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Vandroux D, Aujoulat T, Gaüzère BA, Puech B, Guihard B, Martinet O. Predicting factors for the need of extracorporeal membrane oxygenation for suicide attempts by cardiac medication: a single-center cohort study. World J Emerg Med 2022; 13:283-289. [PMID: 35837565 PMCID: PMC9233975 DOI: 10.5847/wjem.j.1920-8642.2022.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/28/2022] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure. In order to decrease the mortality rate, the most severe patients should be transferred as quickly as possible to an extracorporeal membrane oxygenation (ECMO) center. However, the predictive factors showing the need for venous-arterial ECMO (VA-ECMO) had never been evaluated. METHODS A retrospective, descriptive, and single-center cohort study. All consecutive patients admitted in the largest ICU of Reunion Island (Indian Ocean) between January 2013 and September 2018 for beta-blockers (BB), calcium channel blockers (CCB), renin-angiotensin-aldosterone system blockers, digoxin or anti-arrythmic intentional poisonings were included. ECMO implementation was the primary outcome. RESULTS A total of 49 consecutive admissions were included. Ten patients had ECMO, 39 patients did not have ECMO. Three patients in ECMO group died, while no patients in the conventional group died. The most relevant ECMO-associated factors were pulse pressure and heart rate at first medical contact and pulse pressure, heart rate, arterial lactate concentration, liver enzymes and left ventricular ejection fraction (LVEF) at ICU-admission. Only pulse pressure at first medical contact and LVEF were significant after logistic regression. CONCLUSION A transfer to an ECMO center should be considered for a pulse pressure < 35 mmHg at first medical contact or LVEF < 20% on admission to ICU.
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Affiliation(s)
- David Vandroux
- Intensive Care Unit, Félix Guyon Hospital, University Teaching Hospital of La Réunion, 97400 Saint Denis, Reunion Island, France
- Cardiosurgical Intensive Care Unit, Dupuytren II Hospital, University Teaching Hospital of Limoges, 87042 Limoges, France
- UMR 1094 Neuro-épidémiologie Tropicale, University of Limoges, 87042 Limoges, France
| | - Thomas Aujoulat
- Intensive Care Unit, Félix Guyon Hospital, University Teaching Hospital of La Réunion, 97400 Saint Denis, Reunion Island, France
- Cardiovascular Anesthesia Department, Félix Guyon Hospital, University Teaching Hospital of La Réunion, 97400 Saint Denis, Reunion Island, France
| | - Bernard-Alex Gaüzère
- Intensive Care Unit, Félix Guyon Hospital, University Teaching Hospital of La Réunion, 97400 Saint Denis, Reunion Island, France
| | - Bérénice Puech
- Intensive Care Unit, Félix Guyon Hospital, University Teaching Hospital of La Réunion, 97400 Saint Denis, Reunion Island, France
| | - Bertrand Guihard
- Service d’Aide Médicale d’Urgence, Félix Guyon Hospital, University Teaching Hospital of La Réunion, 97400 Saint Denis, Reunion Island, France
| | - Olivier Martinet
- Intensive Care Unit, Félix Guyon Hospital, University Teaching Hospital of La Réunion, 97400 Saint Denis, Reunion Island, France
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A Farrar R, B Justus A, A Masurkar V, M Garrett P. Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting. Anaesth Intensive Care 2021; 50:250-254. [PMID: 34871510 DOI: 10.1177/0310057x211047603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.
