant interest over the last two decades. Nowadays, its use plays a well-established key role in both the treatment of cardiogenic shock, and as a preventive and protective therapeutic option during high-risk procedures in both cardiac surgery and cardiology, such as complex percutaneous interventions (protected PCI). Thus, it is not surprising that the Impella device is more and more present in the perioperative setting and especially in patients on intensive care units. Despite the numerous advantages such as cardiac resting and hemodynamic stabilization, potential adverse events exist, which may lead to severe, but preventable complications, so that adequate education, early recognition of such events and a subsequent adequate management are crucial in patients with tMCS. This article provides an overview especially for anesthesiologists and intensivists focusing on technical basics, indications and contraindications for its use with special focus on the intra- and postoperative management. Furthermore, troubleshooting for most common complications for patients on Impella support is provided.

Empfehlungen der S3-Leitlinie (AWMF) „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS-/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS-/ECMO-Therapie. Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde. Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

An Agreement Study Between Point-of-Care and Laboratory Activated Partial Thromboplastin Time for Anticoagulation Monitoring During Extracorporeal Membrane Oxygenation

Background

Laboratory activated partial thromboplastin time (LAB-aPTT) is a widely used laboratory assay for monitoring unfractionated heparin (UFH) therapy during extracorporeal membrane oxygenation (ECMO). But LAB-aPTT is confined to a central laboratory, and the procedure is time-consuming. In comparison, point-of-care aPTT (POC-aPTT) is a convenient and quick assay, which might be a promising method for anticoagulation monitoring in ECMO. This study was aimed to evaluate the agreement between POC-aPTT (hemochron Jr. Signature instruments) and LAB-aPTT for anticoagulation monitoring in adult ECMO patients.

Methods

Data of ECMO-supported adult patients anticoagulated with UFH in our institute from January 2017 to December 2020 was retrospectively reviewed. POC-aPTT and LAB-aPTT results measured simultaneously were paired and included in the analysis. The correlation between POC-aPTT and LAB-aPTT was assessed using Spearman’s correlation coefficient. Bias between POC-aPTT and LAB-aPTT were described with the Bland-Altman method. Influence factors for bias were identified using multinomial logistic regression analysis.

Results

A total 286 pairs of aPTT results from 63 patients were included in the analysis. POC-aPTT and LAB-aPTT correlated weakly (r = 0.385, P < 0.001). The overall bias between POC-aPTT and LAB-aPTT was 7.78 [95%CI (−32.49, 48.05)] s. The overall bias between POC-aPTT and LAB-aPTT ratio (to normal value) was 0.54 [95%CI (−0.68, 1.76)]. A higher plasma fibrinogen level [OR 1.353 (1.057, 1.733), P = 0.017] was associated with a higher chance of POC-aPTT underestimating LAB-aPTT. While a lower plasma fibrinogen level [OR 0.809 (0.679, 0.963), P = 0.017] and lower UFH rate [OR 0.928 (0.868, 0.992), P = 0.029] were associated with a higher chance of POC-aPTT overestimating LAB-aPTT.

Conclusion

The present study showed poor agreement between POC-aPTT and LAB-aPTT. POC-aPTT was not suitable for anticoagulation monitoring in adult ECMO patients.

Empfehlungen der S3-Leitlinie (AWMF) Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS/ECMO-Therapie.

Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde.

Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.

Indications and contraindications for extracorporeal life support for severe heart or lung failure: a systematic review

INTRODUCTION

The effectiveness of extracorporeal life support (ECLS) in critically ill patients remains unclear despite a substantial increase in its use. This study critically assesses existing ECLS guidelines, consensus statements, and position papers to systematically review them for agreements and differences regarding indications and contraindications for ECLS.

EVIDENCE ACQUISITION

The aims of this review were to identify available indications and contraindications for ECLS and to evaluate the quality of the evidence on which they are based. Documents containing recommendations regarding indications and/or contraindications for ECLS in adults (aged 18+) were identified through Medline, EMBASE, and CENTRAL searches. Additional documents were identified from guideline-specific databases and the internet websites of professional societies. Based on the Appraisal of Guidelines for Research and Evaluation (AGREE II), four independent reviewers assessed the rigor of development and quality of the documents.

