Impact of an Extracorporeal Membrane Oxygenation Intensivist-Led Multidisciplinary Team on Venovenous Extracorporeal Membrane Oxygenation Outcomes

A systematic review of variability in the reporting of extracorporeal membrane oxygenation-associated infections and recommendations for standardization

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) utilization has surged in recent years, particularly amidst the COVID-19 pandemic, yet standardization of ECMO-associated infection (EAI) reporting remains lacking.

METHODS

This systematic review assessed 60 studies from 2018 to 2023 in PubMed, which used key words related to EAIs. Adherence to reporting data elements that may bias reporting, including the use of standardized rates of infections per 1,000 patient days, describing the use of antimicrobial prophylaxis, infection control, and culture practices, describing the definitions for infection by site, and listing pathogens by infection site were evaluated by study.

RESULTS

Our review revealed considerable heterogeneity in data elements and infection definitions. While 51 (85%) studies reported definition by site, only 17 (28%) reported infection control practices, and only 5 (8%) studies adhered to all the identified essential reporting elements. Variation in infection rates was also evident across the definitions, with studies using their own definition having the greatest variability in reported infection rates. Microbiological differences by geographic region further underscored the need for standardized reporting and challenges with generalizability in the EAI literature.

CONCLUSIONS

Our findings underscore the imperative for consensus on ECMO infection definitions and transparent reporting practices to facilitate meaningful comparisons and advance patient care protocols.

Pediatric Extracorporeal Membrane Oxygenation in Korea: A Multicenter Retrospective Study on Utilization and Outcomes Spanning Over a Decade

BACKGROUND

Over the last decade, extracorporeal membrane oxygenation (ECMO) use in critically ill children has increased and is associated with favorable outcomes. Our study aims to evaluate the current status of pediatric ECMO in Korea, with a specific focus on its volume and changes in survival rates based on diagnostic indications.

METHODS

This multicenter study retrospectively analyzed the indications and outcomes of pediatric ECMO over 10 years in patients at 14 hospitals in Korea from January 2012 to December 2021. Four diagnostic categories (neonatal respiratory, pediatric respiratory, post-cardiotomy, and cardiac-medical) and trends were compared between periods 1 (2012-2016) and 2 (2017-2021).

RESULTS

Overall, 1065 ECMO runs were performed on 1032 patients, with the annual number of cases remaining unchanged over the 10 years. ECMO was most frequently used for post-cardiotomy (42.4%), cardiac-medical (31.8%), pediatric respiratory (17.5%), and neonatal respiratory (8.2%) cases. A 3.7% increase and 6.1% decrease in pediatric respiratory and post-cardiotomy cases, respectively, were noted between periods 1 and 2. Among the four groups, the cardiac-medical group had the highest survival rate (51.2%), followed by the pediatric respiratory (46.4%), post-cardiotomy (36.5%), and neonatal respiratory (29.4%) groups. A consistent improvement was noted in patient survival over the 10 years, with a significant increase between the two periods from 38.2% to 47.1% (P = 0.004). Improvement in survival was evident in post-cardiotomy cases (30-45%, P = 0.002). Significant associations with mortality were observed in neonates, patients requiring dialysis, and those treated with extracorporeal cardiopulmonary resuscitation (P < 0.001). In pediatric respiratory ECMO, immunocompromised patients also showed a significant correlation with mortality (P < 0.001).

CONCLUSION

Pediatric ECMO demonstrated a steady increase in overall survival in Korea; however, further efforts are needed since the outcomes remain suboptimal compared with global outcomes.

Implementing an Adult Extracorporeal Membrane Oxygenation Program During the COVID-19 Pandemic

BACKGROUND

In response to the needs of patients infected with COVID-19, an interdisciplinary team was assembled to implement an adult extracorporeal membrane oxygenation (ECMO) program in the surgical ICU of a West Texas tertiary care hospital. Use of Extracorporeal Life Support Organization (ELSO) guidelines was essential to the development of this effort.

AIM

The aim of this project was to develop, implement, and evaluate an adult ECMO program.

METHODS

A logic model was used in designing and evaluating the adult ECMO program. A 35-hour ECMO specialist training course was developed, and training began in August 2020, a month before implementation of the project began. Patient outcomes were measured between September 2020 and December 2021. Descriptive statistics were used to measure the clinical outcomes of interest.

RESULTS

Seventeen newly trained ECMO specialists included experienced critical care nurses and respiratory therapists. Protocols were developed for the initiation of ECMO, and tracked patient outcomes included survival off ECMO, survival to discharge, major and minor complications, and length of stay. Nine patients had COVID-19 and demonstrated an 11.11% mortality rate after adult ECMO program implementation.

CONCLUSIONS

Use of the ELSO professional guidelines to design and develop this project led to the achievement of a sustainable ECMO program. Hospital leaders can now implement adult ECMO programs amid other demands for resources that may be created by future pandemics.

[Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest]

Objectives

Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown.

Objective

We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA.

Materials and methods

. We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume.

Results

Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups.

Conclusions

After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.