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Affiliation(s)
- Ross A Farrar
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia
| | - Angelo B Justus
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia
| | - Vikram A Masurkar
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia.,Griffith University, Sunshine Coast, Queensland, Australia
| | - Peter M Garrett
- Intensive Care Unit, 523457Sunshine Coast University Hospital, Sunshine Coast University Hospital, Queensland, Australia.,Griffith University, Sunshine Coast, Queensland, Australia
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Upchurch C, Blumenberg A, Brodie D, MacLaren G, Zakhary B, Hendrickson RG. Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations. Clin Toxicol (Phila) 2021; 59:877-887. [PMID: 34396873 DOI: 10.1080/15563650.2021.1945082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT Poisoning may lead to respiratory failure, shock, cardiac arrest, or death. Extracorporeal membrane oxygenation (ECMO) may be used to provide circulatory support, termed venoarterial (VA) ECMO; or respiratory support termed venovenous (VV) ECMO. The clinical utility of ECMO in poisoned patients remains unclear and guidelines on its use in this setting are lacking. OBJECTIVES To perform a literature search and narrative review on the use of ECMO in poisonings. Additionally, to provide recommendations on the use of ECMO in poisonings from physicians with expertise in ECMO, medical toxicology, critical care, and emergency medicine. METHODS A literature search in Ovid MEDLINE from 1946 to October 14, 2020, was performed to identify relevant articles with a strategy utilizing both MeSH terms and adjacency searching that encompassed both extracorporeal life support/ECMO/Membrane Oxygenation concepts and chemically-induced disorders/toxicity/poisoning concepts, which identified 318 unique records. Twelve additional manuscripts were identified by the authors for a total of 330 articles for screening, of which 156 were included for this report. NARRATIVE LITERATURE REVIEW The use of ECMO in poisoned patients is significantly increasing over time. Available retrospective data suggest that patients receiving VA ECMO for refractory shock or cardiac arrest due to poisoning have lower mortality as compared to those who receive VA ECMO for non-poisoning-related indications. Poisoned patients treated with ECMO have reduced mortality as compared to those treated without ECMO with similar severity of illness and after adjusted analyses, regardless of the type of ingestion. This is especially evident for poisoned patients with refractory cardiac arrest placed on VA ECMO (termed extracorporeal cardiopulmonary resuscitation [ECPR]). INDICATIONS We suggest VA ECMO be considered for poisoned patients with refractory cardiogenic shock (continued shock with myocardial dysfunction despite fluid resuscitation, vasoactive support, and indicated toxicologic therapies such as glucagon, intravenous lipid emulsion, hyperinsulinemia euglycemia therapy, or others), and strongly considered for patients with cardiac arrest in institutions which are structured to deliver effective ECPR. VV ECMO should be considered in poisoned patients with ARDS or severe respiratory failure according to traditional indications for ECMO in this setting. CONTRAINDICATIONS Patients with pre-existing comorbidities with low expected survival or recovery. Relative contraindications vary based on each center's experience but often include: severe brain injury; advanced age; unrepaired aortic dissection or severe aortic regurgitation in VA ECMO; irreversible organ injury; contraindication to systemic anticoagulation, such as severe hemorrhage. CONCLUSIONS ECMO may provide hemodynamic or respiratory support to poisoned patients while they recover from the toxic exposure and metabolize or eliminate the toxic agent. Available literature suggests a potential benefit for ECMO use in selected poisoned patients with refractory shock, cardiac arrest, or respiratory failure. Future studies may help to further our understanding of the use and complications of ECMO in poisoned patients.
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Affiliation(s)
- Cameron Upchurch
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Adam Blumenberg
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, Singapore, Singapore.,Paediatric ICU, The Royal Children's Hospital, Melbourne, Australia
| | - Bishoy Zakhary
- Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Robert G Hendrickson
- Department of Emergency Medicine, Section of Medical Toxicology, Oregon Health and Science University, Portland, OR, USA
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4
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Radowsky JS, Mazzeffi MM, Deatrick KB, Galvagno SM, Parker BM, Tabatabai A, Madathil RJ, Kaczorowski DJ, Rabinowitz RP, Herr DL, Scalea T, Menaker J. Intoxication and overdose should not preclude veno-venous extracorporeal membrane oxygenation. Perfusion 2020; 36:839-844. [DOI: 10.1177/0267659120963938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction Acute intoxication (AI) related morbidity and mortality are increasing in the United States. For patients with severe respiratory failure in the setting of an acute ingestion, veno-venous extracorporeal membrane oxygenation (VV ECMO) can provide salvage therapy. The purpose of this study was to evaluate outcomes in patients with overdose-related need for VV ECMO. Methods: We performed a retrospective review of all patients admitted to a specialty VV ECMO unit between August 2014 and August 2018. Patients were stratified by those whose indication for VV ECMO was directly related to an acute ingestion (alcohol, illicit drug, or prescription drug overdose) and those with unrelated diagnoses. Demographics, pre-cannulation clinical characteristics, ECMO parameters, and outcomes data was collected and analyzed with parametric and non-parametric statistics as indicated. Results: 189 patients were enrolled with 27 (14%) diagnosed with AI. Patients requiring VV ECMO for an AI were younger, had lower median BMI and PaO2/FiO2, and higher RESP scores than non-AI patients (p = 0.002, 0.01, 0.03 and 0.01). There was no difference in pre-cannulation pH, lactate, or SOFA scores between the two groups (p = 0.24, 0.5, 0.6). There was no difference in survival to discharge (p = 0.95). Among survivors, there was no difference in ECMO time or hospital stay (p = 0.24, 0.07). Conclusion: We demonstrate no survival difference for patients with and without an AI-related need for VV ECMO. AI patients should be supported with VV ECMO when traditional therapies fail despite potential stigma against acceptance on referral.
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Affiliation(s)
- Jason S Radowsky
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Michael M Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - K Barry Deatrick
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel M Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brandon M Parker
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Ali Tabatabai
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ronson J Madathil
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David J Kaczorowski
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ronald P Rabinowitz
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel L Herr
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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