Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era: A systematic review

Extracorporeal membrane oxygenation technology for adults: an evidence mapping based on systematic reviews

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a cutting-edge life-support measure for patients with severe cardiac and pulmonary illnesses. Although there are several systematic reviews (SRs) about ECMO, it remains to be seen how quality they are and how efficacy and safe the information about ECMO they describe is in these SRs. Therefore, performing an overview of available SRs concerning ECMO is crucial.

METHODS

We searched four electronic databases from inception to January 2023 to identify SRs with or without meta-analyses. The Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) tool, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were used to assess the methodological quality, and evidence quality for SRs, respectively. A bubble plot was used to visually display clinical topics, literature size, number of SRs, evidence quality, and an overall estimate of efficacy.

RESULTS

A total of 17 SRs met eligibility criteria, which were combined into 9 different clinical topics. The methodological quality of the included SRs in this mapping was "Critically low" to "Moderate". One of the SRs was high-quality evidence, three on moderate, three on low, and two on very low-quality evidence. The most prevalent study used to evaluate ECMO technology was observational or cohort study with frequently small sample sizes. ECMO has been proven beneficial for severe ARDS and ALI due to the H1N1 influenza infection. For ARDS, ALF or ACLF, and cardiac arrest were concluded to be probably beneficial. For dependent ARDS, ARF, ARF due to the H1N1 influenza pandemic, and cardiac arrest of cardiac origin came to an inconclusive conclusion. There was no evidence for a harmful association between ECMO and the range of clinical topics.

CONCLUSIONS

There is limited available evidence for ECMO that large sample, multi-center, and multinational RCTs are needed. Most clinical topics are reported as beneficial or probably beneficial of SRs for ECMO. Evidence mapping is a valuable and reliable methodology to identify and present the existing evidence about therapeutic interventions.

Association of COVID-19 with Intracranial Hemorrhage during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A 10-Year Retrospective Observational Study

Extracorporeal membrane oxygenation (ECMO) is potentially lifesaving for patients with acute respiratory distress syndrome (ARDS) but may be accompanied by serious adverse events, including intracranial hemorrhage (ICRH). We hypothesized that ICRH occurs more frequently in patients with COVID-19 than in patients with ARDS of other etiologies. We performed a single-center retrospective analysis of adult patients treated with venovenous (vv-) ECMO for ARDS between January 2011 and April 2021. Patients were included if they had received a cranial computed tomography (cCT) scan during vv-ECMO support or within 72 h after ECMO removal. Cox regression analysis was used to identify factors associated with ICRH. During the study period, we identified 204 patients with vv-ECMO for ARDS, for whom a cCT scan was available. We observed ICRH in 35.4% (n = 17/48) of patients with COVID-19 and in 16.7% (n = 26/156) of patients with ARDS attributable to factors other than COVID-19. COVID-19 (HR: 2.945; 95%; CI: 1.079–8.038; p = 0.035) and carboxyhemoglobin (HR: 0.330; 95%; CI: 0.135–0.806; p = 0.015) were associated with ICRH during vv-ECMO. In patients receiving vv-ECMO, the incidence of ICRH is doubled in patients with COVID-19 compared to patients suffering from ARDS attributable to other causes. More studies on the association between COVID-19 and ICRH during vv-ECMO are urgently needed to identify risk patterns and targets for potential therapeutic interventions.

SEDAR/SECCE ECMO management consensus document

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.

Zinc Poisoning - Symptoms, Causes, Treatments

Zinc poisoning has been reported from many parts of the world. It is one of the global health problems that affect many organs, if exposed by inhalation of zinc vapors or by consumption of contaminated food and water. Long term exposure to zinc compounds from different sources such as air, water, soil, and food, lead to toxic effects on body systems, especially digestive, respiratory, and nerve systems, and also causes cancer. Zinc levels can be determined in blood, urine, hair, and nails. Patients with zinc toxicity need chelating agents, other pharmacological treatment, protective lung ventilation, extracorporeal membrane oxygenation (ECMO), and supportive care.

Extracorporeal membrane oxygenation use in Trauma Quality Improvement Program centers: Temporal trends and future directions

BACKGROUND

Increased clinical experience and the decreased need for systemic anticoagulation have renewed interest in the use of extracorporeal membrane oxygenation (ECMO) for posttraumatic respiratory and cardiopulmonary failure. The objectives of this study were to describe the incidence and temporal trends of ECMO use at trauma centers, the outcomes of trauma patients undergoing ECMO, and the characteristics of trauma centers providing ECMO.

METHODS

Data were derived from the American College of Surgeons Trauma Quality Improvement Program data set. We included adults with at least one severe injury admitted to a level I or II trauma center between 2012 and 2016 who received at least 1 day of mechanical ventilation. Patients were categorized based on whether or not they received ECMO during their admission. The primary outcome was change in the incidence of ECMO across study years. We also evaluated patient outcomes and variation in ECMO volumes across centers.

