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Glance LG, Joynt Maddox KE, Mazzeffi M, Shippey E, Wood KL, Yoko Furuya E, Stone PW, Shang J, Wu IY, Gosev I, Lustik SJ, Lander HL, Wyrobek JA, Laserna A, Dick AW. Insurance-based Disparities in Outcomes and Extracorporeal Membrane Oxygenation Utilization for Hospitalized COVID-19 Patients. Anesthesiology 2024; 141:116-130. [PMID: 38526387 DOI: 10.1097/aln.0000000000004985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
BACKGROUND The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. METHODS Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSIONS Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Laurent G Glance
- Departments of Anesthesiology and Perioperative Medicine and of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York; and RAND Health, RAND, Boston, Massachusetts
| | - Karen E Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, MO.; Center for Advancing Health Services, Policy & Economics Research, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Ernie Shippey
- Vizient Center for Advanced Analytics, Chicago, Illinois
| | - Katherine L Wood
- Department of Surgery (Cardiac), University of Rochester School of Medicine, Rochester, New York
| | - E Yoko Furuya
- Department of Medicine, Division of Infectious Diseases Columbia University Irving Medical Center, New York, New York
| | - Patricia W Stone
- Columbia University School of Nursing, Center for Health Policy, New York, New York
| | - Jingjing Shang
- Columbia University School of Nursing, Center for Health Policy, New York, New York
| | - Isaac Y Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Igor Gosev
- Department of Surgery (Cardiac), University of Rochester School of Medicine, Rochester, New York
| | - Stewart J Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Heather L Lander
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Julie A Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Andres Laserna
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
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Bommareddi S, Lima B, Shah AS, Trahanas JM. Thoraco-abdominal normothermic regional perfusion for thoracic transplantation in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:180-185. [PMID: 38483139 DOI: 10.1097/mot.0000000000001143] [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: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an update regarding the state of thoracoabdominal normothermic regional perfusion (taNRP) when used for thoracic organ recovery. RECENT FINDINGS taNRP is growing in its utilization for thoracic organ recovery from donation after circulatory death donors, partly because of its cost effectiveness. taNRP has been shown to yield cardiac allograft recipient outcomes similar to those of brain-dead donors. Regarding the use of taNRP to recover donor lungs, United Network for Organ Sharing (UNOS) analysis shows that taNRP recovered lungs are noninferior, and taNRP has been used to consistently recover excellent lungs at high volume centers. Despite its growth, ethical debate regarding taNRP continues, though clinical data now supports the notion that there is no meaningful brain perfusion after clamping the aortic arch vessels. SUMMARY taNRP is an excellent method for recovering both heart and lungs from donation after circulatory death donors and yields satisfactory recipient outcomes in a cost-effective manner. taNRP is now endorsed by the American Society of Transplant Surgeons, though ethical debate continues.
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Affiliation(s)
- Swaroop Bommareddi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Harris CS, Lee HJ, Alderete IS, Halpern SE, Gordee A, Jamieson I, Scales C, Hartwig MG. The cost of lung transplantation in the United States: How high is too high? JTCVS OPEN 2024; 18:407-431. [PMID: 38690426 PMCID: PMC11056443 DOI: 10.1016/j.xjon.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/02/2023] [Accepted: 01/05/2024] [Indexed: 05/02/2024]
Abstract
Objectives To identify patient and process factors that contribute to the high cost of lung transplantation (LTx) in the perioperative period, which may allow transplant centers to evaluate situations in which transplantation is most cost-effective to inform judicious resource allocation, avoid futile care, and reduce costs. Methods The MarketScan Research databases were used to identify 582 privately insured patients undergoing single or bilateral LTx between 2013 and 2019. The patients were subdivided into groups by disease etiology using the United Network of Organ Sharing classification system. Multivariable generalized linear models using a gamma distribution with a log link were fit to examine the associations between the etiology of lung disease and costs during the index admission, 3 months before admission, and 3 months after discharge. Results Our results indicate that the index admission contributed the most to the total transplantation costs compared to the 3 months before admission and after discharge. The regression-adjusted mean index hospitalization cost was 35% higher for patients with pulmonary vascular disease compared to those with obstructive lung disease ($527,156 vs $389,055). The use of extracorporeal membrane oxygenation, mechanical ventilation, and surgical complications in the post-transplantation period were associated with higher costs during the index admission. Surprisingly, age ≥55 was associated with lower costs during the index admission. Conclusions This analysis identifies pivotal factors influencing the high cost of LTx, emphasizing the significant impact of the index admission, particularly for patients with pulmonary vascular disease. These insights offer transplant centers an opportunity to enhance cost-effectiveness through judicious resource allocation and service bundling, ultimately reducing overall transplantation costs.