EVIDENCE SYNTHESIS

Eleven documents met the inclusion criteria. Three documents received an average score of ≥50% in all domains. However, the Editorial independence domain only scored <50% in most of the documents. Overall, 13 cardiac and 13 pulmonary ECLS indications, and 23 cardiac and 14 pulmonary contraindications were identified. Indications and contraindications for ECLS use are variable across the documents included and leave considerable room for interpretation.

CONCLUSIONS

The documents included for review show considerable variability, with little consensus on indications and contraindications. This lack of consensus may reflect a lack of clarity regarding ECLS utility. Additionally, it may reveal the necessity for individualized, patient-dependent criteria supported by the best evidence available.

[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.

The peripheral cannulas in extracorporeal life support

Femoral cannulation is a minimally invasive method which is an alternative method for central cannulation. This review focuses on the parameters and features of the available peripheral cannulas. Nowadays there exist many peripheral cannulas in a variety of sizes, configurations and lengths to meet the specific needs of the patients. Modern cannulas are strong, thin-walled and one piece reinforced constructions. Furthermore, modern cannulas are manufactured from a biocompatible material and surface coatings are applied to the cannulas to reduce the activation of the clotting. When peripheral cannulas are applied, bleeding, thrombosis and hemolysis are the most common complications.

Acute heart failure due to giant left atrium: remote ECLS implantation for interhospital transfer and bridging to decision

Background

Remote extracorporeal life support (ECLS) implantation and mobile ECLS are increasingly applied to enable the treatment of patients with refractory heart failure at specialized care centers. Giant left atrium (GLA) is a rare cause but may lead to acute and devastating heart failure.

Case report

Acute heart failure that gave rise to a prolonged period of out-of-hospital cardiopulmonary resuscitation in a patient who underwent remote ECLS implantation was found to have resulted from a GLA of impressive dimensions. There having no reasonable option for immediate surgical therapy, the patient was successfully bridged to recovery with a view to subsequent heart transplantation.

Conclusions

The threshold to rapid institution of ECLS should be low in patients with acute refractory heart failure, including those with uncommon pathologies. Remote ECLS implantation and interhospital transfer on mobile ECLS increase the chances of survival in cases requiring treatment by specialized care centers.

The Early Initiation of Extracorporeal Life Support May Improve the Neurological Outcome in Adults with Cardiac Arrest due to Cardiac Events

Objective Extracorporeal life support (ECLS) is effective for improving the survival rate of patients with refractory cardiac arrest (rCA). As little data are available regarding the impact of ECLS on a favorable neurological outcome, the predictors of a favorable neurological outcome were evaluated in this study. Methods Between January 2007 and August 2016, we retrospectively recruited patients with rCA caused by cardiac events treated with ECLS in our institute. A favorable neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category score 1 at discharge. The study endpoint was the clinical outcomes and predictors of favorable neurologic patients at discharge. Results During the study period, 67 patients with CA caused by cardiac events (acute coronary syndrome, 57 patients; idiopathic ventricular fibrillation, 10 patients) were included. Of these, 20 patients (29.9%) were classified into the favorable neurological group. No marked difference was observed in the patient characteristics between those with and without a favorable outcome except for in the time from CA to starting ECLS (ECLS initiation time). A short ECLS initiation time resulted in a favorable outcome (37.8±28.1 minutes vs. 53.6±30.7 minutes, p=0.05). The cut-off time of ECLS initiation was 46 minutes, which was prolonged by the temporary return of spontaneous circulation before ECLS [odds ratio (OR), 3.69; 95% confidence interval (CI), 1.34-10.19; p=0.01] and transfer to the angiographic room (OR, 4.07; 95% CI, 1.44-11.53, p=0.008). Conclusion The early initiation of ECLS (within 46 minutes) might be associated with a favorable neurological outcome for patients with rCA caused by cardiac events.

Monitoring of adult patient on venoarterial extracorporeal membrane oxygenation in intensive care medicine

Nowadays high-tech medical assist device therapy is a crucial part of intensive care medicine. Especially, management of circulatory assist device systems poses an increasing challenge for intensive care medicine. So far, autonomous recommendations for monitoring of extracorporeal life support systems in the form of guidelines or position papers are lacking. The purpose of this paper was to present an orientation guide on this important topic.

