1
|
Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
Collapse
Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
2
|
Zhang LQ, Chang H, Kalra A, Humayun M, Rosenblatt KR, Shah VA, Geocadin RG, Brown CH, Kim BS, Whitman GJR, Rivera-Lara L, Cho SM. Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation. Neurocrit Care 2024; 41:185-193. [PMID: 38326536 PMCID: PMC11303590 DOI: 10.1007/s12028-023-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/21/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Impaired cerebral autoregulation (CA) is one of several proposed mechanisms of acute brain injury in patients supported by extracorporeal membrane oxygenation (ECMO). The primary aim of this study was to determine the feasibility of continuous CA monitoring in adult ECMO patients. Our secondary aims were to describe changes in cerebral oximetry index (COx) and other metrics of CA over time and in relation to functional neurologic outcomes. METHODS This is a single-center prospective observational study. We measured COx, a surrogate measurement of cerebral blood flow measured by near-infrared spectroscopy, which is an index of CA derived from the moving correlation between mean arterial pressure (MAP) and slow waves of regional cerebral oxygen saturation. A COx value that approaches 1 indicates impaired CA. Using COx, we determined the optimal MAP (MAPOPT) and lower and upper limits of autoregulation for individual patients. These measurements were examined in relation to modified Rankin Scale (mRS) scores. RESULTS Fifteen patients (median age 57 years [interquartile range 47-69]) with 150 autoregulation measurements were included for analysis. Eleven were on veno-arterial ECMO (VA-ECMO), and four were on veno-venous ECMO (VV-ECMO). Mean COx was higher on postcannulation day 1 than on day 2 (0.2 vs. 0.09, p < 0.01), indicating improved CA over time. COx was higher in VA-ECMO patients than in VV-ECMO patients (0.12 vs. 0.06, p = 0.04). Median MAPOPT for the entire cohort was highly variable, ranging from 55 to 110 mm Hg. Patients with mRS scores 0-3 (good outcome) at 3 and 6 months spent less time outside MAPOPT compared with patients with mRS scores 4-6 (poor outcome) (74% vs. 82%, p = 0.01). The percentage of time when observed MAP was outside the limits of autoregulation was higher on postcannulation day 1 than on day 2 (18.2% vs. 3.3%, p < 0.01). CONCLUSIONS In ECMO patients, it is feasible to monitor CA continuously at the bedside. CA improved over time, most significantly between postcannulation days 1 and 2. CA was more impaired in VA-ECMO patients than in VV-ECMO patients. Spending less time outside MAPOPT may be associated with achieving a good neurologic outcome.
Collapse
Affiliation(s)
- Lucy Q Zhang
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Henry Chang
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariyam Humayun
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Kathryn R Rosenblatt
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- Department of Neurology and Center for Academic Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA.
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
3
|
Yu Y, Lettow I, Roedl K, Jarczak D, Pinnschmidt H, Reichenspurner H, Bernhardt AM, Söffker G, Schrage B, Haar M, Weber T, Frings D, Kluge S, Fischer M. Association of early changes in arterial carbon dioxide with acute brain injury in adult patients with extracorporeal membrane oxygenation: A ten-year retrospective study in a German tertiary care hospital. J Crit Care 2024; 84:154880. [PMID: 39024824 DOI: 10.1016/j.jcrc.2024.154880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/21/2024] [Accepted: 07/12/2024] [Indexed: 07/20/2024]
Abstract
PURPOSE To assess the association between fluctuations of arterial carbon dioxide early after start of extracorporeal membrane oxygenation (ECMO) with intracranial hemorrhage (ICH) or ischemic stroke (IS). MATERIALS AND METHODS This single-center retrospective study included patients who required ECMO for circulatory or respiratory failure between January 2011 and April 2021 and for whom a cerebral computed tomography (cCT) scan was available. Multivariable logistic regression models were fitted to evaluate the association between the relative change of arterial carbon dioxide (RelΔPaCO2) and ICH, IS or a composite of ICH, IS, and mortality. RESULTS In 618 patients (venovenous ECMO: n = 295; venoarterial ECMO: n = 323) ICH occurred more frequently in patients with respiratory failure (19.0%) compared with patients with circulatory failure (6.8%). Conversely, the incidence of IS was higher in patients with circulatory failure (19.2%) compared with patients with respiratory failure (4.7%). While patients with ECMO for respiratory failure were more likely to have ICH (OR 3.683 [95% CI: 1.855;7.309], p < 0.001), they had a lower odds for IS (OR 0.360 [95%CI: 0.158;0.820], p = 0.015) compared with patients with circulatory failure. There was no significant association between RelΔPaCO2 and ICH or IS. CONCLUSIONS Irrespective of the indication for ECMO, we did not find a significant association between the relative change in PaCO2 early after ECMO initiation and acute brain injury. Aside from early PaCO2 decline at cannulation, future studies should address fluctuations of PaCO2 throughout the course of ECMO support and their effect on acute brain injury.