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Affiliation(s)
- Chelsea S. Harris
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Hui-Jie Lee
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Isaac S. Alderete
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | | | - Alexander Gordee
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Ian Jamieson
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Charles Scales
- Department of Surgery, Duke University School of Medicine, Durham, NC
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [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: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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Kakuturu J, Dhamija A, Chan E, Lagazzi L, Thibault D, Badhwar V, Hayanga JWA. Mortality and cost of post-cardiotomy extracorporeal support in the United States. Perfusion 2023; 38:1468-1477. [PMID: 35930658 DOI: 10.1177/02676591221117355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality. METHODS We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality. RESULTS There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently. CONCLUSION Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.
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Affiliation(s)
- Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ernest Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luigi Lagazzi
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - J W A Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Jenkins D, Chechel L, Jenkins B. Nursing in deathworlds: Necropolitics of the life, dying and death of an unhoused person in the United States healthcare industrial complex. Nurs Philos 2023; 24:e12458. [PMID: 37332250 DOI: 10.1111/nup.12458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/13/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023]
Abstract
This paper begins with the lived accounts of emergency and critical care medical interventions in which an unhoused person is brought to the emergency department in cardiac arrest. The case is a dramatised representation of the extent to which biopolitical forces via reduction to bare life through biopolitical and necropolitical operations are prominent influences in nursing and medical care. This paper draws on the scholarship of Michel Foucault, Giorgio Agamben, and Achille Mbembe to offer a theoretical analysis of the power dynamics that influence the health care and death care of patients who are caught in the auspices of a neoliberal capitalist healthcare apparatus. This paper offers analysis of the overt displays of biopower over those individuals cast aside as generally unworthy of access to healthcare in a postcolonial capitalist system, in addition to the ways in which humans are reduced to 'bare life' in their dying days. We analyse this case study through Agamben's description of thanatopolitics, a 'regime of death', and the technologies that accompany the dying process, particularly in that of the homo sacer. Additionally, this paper illustrates the ways in which necropolitics and biopower are integral to understanding how the most advanced and expensive medical interventions make visible the political values of the healthcare system and how nurses and healthcare functions in these deathworlds. The purpose of this paper is to develop a greater understanding of biopolitical and necropolitical operations in acute and critical care environments, and to offer guidance to nurses in these spaces as they work to uphold ethical duties in a system that increasingly dehumanises.
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Affiliation(s)
- Danisha Jenkins
- School of Nursing, San Diego State University, San Diego, California, USA
| | - Laura Chechel
- Department of Nursing Research and Education, University of California, San Diego, La Jolla, California, USA
| | - Brian Jenkins
- Department of Women's Studies, San Diego State University, San Diego, California, USA
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Boudreaux JC, Urban M, Thompson SL, Castleberry AW, Moulton MJ, Siddique A. Does Tracheostomy Improve Outcomes in Those Receiving Venovenous Extracorporeal Membrane Oxygenation? ASAIO J 2023; 69:e240-e247. [PMID: 37071756 PMCID: PMC10226464 DOI: 10.1097/mat.0000000000001934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023] Open
Abstract
Patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) often require extended periods of ventilation. We examined the role of tracheostomy on outcomes of patients supported with VV-ECMO. We reviewed all patients at our institution who received VV-ECMO between 2013 and 2019. Patients who received a tracheostomy were compared with VV-ECMO-supported patients without tracheostomy. The primary outcome measure was survival to hospital discharge. Secondary outcome measures included length of intensive care unit (ICU) and hospital stay and adverse events related to the tracheostomy procedure. Multivariable analysis was performed to identify predictors of in-hospital mortality. We dichotomized patients receiving tracheostomy into an "early" and "late" group based on median days to tracheostomy following ECMO cannulation and separate analysis was performed. One hundred and fifty patients met inclusion criteria, 32 received a tracheostomy. Survival to discharge was comparable between the groups (53.1% vs. 57.5%, p = 0.658). Predictors of mortality on multivariable analysis included Respiratory ECMO Survival Prediction (RESP) score (odds ratio [OR] = 0.831, p = .015) and blood urea nitrogen (BUN) (OR = 1.026, p = 0.011). Tracheostomy performance was not predictive of mortality (OR = 0.837, p = 0.658). Bleeding requiring intervention occurred in 18.7% of patients following tracheostomy. Early tracheostomy (<7 days from the initiation of VV-ECMO) was associated with shorter ICU (25 vs. 36 days, p = 0.04) and hospital (33 vs. 47, p = 0.017) length of stay compared with late tracheostomy. We conclude that tracheostomy can be performed safely in patients receiving VV-ECMO. Mortality in these patients is predicted by severity of the underlying disease. Performance of tracheostomy does not impact survival. Early tracheostomy may decrease length of stay.