Mechanical support for high-risk coronary artery bypass grafting

Mechanical circulatory support devices are being used to an increasing extent. The use of these devices as an adjunct to cardiac surgery to support ventricular function has contributed to improved outcomes for the highest risk patients. In the context of patients undergoing coronary artery bypass grafting, there are several potential indications for mechanical circulatory support: preoperatively in the setting of acute cardiogenic shock, or in patients with intractable angina with or without haemodynamic compromise; at induction of anaesthesia prophylactically in patients with critical coronary anatomy and/or severely impaired left ventricular function; intraoperatively in the setting of failure to wean from cardiopulmonary bypass; or postoperatively in patients who develop an intractable low cardiac output state. The use of the intra-aortic balloon pump, veno-arterial extracorporeal membrane oxygenation, TandemHeart, Impella and central ventricular assist devices will be considered in the setting of high-risk patients undergoing coronary artery bypass grafting.

Extracorporeal Lung Support as a Bridge to Diagnosis of Pulmonary Tumor Embolism

Bridging to diagnosis is an emerging technique used in end-stage cardiorespiratory failure that prolongs a patient's life using various modalities of extracorporeal lung support (ECLS) to achieve antemortem diagnosis. Pulmonary tumor embolism occurs when cell clusters travel from primary malignancies through venous circulation to the lungs, causing respiratory failure through inflammatory and venoocclusive pathways. Due to its nonspecific symptomatology, pulmonary tumor embolism remains an elusive diagnosis antemortem. Herein, we bridge a patient who presented in acute respiratory failure to the diagnosis of pulmonary tumor embolism from a gastric signet-ring cell carcinoma using ECLS modalities including venoarterial extracorporeal membrane oxygenation and centrally cannulated Novalung pumpless extracorporeal lung assist. We demonstrate the utility of this approach in diagnostically uncertain cases in unstable patients who are potentially acceptable ECLS and transplant candidates.

Mobile Extracorporeal Membrane Oxygenation Teams: The North American Versus the European Experience

OBJECTIVE

To evaluate differences in the inclusion of anesthesiologists in mobile extracorporeal membrane oxygenation (ECMO) teams between North American and European centers.

DESIGN

A retrospective review of North American versus European mobile ECMO teams. The search terms used to identify relevant articles were the following: "extracorporeal membrane transport," "mobile ECMO," and "interhospital transport."

SETTING

MEDLINE review of articles.

PARTICIPANTS

None.

INTERVENTIONS

None.

RESULTS

Between 1986 and 2015, 25 articles were published that reported the personnel makeup of mobile ECMO teams in North America and Europe: 6 from North American centers and 19 from European centers. The included articles reported a total of 1,329 cases: 389 (29%) adult-only cohorts and 940 (71%) mixed-age cohorts. Among North American studies, 0 of 6 (0%) reported the presence of an anesthesiologist on the mobile ECMO team in contrast to European studies, in which 10 of 19 (53%) reported the inclusion of an anesthesiologist (Fisher exact p for difference = 0.05). In terms of number of cases, this discrepancy translated to 543 total cases in North America (all without an anesthesiologist) and 499 cases in Europe (37%) including an anesthesiologist on the team (Fisher exact p for difference<0.001).

CONCLUSIONS

This study demonstrated significant geographic discrepancies in the inclusion of anesthesiologists on mobile ECMO teams, with European centers more likely to incorporate an anesthesiologist into the mobile ECMO process compared with North American centers.

Extracorporeal Membrane Oxygenation as a Bridge for Heart Failure and Cardiogenic Shock

Heart failure (HF) can be defined as cardiac structural or functional abnormality leading to a series of symptoms due to deficiency of oxygen delivery. In the clinical practice, acute heart failure (AHF) is usually performed as cardiogenic shock (CS), pulmonary edema, and single or double ventricle congestive heart failure. CS refers to depressed or insufficient cardiac output (CO) attributable to myocardial infarction, fulminant myocarditis, acute circulatory failure attributable to intractable arrhythmias or the exacerbation of chronic heart failure, postcardiotomy low CO syndrome, and so forth. Epidemiological studies have shown that CS has higher in-hospital mortality in patients with AHF. Besides, we call the induced, sustained circulatory failure even after administration of high doses of inotropes and vasopressors refractory cardiogenic shock. In handling these cases, mechanical circulatory support devices are usually needed. In this review, we discuss the current application status and clinical points in utilizing extracorporeal membrane oxygenation (ECMO).

