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Hileman BA, Martucci G, Subramanian H. Metabolic support for patients on extra-corporeal membrane oxygenation. Curr Opin Crit Care 2024; 30:305-310. [PMID: 38841988 DOI: 10.1097/mcc.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW The purpose of the review is to summarize recent research on metabolic support during extracorporeal membrane oxygenation. In this review, we cover the evidence on nutritional supplementation, both the route of supplementation, timing of initiation of supplementation as well as quantities of supplementation needed. In addition, we discuss the recent trend in awake extracorporeal membrane oxygenation (ECMO) and its benefits to patients. RECENT FINDINGS As ECMO use continues to increase over the last few years, for both cardiovascular as well as respiratory failure, the need to optimize the metabolic states of patients has arisen. Increasing evidence has pointed towards this hitherto unexplored domain of patient care having a large impact on outcomes. Additionally, strategies such as awake ECMO for select patients has allowed them to preserve muscle mass which could aid in a faster recovery. SUMMARY There is a role of optimal metabolic support in the early recovery of patients on ECMO that is currently under-recognized. Future directions of research that aim to improve post ECMO outcomes must focus on this area.
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Affiliation(s)
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, ISMETT, Palermo, Italy
| | - Harikesh Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Ripoll JG, Chang MG, Nabzdyk CS, Balakrishna A, Ortoleva J, Bittner EA. Should Obesity Be an Exclusion Criterion for Extracorporeal Membrane Oxygenation Support? A Scoping Review. Anesth Analg 2024; 139:300-312. [PMID: 38009837 DOI: 10.1213/ane.0000000000006745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Obesity is often considered a contraindication to extracorporeal membrane oxygenation (ECMO) candidacy due to technical challenges with vascular access, higher cardiac output requirements, and known associations between obesity and overall increased morbidity and mortality due to chronic health conditions. However, a growing body of literature suggests that ECMO may be as safe and efficacious in both obese and nonobese patients. This scoping review provides a synthesis of the available literature on the outcomes of obese patients supported with (1) venovenous (VV)-ECMO in acute respiratory distress syndrome (ARDS) not due to coronavirus disease 2019 (COVID-19), (2) VV-ECMO in ARDS due to COVID-19, (3) venoarterial (VA)-ECMO for all indications, and (4) studies combining data of patients supported with VA- and VV-ECMO. A librarian-assisted search was performed using 4 primary electronic medical databases (PubMed, Web of Science, Excerpta Medica database [Embase], and Cochrane Library) from January 2003 to March 2023. Articles that reported outcomes of obese patients requiring ECMO support were included. Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. A total of 354 publications were imported for screening on titles and abstracts, and 30 studies were selected for full-text review. A total of 26 publications met the inclusion criteria: 7 on VV-ECMO support in non-COVID-19 ARDS patients, 6 on ECMO in COVID-19 ARDS patients, 8 in patients supported with VA-ECMO, and 5 combining both VA- and VV-ECMO data. Although the included studies are limited to retrospective analyses and display a heterogeneity in definitions of obesity and comparison groups, the currently available literature suggests that outcomes and complications of ECMO therapy are equivalent in obese patients as compared to nonobese patients. Hence, obesity as measured by body mass index alone should not be considered an exclusion criterion in the decision to initiate ECMO.
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Affiliation(s)
- Juan G Ripoll
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Marvin G Chang
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christoph S Nabzdyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts
| | - Edward A Bittner
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Huang X, Lin X. Impact of obesity on outcomes of extracorporeal membrane oxygenation support: a systematic review and meta-analysis. BMC Pulm Med 2024; 24:157. [PMID: 38549057 PMCID: PMC10976836 DOI: 10.1186/s12890-024-02971-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/18/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used when standard methods of standard treatment methods are not successful. Obese patients present unique challenges during ECMO due to large body size hindering sufficient flows, difficulties with patient positioning and anatomical landmark identification, and restricted radiology scans. This meta-analysis aims to investigate the impact of obesity on the outcomes of patients undergoing ECMO. METHODS Databases (PubMed, Embase, and Scopus databases) were searched to identify relevant studies published until July 2023. Data were reported as odds ratios (OR) with 95% confidence interval (CI), and the descriptive data were reported as standard difference of means (SDM) by a random effects model. RESULTS A literature search identified 345 studies. Of them, 18 studies met the inclusion criteria. The findings from the meta-analysis revealed no significant association between obesity and survival outcomes after ECMO (odds ratio (OR): 0.91, 95% confidence interval (CI): 0.70-1.17, p: 0.46). Moreover, no comparative significant differences were found between obese and non-obese individuals on the duration of ECMO procedure (standardized mean difference (SMD): 0.07, -0.03-0.17), length of hospital stay (-0.03, -0.19 to 0.12), and duration of ventilation support (-0.10, -0.44 to 0.24). CONCLUSION The meta-analysis findings suggest no significant impact of obesity on the survival outcomes after the ECMO procedure. There was no significant impact of obesity on the duration of ECMO procedures, length of hospital stay, and duration of ventilation support.