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Affiliation(s)
- Joel C. Boudreaux
- From the College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Marian Urban
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Shaun L. Thompson
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Michael J. Moulton
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Aleem Siddique
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
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Mazzeffi M, Curley J, Gallo P, Stombaugh DK, Roach J, Lunardi N, Yount K, Thiele R, Glance L, Naik B. Variation in Hospitalization Costs, Charges, and Lengths of Hospital Stay for Coronavirus Disease 2019 Patients Treated With Venovenous Extracorporeal Membrane Oxygenation in the United States: A Cohort Study. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00237-9. [PMID: 37127521 PMCID: PMC10079589 DOI: 10.1053/j.jvca.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/16/2023] [Accepted: 04/02/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES The aim was to characterize hospitalization costs, charges, and lengths of hospital stay for COVID-19 patients treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) in the United States during 2020. Secondarily, differences in hospitalization costs, charges, and lengths of hospital stay were explored based on hospital-level factors. DESIGN Retrospective cohort study. SETTING Multiple hospitals in the United States. PARTICIPANTS Adult patients with COVID-19 who were on VV ECMO in 2020 and had data in the national inpatient sample. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics and baseline comorbidities were recorded for patients. Primary study outcomes were hospitalization costs, charges, and lengths of hospital stay. Study outcomes were compared after stratification by hospital region, bed size, and for-profit status. The median hospitalization cost for the 3,315-patient weighted cohort was $200,300 ($99,623, $338,062). Median hospitalization charges were $870,513 ($438,228, $1,553,157), and the median length of hospital stay was 30 days (17, 46). Survival to discharge was 54.4% for all patients in the cohort. Median hospitalization cost differed by region (p = 0.01), bed size (p < 0.001), and for-profit status (p = 0.02). Median hospitalization charges also differed by region (p = 0.04), bed size (p = 0.002), and for-profit status (p < 0.001). Length of hospital stay differed by region (p = 0.03) and bed size (p < 0.001), but not for-profit status (p = 0.40). Hospitalization costs were the lowest, and charges were highest in private-for-profit hospitals. Large hospitals also had higher costs, charges, and hospital stay lengths than small hospitals. CONCLUSIONS In this retrospective cohort study, hospitalization costs and charges for patients with COVID-19 on VV ECMO were found to be substantial but similar to what has been reported previously for patients without COVID-19 on VV ECMO. Significant variation was observed in costs, charges, and lengths of hospital stay based on hospital-level factors.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia.
| | - Jonathan Curley
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Paul Gallo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - D Keegan Stombaugh
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Joshua Roach
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Nadia Lunardi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Kenan Yount
- Department of Surgery, Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, Virginia
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Laurent Glance
- Department of Anesthesiology, University of Rochester, Rochester, New York
| | - Bhiken Naik
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
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Rajsic S, Breitkopf R, Jadzic D, Popovic Krneta M, Tauber H, Treml B. Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review. J Clin Med 2022; 11:jcm11175147. [PMID: 36079084 PMCID: PMC9457503 DOI: 10.3390/jcm11175147] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anaesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | | | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Agbafe V, Fugett J, Gall A, Dhamija A, Asad F, Abbas K, Hayanga JA. Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation. Perfusion 2022; 38:791-800. [PMID: 35320025 DOI: 10.1177/02676591221083789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO. METHODS We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA). RESULTS 5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2. CONCLUSION Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.