Catheter Insertion via Extracorporeal Membrane Oxygenation Cannula during Transcatheter Aortic Valve Implantation

Background Patients referred to transcatheter aortic valve implantation (TAVI) present with multiple risk factors for intraprocedural complications.

Case Description We describe a TAVI procedure with sudden hemodynamic collapse and cardiopulmonary resuscitation. Therefore, extracorporeal membrane oxygenation cannulas were immediately implanted via vessels of the groin. A Y-connector was inserted into the arterial line of the extracorporeal membrane oxygenator using an additional sheath facilitating to insert a pigtail catheter to guide the further valve implantation.

Conclusion This case report provides an option to insert a pigtail catheter after implantation of extracorporeal membrane oxygenator cannulas without need for additional vascular access.

Extracorporeal support for pulmonary resection: current indications and results

Extracorporeal assistances are exponentially used for patients, with acute severe but reversible heart or lung failure, to provide more prolonged support to bridge patients to heart and/or lung transplantation. However, experience of use of extracorporeal assistance for pulmonary resection is limited outside lung transplantation. Airways management with standard mechanical ventilation system may be challenging particularly in case of anatomical reasons (single lung), presence of respiratory failure (ARDS), or complex tracheo-bronchial resection and reconstruction. Based on the growing experience during lung transplantation, more and more surgeons are now using such devices to achieve good oxygenation and hemodynamic support during such challenging cases. We review the different extracorporeal device and attempt to clarify the current practice and indications of extracorporeal support during pulmonary resection.

Comparison of Extracorporeal Cardiopulmonary Resuscitation with Conventional Cardiopulmonary Resuscitation: Is Extracorporeal Cardiopulmonary Resuscitation Beneficial?

BACKGROUND

With improvements in cardiopulmonary resuscitation (CPR) techniques, the quality and the effectiveness of CPR have been established; nevertheless, the survival rate after cardiac arrest still remains poor. Recently, many reports have shown good outcomes in cases where extracorporeal membrane oxygenation (ECMO) was used during prolonged CPR. Accordingly, we attempted to evaluate the impact of extracorporeal cardiopulmonary resuscitation (ECPR) on the survival of patients who experienced a prolonged cardiac arrest and compared it with that of conventional CPR (CCPR).

METHODS

Between March 2009 and April 2014, CPR, including both in-hospital and out-of-hospital CPR, was carried out in 955 patients. The ECPR group, counted from the start of the ECPR program in March 2010, included 81 patients in total, and the CCPR group consisted of 874 patients. All data were retrospectively collected from the patients' medical records.

RESULTS

The return of spontaneous circulation (ROSC) rate was 2.24 times better in CPR of in-hospital cardiac arrest (IHCA) patients than in CPR of out-of-hospital CA (OHCA) patients (p=0.0012). For every 1-minute increase in the CPR duration, the ROSC rate decreased by 1% (p=0.0228). Further, for every 10-year decrease in the age, the rate of survival discharge increased by 31%. The CPR of IHCA patients showed a 2.49 times higher survival discharge rate than the CPR of OHCA patients (p=0.03). For every 1-minute increase in the CPR duration, the rate of survival discharge was decreased by 4%. ECPR showed superiority in terms of the survival discharge in the univariate analysis, although with no statistical significance in the multivariate analysis.

CONCLUSION

The survival discharge rate of the ECPR group was comparable to that of the CCPR group. As the CPR duration increased, the survival discharge and the ROSC rate decreased. Therefore, a continuous effort to reduce the time for the decision of ECMO initiation and ECMO team activation is necessary, particularly during the CPR of relatively young patients and IHCA patients.

Short-term heart and lung support: extracorporeal membrane oxygenation and extracorporeal life support

In the last few years, progress in engineering has helped to develop minimized systems for extracorporeal membrane oxygenation and circulatory support. However, despite progress in engineering, the use of these systems still requires a trained team with special skills to be a beneficial and safe tool in the care of critically ill patients. The described indications and proceedings are based on the daily experience of the Freiburg group using these systems both on site in our own hospital and for transport purposes from primary care hospitals into our center of maximum care. The aim of this review is to share our hands-on experience in urgent/emergent implantations and therefore contribute to the knowledge within the growing community of users in this specialized field of extracorporeal support.