Collapse
Affiliation(s)
- Yuanyuan Yu
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Iris Lettow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Markus Haar
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Theresa Weber
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Frings
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
4
|
Xu M, Yan JY, Jin JJ, Li T. Cerebral pseudoinfarction due to venoarterial extracorporeal membrane oxygenation: A case report. World J Clin Cases 2024; 12:3130-3137. [PMID: 38898845 PMCID: PMC11185375 DOI: 10.12998/wjcc.v12.i17.3130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/16/2024] [Accepted: 04/22/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Neurological complications are common in the management of venoarterial extracorporeal membrane oxygenation (VA-ECMO), with most patients requiring sedation and intubation, limiting the assessment of neurological function. There-fore, we must rely on advanced neuroimaging techniques, such as computed tomography angiography (CTA) and computed tomography perfusion (CTP). Because ECMO changes the normal blood flow pattern, it may interfere with the contrast medium in some special cases, leading to artifacts and ultimately mis-leading clinical decisions. CASE SUMMARY A 61-year-old man presented to a local hospital with chest tightness and pain 1 d prior to presentation. The patient was treated with VA-ECMO after sudden car-diac and respiratory arrest at a local hospital. For further treatment, the patient was transferred to our hospital. The initial consciousness assessment was not clear, and routine CTP was performed to understand the intracranial changes, which suggested a large area of cerebral infarction on the right side; however, the cerebral oxygen was not consistent with the CTP results, and the reexamination of CTA still suggested a right cerebral infarction. To identify this difference, bedside transcranial Doppler was performed, and the blood flow on both sides was different. By reducing the ECMO flow, CTP reexamination showed that the results were normal and consistent with the clinical results. On day 3, the patient was alert and showed good limb movements. CONCLUSION In patients with peripheral VA-ECMO, cerebral perfusion confirmed by CTP and CTA may lead to false cerebral infarction.
Collapse
Affiliation(s)
- Mi Xu
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Jue-Yue Yan
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Jia-Jia Jin
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Tong Li
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| |
Collapse
|
5
|
Johannes F, Frohofer-Vollenweider R, Teuschl Y. Neurological Complications of the Lower Extremities After Femoral Cannulated Extracorporeal Membrane Oxygenation: A Systematic Review. J Intensive Care Med 2024; 39:534-541. [PMID: 38018080 PMCID: PMC11092294 DOI: 10.1177/08850666231217679] [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: 08/13/2023] [Revised: 11/10/2023] [Accepted: 11/15/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Femoral cannulated extracorporeal membrane oxygenation (ECMO) has been associated with neurologic complications in the lower extremity ipsilateral to the cannulation. There is uncertainty about the prevalence of these complications and their mechanisms of development. OBJECTIVE Aim of this systematic review was to investigate the prevalence of neurological complications after ECMO and to describe possible underlying mechanisms. METHOD A systematic literature search was performed in Medline-Ovid, Embase, Cochrane Library, CINAHL, and PEDro until April 2021 for clinical trials in English or German language which quantified neurologic complications in the lower extremity ipsilateral to the ECMO cannulation of adults. The complications had to be delimitable to intensive care unit-acquired weakness. Methodological quality was assessed by 2 independent investigators using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the National Heart, Lung, and Blood Institute. RESULTS Eight observational studies were included in the synthesis. Study quality was good to fair in 88% of the papers. Overall, 47 of 202 patients (23.3%; ranging from 3% to 48% across studies) with femoral ECMO cannulation showed neurologic complications of the lower extremity ipsilateral to the cannulation. Peripheral ischemia and compression of nerves by the ECMO cannula are discussed as mechanisms of injury. CONCLUSION The occurrence of neurological complications after ECMO was common and can lead to long-term impairment. The mechanisms are largely unknown but currently there is no sufficient evidence for the involvement of ECMO. Standardized assessments are needed to systematically screen for neurological complications early after ECMO, to enable countermeasures and prevent further complications.