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Affiliation(s)
- Victor Agbafe
- 12266University of Michigan Medical School, Ann Arbor, MI, USA
| | - James Fugett
- Department of Cardiovascular and Thoracic Surgery, 5631West Virginia University, Morgantown, WV, USA
| | - Ashley Gall
- 12355West Virginia University School of Medicine, Morgantown, WV, USA
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, 5631West Virginia University, Morgantown, WV, USA
| | - Fatima Asad
- 12355West Virginia University School of Medicine, Morgantown, WV, USA
| | - Kamil Abbas
- Immunology & Medical Microbiology, 5631West Virginia University, Morgantown, WV, USA
| | - Jeremiah A Hayanga
- Department of Cardiovascular and Thoracic Surgery, 5631West Virginia University, Morgantown, WV, USA
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Plazak ME, Grazioli A, Powell EK, Menne AR, Bathula AL, Madathil RJ, Krause EM, Deatrick KB, Mazzeffi MA. Precannulation International Normalized Ratio is Independently Associated With Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 36:1092-1099. [PMID: 34330572 DOI: 10.1053/j.jvca.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To explore whether precannulation international normalized ratio (INR) is associated with in-hospital mortality in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. DESIGN A retrospective, observational cohort study. SETTING A quaternary care academic medical center. PARTICIPANTS Patients with cardiogenic shock on VA-ECMO for >24 hours. INTERVENTIONS None, observational study. MEASUREMENTS AND MAIN RESULTS A total of 188 patients who were on VA-ECMO were included over three years. Patients were stratified into three groups based on their pre-ECMO INR: INR <1.5, INR 1.5 to 1.8, and INR >1.8. For all patients, demographics, comorbidities, and ECMO details were recorded. The study's primary outcome was in-hospital mortality and secondary outcomes included major bleeding, minor bleeding, allogeneic transfusion, ischemic stroke, intracranial hemorrhage, acute renal failure, acute liver failure, gastrointestinal bleeding, intensive care unit and hospital lengths of stay. A multivariate logistic regression was used to determine whether precannulation INR was associated independently with in-hospital mortality. In-hospital mortality differed significantly by INR group (51.6% INR >1.8 v 42.3% INR 1.5-1.8 v 24.3% INR <1.5; p = 0.004). In a multivariate logistic regression model, precannulation INR >1.8 was associated independently with an increased odds of mortality (odds ratio, 2.48; 95% confidence interval, 1.05-6.04) after controlling for sex, Survival after VA- ECMO score, and ECMO indication. An INR within 1.5 to 1.8 did not confer an increased mortality risk. CONCLUSIONS An INR >1.8 before VA-ECMO cannulation is associated independently with in-hospital mortality. Precannulation INR should be considered by clinicians so that ECMO resources can be better allocated and risks of organ failure and intracranial hemorrhage can be better understood.
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Affiliation(s)
- Michael E Plazak
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Alison Grazioli
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Elizabeth K Powell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Ashley R Menne
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Allison L Bathula
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
| | - Ronson J Madathil
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eric M Krause
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Kristopher B Deatrick
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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Kowalewski M, Zieliński K, Brodie D, MacLaren G, Whitman G, Raffa GM, Boeken U, Shekar K, Chen YS, Bermudez C, D’Alessandro D, Hou X, Haft J, Belohlavek J, Dziembowska I, Suwalski P, Alexander P, Barbaro RP, Gaudino M, Mauro MD, Maessen J, Lorusso R. Venoarterial Extracorporeal Membrane Oxygenation for Postcardiotomy Shock-Analysis of the Extracorporeal Life Support Organization Registry. Crit Care Med 2021; 49:1107-1117. [PMID: 33729722 PMCID: PMC8217275 DOI: 10.1097/ccm.0000000000004922] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. DESIGN Analysis of extracorporeal life support organization registry from January 2010 to December 2018. SETTING Multicenter worldwide registry. PATIENTS Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. INTERVENTIONS Venoarterial extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS Hospital death, weaning from extracorporeal membrane oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane oxygenation. A significant trend toward more extracorporeal membrane oxygenation use in recent years (coefficient, 0.009; p < 0.001) was found. Mean age was 56.3 ± 14.9 years and significantly increased over time (coefficient, 0.513; p < 0.001). Most commonly, venoarterial extracorporeal membrane oxygenation was instituted after coronary artery bypass surgery (26.8%) and valvular surgery (25.6%), followed by heart transplantation (20.7%). Overall, successful extracorporeal membrane oxygenation weaning was possible in 4,520 cases (56.4%), and survival to hospital discharge was achieved in 41.7% of cases. In-hospital mortality rates remained constant over time (coefficient, -8.775; p = 0.682), whereas complication rates were significantly reduced (coefficient, -0.009; p = 0.003). Higher mortality was observed after coronary artery bypass surgery (65.4%), combined coronary artery bypass surgery with valve (68.4%), and aortic (69.6%) procedures than other indications. Lower mortality rates were observed in heart transplantation recipients (46.0%). Age (p < 0.001), central cannulation (p < 0.001), and occurrence of complications while on extracorporeal membrane oxygenation were independently associated with poorer prognosis. CONCLUSIONS The analysis confirmed increased use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.