When all else fails: extracorporeal life support in therapy-refractory cardiogenic shock

OBJECTIVES

No guidelines for mechanical circulatory support in patients with therapy-refractory cardiogenic shock and multiorgan failure including ongoing cardiopulmonary resuscitation (CPR) exist. To achieve immediate cardiopulmonary stabilization, we established an interdisciplinary concept with on-site percutaneous extracorporeal life support (ECLS) implantation.

METHODS

From February 2012 to November 2014, 96 patients were deemed eligible for ECLS implantation. Establishing ECLS was successful in 87 patients (mean age 54 ± 13 years, 16% female, initial flow 4.4 ± 0.9 l/min). Aetiologies included acute coronary syndromes (n = 52, 60%), cardiomyopathies (n = 25, 29%) and other pathologies. Fifty-nine patients (68%) had been resuscitated, and in 27 (31%), implantation was performed during CPR; 11 patients (13%) were awake at implantation and 20 (23%) underwent implantation in the referring hospital.

RESULTS

Metabolic parameters differed in non-survivors versus survivors before ECLS implantation (pH 7.15 ± 0.23 vs. 7.27 ± 0.18, P = 0.007; lactate levels 10.90 ± 6.00 mmol/l vs. 8.79 ± 5.78 mmol/l, P = 0.091) and 6 h postimplantation (pH 7.27 ± 0.11 vs. 7.37 ± 0.11, P < 0.001; lactate levels 10.19 ± 5.52 mmol/l vs. 5.52 ± 4.17 mmol/l, P < 0.001). Altogether 44 patients could be weaned, and 9 were bridged to assist device implantation and 1 to heart transplantation. The mean time of support was 6 days, and the 30-day survival rate was 47% (n = 41).

CONCLUSIONS

ECLS serves as a bridge-to-decision and bridge-to-treatment device. Our interdisciplinary ECLS programme achieved acceptable survival of critically ill patients despite a substantial percentage of patients having been resuscitated and no absolute exclusion criteria. Further studies defining inclusion- and exclusion criteria might additionally improve outcome.

[Veno-arterial extracorporeal membrane oxygenation. Indications, limitations and practical implementation]

Due to the technical advances in pumps, oxygenators and cannulas, veno-arterial extracorporeal membrane oxygenation (va-ECMO) or extracorporeal life support (ECLS) has been widely used in emergency medicine and intensive care medicine for several years. An accepted indication is peri-interventional cardiac failure in cardiac surgery (postcardiotomy low cardiac output syndrome). Furthermore, especially the use of va-ECMO for other indications in critical care medicine, such as in patients with severe sepsis with septic cardiomyopathy or in cardiopulmonary resuscitation has tremendously increased. The basic indications for va-ECMO are therapy refractory cardiac or cardiopulmonary failure. The fundamental purpose of va-ECMO is bridging the function of the lungs and/or the heart. Consequently, this support system does not represent a causal therapy by itself; however, it provides enough time for the affected organ to recover (bridge to recovery) or for the decision for a long-lasting organ substitution by a ventricular assist device or by transplantation (bridge to decision). Although the outcome for bridged patients seems to be favorable, it should not be forgotten that the support system represents an invasive procedure with potentially far-reaching complications. Therefore, the initiation of these systems needs a professional and experienced (interdisciplinary) team, sufficient resources and an individual approach balancing the risks and benefits. This review gives an overview of the indications, complications and contraindications for va-ECMO. It discusses its advantages in organ transplantation and transport of critically ill patients. The reader will learn the differences between peripheral and central cannulation and how to monitor and manage va-ECMO.

Results of extracorporeal life support implementation in routine clinical practice: single center experience

Aim

To describe our experience in the clinical application of extracorporeal life support (ECLS) and analyze whether ECLS leads to acceptable clinical outcomes in patients with cardiac failure.

Methods

Data from clinical database of University Hospital Center Zagreb, Croatia, on 75 patients undergoing ECLS support from 2009 to 2014 due to cardiac failure were retrospectively analyzed. Outcomes were defined as procedural and clinical outcomes. ECLS as a primary procedure and ECLS as a postcardiotomy procedure due to inability to wean from cardiopulmonary bypass were analyzed.