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Affiliation(s)
- Xinhua Huang
- Department of Geriatric, HuZhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, 2088 Tiaoxi East Road, Wuxing District, Huzhou City, Zhejiang Province, China
| | - Xiaoqing Lin
- Department of Geriatric, HuZhou Third Municipal Hospital, the Affiliated Hospital of Huzhou University, 2088 Tiaoxi East Road, Wuxing District, Huzhou City, Zhejiang Province, China.
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Ripoll JG, ElSaban M, Nabzdyk CS, Balakrishna A, Villavicencio MA, Calderon-Rojas RD, Ortoleva J, Chang MG, Bittner EA, Ramakrishna H. Obesity and Extracorporeal Membrane Oxygenation (ECMO): Analysis of Outcomes. J Cardiothorac Vasc Anesth 2024; 38:285-298. [PMID: 37953169 DOI: 10.1053/j.jvca.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
Traditionally, patients with obesity have been deemed ineligible for extracorporeal life support (ELS) therapies such as extracorporeal membrane oxygenation (ECMO), given the association of obesity with chronic health conditions that contribute to increased morbidity and mortality. Nevertheless, a growing body of literature suggests the feasibility, efficacy, and safety of ECMO in the obese population. This review provides an in-depth analysis of the current literature assessing the effects of obesity on outcomes among patients supported with ECMO (venovenous [VV] ECMO in noncoronavirus disease 2019 and coronavirus disease 2019 acute respiratory distress syndrome, venoarterial [VA] ECMO, and combined VV and VA ECMO), offer a possible explanation of the current findings on the basis of the obesity paradox phenomenon, provides a framework for future studies addressing the use of ELS therapies in the obese patient population, and provides guidance from the literature for many of the challenges related to initiating, maintaining, and weaning ELS therapy in patients with obesity.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mariam ElSaban
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Christoph S Nabzdyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Zhang R, Hou QC, Li BH, Deng L, Yang YM, Li TX, Yao XQ, Yang LL, Lin XL, Liao YQ, Wang L, Liu YP, Tan J, Wan ZW, Shuai P. Efficacy and safety of subcutaneous semaglutide in adults with overweight or obese: a subgroup meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2023; 14:1132004. [PMID: 37455913 PMCID: PMC10338217 DOI: 10.3389/fendo.2023.1132004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/29/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Semaglutide shows significant performance on weight reduction in several clinical trials. However, it is not clear what kind of administration frequency or dosage will achieve better effects. This study aims to explore the different therapeutic effect of semaglutide on weight control under the diverse administration circumstances. Methods The PubMed, Embase, Web of Science, Cochrane Library, and the Clinical Trials.gov were searched from inception until 6 June, 2022 to include randomized controlled trials evaluating the Efficacy and safety of subcutaneous semaglutide in overweight or obese adults. Random effects or fixed effects model was conducted based on the heterogeneity among trials. Subgroup analysis was performed to identify the detailed effects under different intervention situations. Results and discussion Our study included 13 RCTs involving 5,838 participants with 3,794 ones in semaglutide group and 2,044 in placebo group. Semaglutide was associated with a significant reduction on weight loss related outcomes, including the absolute value of weight loss (WMD -8·97, 95% CI -10·73 to -7·21), percentage of weight loss (WMD -10·00, 95% CI -11·99 to -8·00), body mass index (WMD-3·19, 95% CI -4·02 to -2·37) and waist circumference (WMD -7·21,95% CI -8·87 to -5·56). Subgroup analyses illustrated participants with high weekly dosage, long-term treatment duration and severe baseline BMI (Class II obesity) had a more remarkably decreasing on the main outcomes of weight loss (P for interaction<0·05). Total adverse reactions occurred more frequently in the daily administration group than that in the weekly group (P for interaction =0·01). During the treatment, the incidence rate of hypoglycemia was higher in the group without lifestyle intervention compared with that with lifestyle intervention (P for interaction =0·04). Interpretation Subcutaneous semaglutide had significant benefits on weight loss with reasonable safety in overweight or obese adults. Moreover, additional benefits on cardiometabolic profiles were also seen. We recommended semaglutide treatment to be coupled with lifestyle interventions, and target dose of 2·0 mg or more subcutaneously once weekly. Clinicians can choose suitable treatment schemes based on diverse individual situations. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=337099, identifier PROSPERO (CRD42022337099).