Collapse
Affiliation(s)
- Frauke Johannes
- Department of Clinical Neurosciences and Preventive Medicine, University of Continuing Education Krems, Krems, Austria
| | - Rahel Frohofer-Vollenweider
- Nursing and Allied Health Profession Office, Physiotherapy Occupational Therapy, University Hospital Zurich, Zurich, Switzerland
| | - Yvonne Teuschl
- Department of Clinical Neurosciences and Preventive Medicine, University of Continuing Education Krems, Krems, Austria
| |
Collapse
|
6
|
Ratay C, Elmer J, Callaway CW, Flickinger KL, Coppler PJ. Brain computed tomography after resuscitation from in-hospital cardiac arrest. Resuscitation 2024; 198:110181. [PMID: 38492716 DOI: 10.1016/j.resuscitation.2024.110181] [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: 02/01/2024] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Few data characterize the role of brain computed tomography (CT) after resuscitation from in-hospital cardiac arrest (IHCA). We hypothesized that identifying a neurological etiology of arrest or cerebral edema on brain CT are less common after IHCA than after resuscitation from out-of-hospital cardiac arrest (OHCA). METHODS We included all patients comatose after resuscitation from IHCA or OHCA in this retrospective cohort analysis. We abstracted patient and arrest clinical characteristics, as well as pH and lactate, to estimate systemic illness severity. Brain CT characteristics included quantitative measurement of the grey-to-white ratio (GWR) at the level of the basal ganglia and qualitative assessment of sulcal and cisternal effacement. We compared GWR distribution by stratum (no edema ≥1.30, mild-to-moderate <1.30 and >1.20, severe ≤1.20) and newly identified neurological arrest etiology between IHCA and OHCA groups. RESULTS We included 2,306 subjects, of whom 420 (18.2%) suffered IHCA. Fewer IHCA subjects underwent post-arrest brain CT versus OHCA subjects (149 (35.5%) vs 1,555 (82.4%), p < 0.001). Cerebral edema for IHCA versus OHCA was more often absent (60.1% vs. 47.5%) or mild-to-moderate (34.3% vs. 27.9%) and less often severe (5.6% vs. 24.6%). A neurological etiology of arrest was identified on brain CT in 0.5% of IHCA versus 3.2% of OHCA. CONCLUSIONS Although severe edema was less frequent in IHCA relative to OHCA, mild-to-moderate or severe edema occurred in one in three patients after IHCA. Unsuspected neurological etiologies of arrest were rarely discovered by CT scan in IHCA patients.
Collapse
Affiliation(s)
- Cecelia Ratay
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katharyn L Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
7
|
Siddiqui K, Hafeez MU, Ahmad A, Kazmi SO, Chatterjee S, Bershad E, Hirzallah M, Rao C, Damani R. Multimodal Neurologic Monitoring in Patients Undergoing Extracorporeal Membrane Oxygenation. Cureus 2024; 16:e59476. [PMID: 38826870 PMCID: PMC11140437 DOI: 10.7759/cureus.59476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) is associated with a high rate of neurologic complications. Multimodal neurologic monitoring (MNM) has the potential for early detection and intervention. We examined the safety and feasibility of noninvasive MNM during ECMO. We hypothesized that survivors and non-survivors would have meaningful differences in transcranial Doppler (TCD) sonography and electroencephalographic (EEG) characteristics, which we aimed to identify. We also investigated adverse neurologic events and attempted to identify differences in EEG and TCD characteristics among patients based on the type of ECMO and the occurrence of these events. Material and methods We performed an observational study on all patients undergoing ECMO at Baylor St. Luke's Medical Center's critical care unit in Houston, Texas, United States, from January 2017 to February 2019. All patients underwent a noninvasive MNM protocol. Results NM was completed in 75% of patients; all patients received at least one component of the monitoring protocol. No adverse events were noted, showing the feasibility and safety of the protocol. The 60.4% of patients who did not survive tended to be older, had lower ejection fractions, and had lower median right middle cerebral artery (MCA) pulsatility and resistivity indexes. Patients undergoing venoarterial (VA)-ECMO had lower median left and right MCA velocities and lower right Lindegaard ratios than patients who underwent venovenous-ECMO. In VA-ECMO patients, EEG less often showed sleep architecture, while other findings were similar between groups. Adverse neurologic events occurred in 24.7% of patients, all undergoing VA-ECMO. Acute ischemic stroke occurred in 22% of patients, intraparenchymal hemorrhage in 4.9%, hypoxic-ischemic encephalopathy in 3.7%, subarachnoid hemorrhage in 2.5%, and subdural hematoma in 1.2%. Conclusion Our results suggest that MNM is safe and feasible for patients undergoing ECMO. Certain EEG and TCD findings could aid in the early detection of neurologic deterioration. MNM may not just be used in monitoring patients undergoing ECMO but also in prognostication and aiding clinical decision-making.