Results

ECLS was used in 75 adult patients, and in 24 (32%) of those procedural success was noted. ECLS was implemented as a primary procedure in 36 patients and as a postcardiotomy procedure in 39 patients. Nine out of 39 (23.08%) patients had postcardiotomy ECLS after heart transplantation. Bleeding complications occurred in 30 (40%) patients, both in primary (11/36 patients) and postcardiotomy group (19/39 patients). ECLS was established by peripheral approach in 46 patients and by central cannulation in 27 patients. In 2 patients, combined cannulation was performed, with an inflow cannula placed into the right atrium and an outflow cannula placed into the femoral artery. Eleven patients treated with peripheral approach had ischemic complications.

Conclusion

ECLS is a useful tool in the treatment of patients with refractory cardiac failure and its results are encouraging in patients who otherwise have an unfavorable prognosis.

[Use of ECMO in adult patients with cardiogenic shock: a position paper of the Austrian Society of Cardiology]

The use of ECMO to stabilize critically ill patients with severely depressed cardiac function and hemodynamics increased in the last years due to broader availability, better performance and easier implantation of the devices. The present guidelines of the Austrian Society of Cardiology focus on the use of ECMO in adult non-operated patients with cardiac diseases. Not only indications and contraindications are highlighted, but also the equally important issues of monitoring, complication management, measures during implantation and operation, and weaning of the devices are treated in detail. Thereby the present guidelines aim to optimize the use of ECMO in the individual centers, and aim to help current non-ECMO centers in developing a local ECMO-program or to contact ECMO-centers for discussion of individual patients.

Extracorporeal membrane oxygenation as bridge-to-decision in acute heart failure due to systemic light-chain amyloidosis

Patient: Female, 58

Final Diagnosis: Acute hear failure

Symptoms: Dispnoea • edema • fatigue

Medication: —

Clinical Procedure: Bone marrow biopsy • endomyocardial biopsy • abdominal subcutaneous fat biopsy under ECMO support

Specialty: Cardiology

A novel echocardiographic imaging technique, intracatheter echocardiography, to guide veno-venous extracorporeal membrane oxygenation cannulae placement in a validated ovine model

Background

Echocardiography plays a fundamental role in cannulae insertion and positioning for extracorporeal membrane oxygenation (ECMO). Optimal access and return cannulae orientation is required to prevent recirculation. The aim of this study was to compare a novel imaging technique, intracatheter echocardiography (iCATHe), with conventional intracardiac echocardiography (ICE) to guide placement of ECMO access and return venous cannulae.

Methods

Twenty sheep were commenced on veno-venous ECMO (VV ECMO). Access and return ECMO cannulae were positioned using an ICE-guided technique. Following the assessment of cannulae position, the ICE probe was then introduced inside the cannulae, noting location of the tip. After 24 h, the sheep were euthanized and cannulae position was determined at post mortem. The two-tailed McNemar test was used to compare iCATHe with ICE cannulae positioning.

Results

ICE and iCATHe imaging was possible in all 20 sheep commenced on ECMO. There was no significant difference between the two methods in assessing access cannula position (proportion correct for each 90%, incorrect 10%). However, there was a significant difference between ICE and iCATHe success rates for the return cannula (p = 0.001). Proportion correct for iCATHe and ICE was 80% and 15% respectively. iCATHe was 65% more successful (95% CI 27% to 75%) at predicting the placement of the return cannula. There were no complications related to the ICE or iCATHe imaging.

Conclusion

iCATHe is a safe and feasible imaging technique to guide real-time VV ECMO cannulae placement and improves accuracy of return cannula positioning compared to ICE.

Electronic supplementary material

The online version of this article (doi:10.1186/2197-425X-2-2) contains supplementary material, which is available to authorized users.

Percutaneous extracorporeal life support for patients in therapy refractory cardiogenic shock: initial results of an interdisciplinary team

OBJECTIVES

Therapy refractory cardiogenic shock is associated with dismal outcome. Percutaneous implantation of an extracorporeal life support (ECLS) system achieves immediate cardiopulmonary stabilization, sufficient end-organ perfusion and reduction of subsequent multiorgan failure (MOF).