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Affiliation(s)
- Rui Zhang
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- School of Public Health, Southwest Medical University, Luzhou, China
| | - Qin-chuan Hou
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- School of Public Health, Southwest Medical University, Luzhou, China
| | - Bing-hong Li
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ling Deng
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yu-mei Yang
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Ting-xin Li
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiao-qin Yao
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Liang-liang Yang
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xi-long Lin
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yi-qian Liao
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lin Wang
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yu-ping Liu
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jing Tan
- Chinese Evidence-based Medicine Center and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zheng-wei Wan
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Ping Shuai
- Department of Health Management & Physical Examination, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- School of Public Health, Southwest Medical University, Luzhou, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Gerfer S, Djordjevic I, Maier J, Movahed A, Elskamp M, Kuhn E, Liakopoulos O, Wahlers T, Deppe AC. Endothelial and Hemodynamic Function in a Large Animal Model in Relation to Different Extracorporeal Membrane Oxygenation Cannulation Strategies and Intra-Aortic Balloon Pumping. J Clin Med 2023; 12:4038. [PMID: 37373730 DOI: 10.3390/jcm12124038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND The use of simultaneous veno-arterial extracorporeal membrane oxygenation (ECMO) with or without an Intra-Aortic Balloon Pump (IABP) is a widely used tool for mechanical hemodynamic support. Endothelial function, especially in relation to different cannulation techniques, is rarely investigated in the setting of extracorporeal life support (ECLS). In this study, we analyzed endothelial function in relation to hemodynamic and laboratory parameters for central and peripheral ECMO, with or without concomitant IABP support in a large animal model to gain a better understanding of the underlying basic mechanisms. METHODS In this large animal model, healthy female pigs with preserved ejection fraction were divided into the following groups related to cannulation strategy for ECMO and simultaneous IBAP support: control (no ECMO, no IABP), peripheral ECMO (pECMO), central ECMO (cECMO), pECMO and IABP or cECMO and IABP. During the experimental setting, the blood flow in the ascending aorta, left coronary artery and arteria carotis was measured. Afterwards, endothelial function was investigated after harvesting the right coronary artery, arteria carotis and renal artery. In addition, laboratory markers, such as creatine kinase (CK), creatine kinase muscle-brain (CK-MB), troponin, creatinine and endothelin were analyzed. RESULTS The blood flow in the ascending aorta and the left coronary artery was significantly lower in all discussed experimental settings compared to the control group. Of note, the cECMO cannulation strategy generated favorable hemodynamic circumstances with higher blood flow in the coronary arteries than pECMO regardless of flow circumstances in the ascending aorta. The concomitant usage of IABP did not result in an improvement of the coronary blood flow, but partially showed a negative impact on the endothelial function of coronary arteries in comparison to the control. These findings correlate to higher CK/CK-MB levels in the setting of cECMO + IABP and pECMO + IABP. CONCLUSIONS The usage of mechanical circulatory support with concomitant ECMO and IABP in a large animal model might have an influence on the endothelial function of coronary arteries while not improving the coronary artery perfusion in healthy hearts with preserved ejection.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, 50924 Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, 50924 Cologne, Germany
| | - Johanna Maier
- Division of Thoracic and Cardiovascular Surgery, HELIOS Klinikum Siegburg, 53721 Siegburg, Germany
| | - Ana Movahed
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, 50924 Cologne, Germany
| | - Mara Elskamp
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, 50924 Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, 50924 Cologne, Germany
| | - Oliver Liakopoulos
- Department of Cardiac Surgery, Kerckhoff-Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, 61231 Bad Nauheim, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, 50924 Cologne, Germany
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, 50924 Cologne, Germany
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Krasivskyi I, Ivanov B, Vehrenberg J, Eghbalzadeh K, Gerfer S, Gaisendrees C, Kuhn E, Sabashnikov A, Mader N, Djordjevic I, Wahlers T. Sex-Related Differences in Short-Term Outcomes after Mobile VA-ECMO Implantation: Five-Year Experience of an ECMO Retrieval Program. Life (Basel) 2022; 12:life12111746. [PMID: 36362901 PMCID: PMC9695761 DOI: 10.3390/life12111746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) represents an increasingly used method for circulatory support. Despite the ongoing research, survival following VA-ECMO therapy remains low. Sex-related differences might impact the outcome of therapeutic measures. We aimed to compare all-cause mortality among female and male patients who underwent VA-ECMO as a bridge to recovery investigating sex-related differences. From January 2015 until August 2020, 87 patients were supported by VA-ECMO as a part of our out-of-center mobile ECMO program. In order to analyze sex-associated differences in early clinical outcomes, patients were divided into two sex categories: men (n = 62) and women (n = 25). All relevant data (in-hospital mortality, ICU and hospital stay, renal failure requiring dialysis, lung failure, bleeding, stroke and septic shock) were analyzed retrospectively after the extraction from our institutional database. Mean age of the study population was 53 ± 14 years. Mean EuroSCORE II predicted mortality was 6.5 ± 3.7. In-hospital mortality rate was not significantly lower in the female group (58.3%) vs. the male group (71.2%), p = 0.190. The mean length of ICU and hospital stay was 9 ± 11 in the male group vs. 10 ± 13 in the female group, p = 0.901, and 10 ± 12 (male group) vs. 11 ± 13 (female group), p = 0.909, respectively. Renal failure requiring hemodialysis (36.2% (males) vs. 28.6% (females), p = 0.187) was comparable between both groups. Respiratory failure was diagnosed in 31 (56.4%) male vs. 8 (34.8%) female patients, p = 0.068, while 16 (28.6%) male vs. 3 (13.0%) female patients (p = 0.118) suffered from septic shock. Based on our data, there were no sex-specific outcome discrepancies in patients treated with mobile VA-ECMO implantation.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-176-353-88-719
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, 53721 Siegburg, Germany
| | - Johannes Vehrenberg
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | | | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
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