RESULTS

Of 194,314 severely injured patients undergoing mechanical ventilation across 450 centers, 269 (0.14%) received ECMO. Extracorporeal membrane oxygenation patients had significantly higher mortality than non-ECMO patients (32% vs. 19%). The standardized rate of ECMO from 2012 to 2016 increased significantly from 75.2 to 179.0 cases per 100,000 severely injured patients undergoing mechanical ventilation. The average annual growth rate was 24%. Of the 82 centers(18%) reporting at least 1 ECMO trauma case, 34 (41%) reported only a single case.

CONCLUSION

The use of ECMO for trauma, although rare, is rapidly increasing. Two thirds of patients who receive ECMO following traumatic injury survive their hospitalization. These data suggest that ECMO represents a potential treatment strategy for trauma patients with respiratory or cardiopulmonary failure. However, given the rarity of the procedure, there exists an opportunity to develop practice guidelines regarding the indications for, and approach to, ECMO in the setting of trauma.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Supportive care for patient with respiratory diseases: an umbrella review

Background

Supportive treatment is an important and effective part of the management for patients with life-threatening diseases. This study aims to identify and evaluate the forms of supportive care for patients with respiratory diseases.

Methods

An umbrella review of supportive care for patient with respiratory diseases was undertaken. We comprehensively searched the following databases: Medline, EMBASE, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang Data and CBM (SinoMed) from their inception to 31 March 2020, and other sources to identify systematic reviews and meta-analyses related to supportive treatments for patient with respiratory diseases including Coronavirus Disease 2019 (COVID-19), severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and influenza. We assessed the methodological quality using the AMSTAR score and the quality of the evidence for the primary outcomes of each included systematic review and meta-analysis.

Results

We included 18 systematic reviews and meta-analyses in this study. Most studies focused on the respiratory and circulatory support. Ten studies were of high methodological quality, five studies of medium quality, and three studies of low quality. According to four studies extracorporeal membrane oxygenation did not reduce mortality in adults [odds ratio/relative risk (OR/RR) ranging from 0.71 to 1.28], but two studies reported significantly lower mortality in patients receiving venovenous extracorporeal membrane oxygenation than in the control group (OR/RR ranging from 0.38 to 0.73). Besides, monitoring of vital signs and increasing the number of medical staff may also reduce the mortality in patients with respiratory diseases.

Conclusions

Our overview suggests that supportive care may reduce the mortality of patients with respiratory diseases to some extent. However, the quality of evidence for the primary outcomes in the included studies was low to moderate. Further systematic reviews and meta-analyses are needed to address the evidence gap regarding the supportive care for SARS, MERS and COVID-19.

Protective effect of extracorporeal membrane oxygenation on intestinal mucosal injury after cardiopulmonary resuscitation in pigs

The present study aimed to explore the protective effects of extracorporeal membrane oxygenation (ECMO) on intestinal mucosal injury following cardiopulmonary resuscitation (CPR), and to assess the potential mechanisms involved. A total of 24 healthy adult domestic pigs were selected as the study subjects. A ventricular fibrillation model was induced through programmed electric stimulation. Subsequently, the animals were randomly divided into conventional CPR and CPR+ECMO groups (n=12 per group). The mortality and hemodynamic parameters of the two groups were compared. The expression levels of inflammatory cytokines in the serum and intestinal mucosa were detected by ELISAs. The intestinal mucosa was subjected to hematoxylin and eosin, and immunohistochemical staining, followed by electron microscopy, to assess the degree of apoptosis and necrosis. The animals in both groups recovered from the programmed ventricular fibrillation. In the CPR group, two animals died at 2 h and two more animals died a further 2 h later, resulting in a 33.3% mortality rate, whereas no cases of mortality were observed in the CPR+ECMO group. Compared with the animals in the CPR group, the hemodynamic parameters of the animals in the CPR+ECMO group revealed significantly improved outcomes. Multiple inflammatory factors (tumor necrosis factor α, interleukin-1 and interleukin-6), myeloperoxidase and malondialdehyde levels were decreased, whereas Na/Ca-ATPase and superoxide dismutase levels were elevated in the intestinal mucosa of animals in the CPR+ECMO group compared with those in the CPR group. Additionally, pathological staining demonstrated that the intestinal mucosa tissue in the CPR+ECMO group exhibited less apoptosis, necrosis and inflammatory cell infiltration, which was further supported by a decrease in Bax expression and an increase in Bcl-2 expression. Overall, ECMO after CPR reduced the intestinal mucosal barrier injury after spontaneous circulation recovery, and the mechanism involved decreased inflammation and apoptosis.

Quality of Life and Lung Function in Survivors of Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Survivors of acute respiratory distress syndrome (ARDS) have long-term impairment of pulmonary function and health-related quality of life, but little is known of outcomes of ARDS survivors treated with extracorporeal membrane oxygenation. The aim of this study was to compare long-term outcomes of ARDS patients treated with or without extracorporeal membrane oxygenation.

Methods

A prospective, observational study of adults with ARDS (January 2013 to December 2015) was conducted at a single center. One year after discharge, survivors underwent pulmonary function tests, computed tomography of the chest, and health-related quality-of-life questionnaires.