METHODS

Forty-one patients undergoing percutaneous ECLS implantation for cardiogenic shock from February 2012 until August 2013 were retrospectively analysed. Mean age was 52 ± 13 years, 6 (15%) were female. Mean pH values obtained before ECLS implantation were 7.15 ± 0.24, mean lactate concentration was 11.7 ± 6.4 mmol/l. Levels obtained 6 h after ECLS implantation were 7.30 ± 0.14 and 8.7 ± 5.0 mmol/l, respectively. In 23 patients (56%) cardiogenic shock resulted from an acute coronary syndrome in 13 (32%) from cardiomyopathy, in 5 (12%) from other causes. Twenty-seven (66%) had been resuscitated, in 14 (34%) implantation was performed under ongoing cardiopulmonary resuscitation (CPR). Of note, 97% of the acute coronary syndrome patients underwent percutaneous coronary intervention (PCI) either before ECLS implantation or under ECLS support. Extracorporeal life support implantation was performed on scene (Emergency Department, Cath Lab, Intensive Care Unit) by a senior cardiac surgeon and a trained perfusionist, in 8 cases (20%) in the referring hospital.

RESULTS

Thirty-day mortality was 51% [21 patients, due to MOF (n = 14), cerebral complications (n = 6) and heart failure (n = 1)]. Logistic regression analysis identified 6-h pH values as an independent risk factor of 30-day mortality (P < 0.001, OR = 0.000, 95% CI 0.000-0.042). Neither CPR nor implantation under ongoing CPR resulted in significant differences. In 26 cases (63%), the ECLS system could be explanted, after mean support of 169 ± 67 h. Seven of these patients received cardiac surgery [ventricular assist device implantation (n = 4), heart transplantation (n = 1), other procedures (n = 2)].

CONCLUSIONS

Due to the evolution of transportable ECLS systems and percutaneous techniques implantation on scene is feasible. Extracorporeal life support may serve as a bridge-to-decision and bridge-to-treatment device. Neurological evaluation before ventricular assist device implantation and PCI under stable conditions are possible. Despite substantial mortality, ECLS implantation in selected patients by an experienced team offers additional support to conventional therapy as well as CPR and allows survival in patients that otherwise most likely would have died. This concept has to be implemented in cardiac survival networks in the future.

Interhospital transfer of seriously sick ARDS patients using veno-venous Extracorporeal Membrane Oxygenation (ECMO): Concept of an ECMO transport team

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) therapy constitutes the last option for patients with acute respiratory distress syndrome (ARDS) refractory to conservative treatment. Since primary care centers are unable to provide this therapy, such patients need a transfer to a tertiary care center, which may be life-threatening without extracorporeal support.

METHODS

An ECMO transport team implanted an ECMO at the site of the primary care center with subsequent transport of the patient to the tertiary care center. Between September 2009 and March 2011, six patients with ARDS were treated by our ECMO transport team. Mean age was 39.5±12.0 years. All implantations were done percutaneously in a veno-venous configuration.

RESULTS

No complications occurred during the implant procedure and the subsequent transport. Four patients (67%) were successfully weaned from ECMO-therapy, and discharged from hospital.

CONCLUSION

With a specialized ECMO transport team, ECMO-implantation can be achieved successfully in a peripheral hospital, and patients can be transported safely.

Effects of continuous renal replacement therapy on renal inflammatory cytokines during extracorporeal membrane oxygenation in a porcine model

Background

Extracorporeal membrane oxygenation (ECMO) has been recommended for the treatment of patients with acute, potentially reversible, life-threatening respiratory failure which unresponsive to conventional therapy. But it is unclear about how ECMO affects renal tissue.

Methods

Twenty-four piglets weighing 25 to 32 kg were used in this experiment. The piglets were randomly allocated to 4 groups of 6 animals each: sham group (S group), control group (C group), VV-ECMO group (E group), VV-ECMO combined with CRRT group (EC group). The piglets were sacrificed and the kidney tissue were harvest to determine the levels of IL-1β, IL-6, TNF-α and NF-КB by using the ELISA and RT-PCR method, respectively.

Results

Compared with C group and S group, E group renal tissue IL-1β, IL-6, TNF-α and NF-КB expression increased significantly, respectively (p < 0.01). Compared with E group, EC group showed renal tissue IL-1β, IL-6, TNF-α and NF-КB expression decreased significantly, respectively (p < 0.05).