Intensivist coverage and critically ill COVID-19 patient outcomes: a population-based cohort study

BACKGROUND

Trained intensivist staffing improves survival outcomes in critically ill patients at intensive care units. However, the impact on outcomes of critically ill patients with coronavirus disease 2019 has not yet been evaluated. We aimed to investigate whether trained intensivists affect outcomes among critically ill coronavirus disease 2019 patients in South Korean intensive care units.

METHODS

Using a nationwide registration database in South Korea, we included adult patients admitted to the intensive care unit from October 8, 2020, to December 31, 2021, with a main diagnosis of coronavirus disease 2019. Critically ill patients admitted to intensive care units that employed trained intensivists were included in the intensivist group, whereas all other critically ill patients were assigned to the non-intensivist group.

RESULTS

A total of 13,103 critically ill patients were included, with 2653 (20.2%) patients in the intensivist group and 10,450 (79.8%) patients in the non-intensivist group. In the covariate-adjusted multivariable logistic regression model, the intensivist group exhibited 28% lower in-hospital mortality than that of the non-intensivist group (odds ratio: 0.72; 95% confidence interval: 0.62, 0.83; P < 0.001).

CONCLUSIONS

Trained intensivist coverage was associated with lower in-hospital mortality among critically ill coronavirus disease 2019 patients who required intensive care unit admission in South Korea.

An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years

We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.

Intensivist-Led Transportation of Patients on Extracorporeal Membrane Oxygenation: A Single Center Experience

This study evaluated the suitability, feasibility, safety, and outcomes of transport of the ECMO-dependent patient (EDP) by EDP transport team (EDPTT) in China. Eighty-two EDPs (forty-one cases on VV ECMO and forty-one cases on VA ECMO) received transport between June 2018 and June 2021 and were retrospectively analyzed. ECMO circulation was performed by the outlying hospital, mainly using percutaneous ECMO cannulation. The EDPTT consists of three intensive therapists, one of whom serves as a team leader, and one intensive care unit nurse. Of these, 81 (98.8%) patients were transferred by ambulance, no deaths occurred during transport, the EDP-related complications were 19% (n = 16); bleeding at the cannula site (n = 7, 8.5%) was the most prominent; equipment-related problems accounted for 14.6% of the problems requiring urgent intervention, with hand cranking being the most common (9.7%). The survival rate during transport was 100%, with 36 (43.9%) patients surviving to discharge. The ECMO weaning rate was 61% for VV ECMO and 63.7% for VA ECMO. The results demonstrated the suitability, feasibility, and safety of transporting EDP in a team led by an intensivist, with few complications and no deaths during transport. This may be the recommended staffing model for EDP transport in developing countries.

Trained intensivist coverage and survival outcomes in critically ill patients: a nationwide cohort study in South Korea

BACKGROUND

The difference in survival outcomes between closed and open intensive care unit (ICU) designs with respect to trained intensivist coverage remains unknown. We aimed to investigate whether trained intensivist coverage is associated with mortality in critically ill patients admitted to the ICU in South Korea.

METHODS

This population-based cohort study used nationwide registration data from South Korea. This study enrolled all adult patients admitted to the ICU between January 1, 2016, and December 31, 2019. Patients, who were admitted ICU in a hospital that employed trained intensivists, were designated as the intensivist group.

RESULTS

This study included 1,147,493 critically ill patients admitted to the ICU. The intensivist and non-intensivist groups consisted of 484,004 (42.2%) and 663,489 (57.8%) patients, respectively. Mixed effect logistic regression revealed a 22% lower in-hospital mortality rate (odds ratio: 0.78. 95% confidence interval: 0.74, 0.81; P < 0.001) than that in the non-intensivist group. Mixed effect Cox regression revealed a 15% lower 1-year mortality rate (hazard ratio: 0.85. 95% confidence interval: 0.83, 0.89; P < 0.001) in the intensivist group than that in the non-intensivist group. Moreover, the in-hospital mortality was significantly lower in the intensivist group than that in the non-intensivist group, irrespective of age, Charlson comorbidity index, surgery or non-surgery associated admission, and invasive treatment during ICU stay.

CONCLUSIONS

A closed ICU design with trained intensivist coverage was associated with lower in-hospital and 1-year mortality rates. Our results suggest that hospitals should employ trained intensivists to improve both short-term and long-term survival outcomes of critically ill patients.

Annual hospital procedural volume and outcome in extracorporeal membrane oxygenation for respiratory failure

BACKGROUND

The hospital mortality of patients suffering from pulmonary failure requiring venovenous extracorporeal membrane oxygenation (V-V ECMO) or extracorporeal carbon dioxide removal (ECCO₂ R) is high. It is unclear whether outcome correlates with a hospital's annual procedural volume.

METHODS

Data on all V-V ECMO and ECCO₂ R cases treated from 2007 to 2019 was retrieved from the German Institute for Medical Documentation and Information. Comorbidities and outcomes were assessed by DRG, OPS, and ICD codes. The study population was divided into 5 groups depending on annual hospital V-V ECMO and ECCO₂ R volumes (<10 cases; 10-19 cases; 20-29 cases; 30-49 cases; ≥50 cases). Primary outcome was hospital mortality.