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Affiliation(s)
- Mariusz Kowalewski
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | | | - Daniel Brodie
- Center for Acute Respiratory Failure and Department of Medicine, Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | | - Udo Boeken
- Department of Cardiac Surgery, University of Dusseldorf, Dusseldorf, Germany
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Pediatric Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Christian Bermudez
- Department of Cardiothoracic Surgery, Jefferson University, Philadelphia, PA, USA
| | - David D’Alessandro
- Cardio-Thoracic Surgery Dept., Massachusetts Medical Centre, Boston, MA, USA
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. of China
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jan Belohlavek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, Prague, and General University Hospital, Prague, Czech Republic
| | - Inga Dziembowska
- Department of Pathophysiology, Faculty of Pharmacy, Collegium Medicum, Nicolaus Copernicus University, Toruń, Poland
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Peta Alexander
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan Ann Arbor, Michigan, USA
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery, Well Cornell Medicine, New York, NY, USA
| | - Michele Di Mauro
- Cardiac Surgery Unit, University Hospital, University of Chieti, Chieti, Italy
| | - Jos Maessen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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13
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Dhamija A, Kakuturu J, Schauble D, Hayanga HK, Jacobs JP, Badhwar V, Hayanga JWA. Outcome and Cost of Nurse-led versus Perfusionist-led Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2021; 113:1127-1134. [PMID: 34043952 DOI: 10.1016/j.athoracsur.2021.04.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality of care whose use has grown exponentially. We examined volume and utilization trends to identify the financial break-even point that might serve to dichotomize between nurse specialist-led and perfusionist-led ECMO programs. METHODS Data pertaining to patients who required ECMO support between 2018 and 2019 were reviewed. ECMO staffing costs were estimated based on national trends and modelled by annual utilization and case volume. A break-even point was derived from a comparison between nurse specialist-led and perfusionist-led models. For each scenario, direct medical costs were calculated based on utilization which was in turn defined by "low" (4 days), "average" (10 days), and "high" (30 days) duration of time spent on ECMO. RESULTS Within the time frame, there was a total of 107 ECMO cases with a mean ECMO duration of 11 days, within the study time frame. Overall, ECMO nursing personnel costs were less than those for perfusionists ($108,000 vs $175,000). Programmatic costs were higher in the perfusionist-led versus nurse specialist-led model when annual utilization was greater than 10 cases and ECMO duration was longer than a mean of 9.7 days. There was no difference in survival between the two models. CONCLUSIONS Use of a perfusionist-led ECMO model may be more cost-conscious in the context of low utilization, smaller case volume and shorter ECMO duration. However, once annual case volume exceeds 10 and mean ECMO duration exceeds 10 days, the nurse specialist-led model may be more cost-conscious.
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Affiliation(s)
- Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Drew Schauble
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Heather K Hayanga
- Division of Cardiac Anesthesia, Department of Anesthesia, West Virginia University, Morgantown, WV, USA
| | - Jeffrey P Jacobs
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA; Congenital Heart Center, Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, FL, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA.
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14
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Dhamija A, Thibault D, Fugett J, Hayanga HK, McCarthy P, Badhwar V, Awori Hayanga JW. Incremental effect of complications on mortality and hospital costs in adult ECMO patients. Perfusion 2021; 37:461-469. [PMID: 33765884 DOI: 10.1177/02676591211005697] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO. METHODS Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs. RESULTS Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529. CONCLUSION In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.
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Affiliation(s)
- Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Dylan Thibault
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - James Fugett
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Heather K Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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