Results

Eighty-four patients (34 extracorporeal membrane oxygenation, 50 non–extracorporeal membrane oxygenation) were studied; both groups had similar characteristics at baseline, but comorbidity was more common in non–extracorporeal membrane oxygenation (23 of 50 vs. 4 of 34, 46% vs. 12%, P < 0.001), and severity of hypoxemia was greater in extracorporeal membrane oxygenation (median Pao2/Fio2 72 [interquartile range, 50 to 103] vs. 114 [87 to 133] mm Hg, P < 0.001) and respiratory compliance worse. At 1 yr, survival was similar (22/33 vs. 28/47, 66% vs. 59%; P = 0.52), and pulmonary function and computed tomography were almost normal in both groups. Non–extracorporeal membrane oxygenation patients had lower health-related quality-of-life scores and higher rates of posttraumatic stress disorder.

Conclusions

Despite more severe respiratory failure at admission, 1-yr survival of extracorporeal membrane oxygenation patients was not different from that of non–extracorporeal membrane oxygenation patients; each group had almost full recovery of lung function, but non–extracorporeal membrane oxygenation patients had greater impairment of health-related quality of life.

The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.

Outcomes of extracorporeal membrane oxygenation in adult patients with hypoxemic respiratory failure refractory to mechanical ventilation

Introduction

Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that has been used to support cardiopulmonary disease refractory to conventional therapy. The experience with the use of ECMO in acute hypoxemic respiratory failure is still limited. The aim of this study was to report clinical outcomes in adult patients with acute hypoxemic respiratory failure refractory to mechanical ventilation treated with ECMO.

Methods

Between July 2011 and October 2017, 18 adult patients with hypoxemic respiratory failure refractory to mechanical ventilation were admitted to the Intensive Care Unit of an acute care tertiary hospital in Barcelona, Spain. These patients were treated with ECMO as salvage respiratory therapy. Outcomes included clinical data, ventilatory and blood gas characteristics, survival, and complications.

Results

Fifteen patients (83.3%) were previously treated in prone position. The indication of VV-ECMO was established at an early stage after a mean (SD) of 3.8 (2.5) days on mechanical ventilation. The mean duration of ECMO was 10.4 days, and 16 patients (88.9%) required venous cannulation, mostly femoral-internal jugular. The mean length of ICU stay was 27 days and the mean hospital stay was 42.1 days. The ICU survival rate was 55.5% (n = 10) and the hospital survival rate was 50% (n = 9).

Conclusions

This clinical study in a small series of ICU patients treated with ECMO confirms the usefulness of this technique as a ventilatory support in patients with refractory hypoxemic respiratory failure. However, the indication of this procedure is also committed to an ethical reflection considering the possible futility of the measure on a case-by-case basis and associated complications.

[Advances in the diagnosis and treatment of pediatric acute respiratory distress syndrome]

Pediatric acute respiratory distress syndrome (ARDS) is an important cause of deaths in critically ill children admitted to the pediatric intensive care unit. Although lung-protective ventilation improves the prognosis of pediatric ARDS, the mortality rate of children with moderate or severe ARDS is still high. Given that the epidemiology, treatment, and prognosis of pediatric ARDS are different from those of adult ARDS, pediatric ARDS was first defined in the 2015 Pediatric Acute Lung Injury Consensus Conference. Early diagnosis and appropriate clinical management of ARDS are still great challenges for pediatric critical care medicine. This paper focuses on the definition, epidemiology, and management of pediatric ARDS.

Hypoxemic Respiratory Failure from Acute Respiratory Distress Syndrome Secondary to Leptospirosis

Acute respiratory distress syndrome (ARDS), characterized by hypoxemic respiratory failure, is associated with a mortality of 30–50% and is precipitated by both direct and indirect pulmonary insults. Treatment is largely supportive, consisting of lung protective ventilation and thereby necessitating Intensive Care Unit (ICU) admission. The most common precipitant is community-acquired bacterial pneumonia, but other putative pathogens include viruses and fungi. On rare occasions, ARDS can be secondary to tropical disease. Accordingly, a history should include travel to endemic regions. Leptospirosis is a zoonotic disease most common in the tropics and typically associated with mild pulmonary complications. We describe a case of a 25-year-old male with undiagnosed leptospirosis, presenting with fever and severe hypoxemic respiratory failure, returning from a Costa Rican holiday. There was no other organ failure. He was intubated and received lung protective ventilation. His condition improved after ampicillin and penicillin G were added empirically. This case illustrates the rare complication of ARDS from leptospirosis, the importance of taking a travel history, and the need for empiric therapy because of diagnostic delay.

Clinical Implications of Single-Cell Microfluidic Devices for Hematological Disorders

Single-cell microfluidic devices are poised to substantially impact the hematology field by providing a high-throughput and rapid device to analyze disease-mediated biophysical cellular changes in the clinical setting in order to diagnose patients and monitor disease prognosis. In this Feature, we cover recent advances of single-cell microfluidic devices for studying and diagnosing hematological dysfunctions and the clinical impact made possible by these advances.