RESULTS

A total of 25,096 V-V ECMO and 3,607 ECCO₂ R cases were analyzed. V-V ECMO hospitals increased from 89 in 2007 to 214 in 2019. Hospitals handling <10 cases annually increased especially (64 in 2007 to 149 in 2019). V-V ECMO cases rose from 807 in 2007 to 2,597 in 2019. Over 50% were treated in hospitals handling ≥30 cases annually. Hospital mortality was independent of the annual hospital procedural volume (55.3%; 61.3%; 59.8%; 60.2%; 56.3%, respectively, p=0.287). We detected no differences when comparing hospitals handling <30 cases to those with ≥30 annually (p=0.659). The numbers of ECCO₂ R hospitals and cases has dropped since 2011 (287 in 2007 to 48 in 2019). No correlation between annual hospital procedural volume and hospital mortality was identified (p=0.914).

CONCLUSION

The number of hospitals treating patients requiring V-V ECMO and V-V ECMO cases rose from 2007 to 2019, while ECCO₂ R hospitals and their case numbers decreased. We detected no correlation between annual hospital V-V ECMO or ECCO₂ R volume and hospital mortality.

Implementation of a regional multidisciplinary veno-venous extracorporeal membrane oxygenation unit improved survival: a historical cohort study

PURPOSE

Veno-venous extracorporeal membrane oxygenation (vvECMO) is a highly invasive technique with a high risk of mortality. Based on reports of improved outcomes in high-volume ECMO centers, we established a regional vvECMO unit. The objective of this study was to evaluate how the vvECMO unit affected patient mortality rates.

METHODS

This was a historical cohort study of all patients admitted to Dijon University Hospital and supported by vvECMO between January 2011 and June 2021. Patients managed with the vvECMO unit were compared with patients managed with non-vvECMO units. The primary outcome was 90-day mortality.

RESULTS

Of 172 patients treated using vvECMO, 69% were men, and the median [interquartile range] age was 59 [48-66] yr. Of the 172 patients, 35 were treated in the vvECMO unit and 137 were treated elsewhere (110/137 before the unit was established and 27/137 after). Ninety-day mortality was lower in patients managed in the vvECMO unit (15/35, 43% vs 92/137, 67%; P = 0.005). Within the vvECMO unit, mortality rates were also lower for the subgroup of patients managed after the specialized unit was established (15/35, 43% vs 20/27, 74%; P = 0.002). After adjusting for baseline severity of illness at vvECMO initiation, the vvECMO unit was independently associated with a lower 90-day mortality rate (hazard ratio, 0.41; 95% confidence interval, 0.21 to 0.80).

CONCLUSION

The establishment of a vvECMO unit was associated with reduced 90-day mortality. This improved survival may relate to patient selection, more specialized mechanical ventilation support, and/or improvement of vvECMO care.

Similarities in extracorporeal membrane oxygenation management across intensive care unit types in the United States: An analysis of the Extracorporeal Life Support Organization Registry

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) use in the United States occurs often in cardiothoracic ICUs (CTICU). It is unknown how it varies across ICU types.

METHODS

We identified 10,893 ECMO runs from the Extracorporeal Life Support Organization (ELSO) Registry across 2018 and 2019. Primary outcome was ECMO case volume by ICU type (CTICU vs. non-CTICU). Adjusting for pre-ECMO characteristics and case mix, secondary outcomes were on-ECMO physiologic variables by ICU location stratified by support type.

RESULTS

CTICU ECMO occurred in 65.1% and 55.1% (2018 and 2019) of total runs. A minority of total runs related to cardiac surgery procedures (CTICU: 21.7% [2018], 18% [2019]; non-CTICU: 11.2% [2018], 13% [2019]). After multivariate adjustment, non-CTICU ECMO for cardiac support associated with lower 4- and 24-hour circuit flow (3.9 liters per minute [LPM] vs. 4.1 LPM, p<0.0001; 4.1 LPM vs. 4.3 LPM, p<0.0001); for respiratory support, lower on-ECMO mean fraction of inspired oxygen ([F_i O₂ ], 67% versus 69%, p=0.02) and lower respiratory rate (14 versus 15, p<0.0001); and, for extracorporeal cardiopulmonary resuscitation (ECPR), lower ECMO flow rates at 24 hours (3.5 liters per minute [LPM] versus 3.7 LPM, p=0.01).

CONCLUSIONS

ECMO mostly remains in CTICUs though a minority is associated with cardiac surgery. Statistically significant but clinically minor differences in on-ECMO metrics were observed across ICU types.

Rapid Development and Deployment of an Intensivist-Led Venovenous Extracorporeal Membrane Oxygenation Cannulation Program

OBJECTIVES

To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program.

DESIGN

A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program.

SETTING

An adult ICU in a tertiary academic medical center in Camden, NJ.

PATIENTS

Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation.

INTERVENTIONS

Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists.

MEASUREMENTS AND MAIN RESULTS

Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1).

CONCLUSIONS

There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.