Conclusion

ECMO enables to inflammatory cytokines including IL-1β, IL-6, TNFα, NF-КB released significantly, renal function impaired and immune homeostasis were to imbalance; ECMO combined with CRRT treatment can alleviate levels of inflammatory cytokines, maintain immune homeostasis balance and thus ameliorate the ECMO-related acute kidney injury(AKI).

ASAP ECMO: Antibiotic, Sedative and Analgesic Pharmacokinetics during Extracorporeal Membrane Oxygenation: a multi-centre study to optimise drug therapy during ECMO

Background

Given the expanding scope of extracorporeal membrane oxygenation (ECMO) and its variable impact on drug pharmacokinetics as observed in neonatal studies, it is imperative that the effects of the device on the drugs commonly prescribed in the intensive care unit (ICU) are further investigated. Currently, there are no data to confirm the appropriateness of standard drug dosing in adult patients on ECMO. Ineffective drug regimens in these critically ill patients can seriously worsen patient outcomes. This study was designed to describe the pharmacokinetics of the commonly used antibiotic, analgesic and sedative drugs in adult patients receiving ECMO.

Methods/Design

This is a multi-centre, open-label, descriptive pharmacokinetic (PK) study. Eligible patients will be adults treated with ECMO for severe cardiac and/or respiratory failure at five Intensive Care Units in Australia and New Zealand. Patients will receive the study drugs as part of their routine management. Blood samples will be taken from indwelling catheters to investigate plasma concentrations of several antibiotics (ceftriaxone, meropenem, vancomycin, ciprofloxacin, gentamicin, piperacillin-tazobactum, ticarcillin-clavulunate, linezolid, fluconazole, voriconazole, caspofungin, oseltamivir), sedatives and analgesics (midazolam, morphine, fentanyl, propofol, dexmedetomidine, thiopentone). The PK of each drug will be characterised to determine the variability of PK in these patients and to develop dosing guidelines for prescription during ECMO.

Discussion

The evidence-based dosing algorithms generated from this analysis can be evaluated in later clinical studies. This knowledge is vitally important for optimising pharmacotherapy in these most severely ill patients to maximise the opportunity for therapeutic success and minimise the risk of therapeutic failure.

Trial registration

ACTRN12612000559819

Established markers of renal and hepatic failure are not appropriate to predict mortality in the acute stage before extracorporeal life support implantation

OBJECTIVES

End-organ function, especially of the kidney and liver, actual inflammation and acid-base balance affect the outcome in extracorporeal life support (ECLS) patients. However, the often unexpected necessity of ECLS implies that information on patients is scarce. Even established global scores are not always useful in the rapid decision process for ECLS. Therefore, we evaluated laboratory parameters for kidney or liver function and for inflammation and acid-base balance with regard to outcome.

METHODS

The retrospective analysis includes 69 consecutive adult patients with veno-arterial ECLS. Laboratory markers for function of kidney (creatinine, urea) and liver (total bilirubin in plasma, glutamate oxaloacetate transaminase and glutamate pyruvate transaminase) as well as for inflammation (C-reactive protein, leucocyte counts) and acid-base balance (pH, lactate) were acquired within 24 h before ECLS implantation.

RESULTS

A total of 38 patients (55%) could be weaned or bridged. Bridged patients were switched to ventricular assist devices, n=10, or total artificial hearts, n=2, and one patient underwent heart transplantation. Overall, 26 ECLS patients (38%) survived for >4 weeks. Thirty-one patients (45%) died on ECLS. About three out of four patients presented with impaired renal or hepatic performance, approximately two-thirds with signs of increased inflammatory state, and more than a half with deranged acid-base balance. Neither signs of hepatic or renal failure nor of inflammation or impaired acid-base balance allowed a prediction of survival in these patients. The outcome did also not depend on indication for ECLS implantation. However, there was a significant correlation between the patients' age and mortality (P=0.006).

CONCLUSIONS

Our data indicate that renal and hepatic insufficiency, increased inflammatory state and deranged acid-base balance as determined by pre-operative laboratory data are not associated with poor outcome of ECLS. Further, survival is not related to indications for ECLS. In a number of patients, ECLS allows for successful bridging to other treatment options.