Collapse
Affiliation(s)
| | | | - Ali Ahmad
- Neurology, Baylor College of Medicine, Houston, USA
| | - Syed O Kazmi
- Neurology, Salem Health Hospitals & Clinics, Salem, USA
| | | | - Eric Bershad
- Neurology, Baylor College of Medicine, Houston, USA
| | | | - Chethan Rao
- Neurocritical Care, Baylor College of Medicine, Houston, USA
| | - Rahul Damani
- Neurology, Baylor College of Medicine, Houston, USA
| |
Collapse
|
8
|
Balucani C, Canner JK, Tonna JE, Dalton H, Bianchi R, Al-Kawaz MNG, Choi CW, Etchill E, Kim BS, Whitman GJ, Cho SM. Sex-Related Differences in Utilization and Outcomes of Extracorporeal Cardio-Pulmonary Resuscitation for Refractory Cardiac Arrest. ASAIO J 2024:00002480-990000000-00461. [PMID: 38588589 DOI: 10.1097/mat.0000000000002210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
Sparse data exist on sex-related differences in extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (rCA). We explored the role of sex on the utilization and outcomes of ECPR for rCA by retrospective analysis of the Extracorporeal Life Support Organization (ELSO) International Registry. The primary outcome was in-hospital mortality. Exploratory outcomes were discharge disposition and occurrence of any specific extracorporeal membrane oxygenation (ECMO) complications. From 1992 to 2020, a total of 7,460 adults with ECPR were identified: 30.5% women; 69.5% men; 55.9% Whites, 23.7% Asians, 8.9% Blacks, and 3.8% Hispanics. Women's age was 50.4 ± 16.9 years (mean ± standard deviation) and men's 54.7 ± 14.1 (p < 0.001). Ischemic heart disease occurred in 14.6% women vs. 18.5% men (p < 0.001). Overall, 28.5% survived at discharge, 30% women vs. 27.8% men (p = 0.138). In the adjusted analysis, sex was not associated with in-hospital mortality (odds ratio [OR] = 0.93 [confidence interval {CI} = 0.80-1.08]; p = 0.374). Female sex was associated with decreased odds of neurologic, cardiovascular, and renal complications. Despite being younger and having fewer complications during ECMO, women had in-hospital mortality similar to men. Whether these findings are driven by biologic factors or disparities in health care warrants further investigation.
Collapse
Affiliation(s)
- Clotilde Balucani
- From the Neurocritical Care Division, Department of Neurology, New York University Langone/Bellevue Hospital, New York, New York
| | - Joseph K Canner
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Heidi Dalton
- Division of Critical Care Medicine, Department of Pediatrics, INOVA Heart and Vascular Institute, Inova Fairfax Medical Institute, Falls Church, Virginia
| | - Riccardo Bianchi
- Department of Physiology and Pharmacology, College of Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, New York
| | - Mais N G Al-Kawaz
- Department of Neurology, Neurosurgery, and Radiology, University of Kentucky HealthCare, Lexington, Kentucky
| | - Chun Woo Choi
- Department of Cardiothoracic Surgery, Virtua Our Lady of Lourdes Hospital, Camden, New Jersey
| | - Eric Etchill
- Department of Cardiothoracic Surgery, Virtua Our Lady of Lourdes Hospital, Camden, New Jersey
| | - Bo Soo Kim
- Department of Cardiothoracic Surgery, Virtua Our Lady of Lourdes Hospital, Camden, New Jersey
| | - Glenn J Whitman
- Department of Cardiothoracic Surgery, Virtua Our Lady of Lourdes Hospital, Camden, New Jersey
| | - Sung-Min Cho
- Department of Cardiothoracic Surgery, Virtua Our Lady of Lourdes Hospital, Camden, New Jersey
- Division of Neuroscience Critical Care and Cardiac Surgery, Departments of Neurology, Anesthesia & Critical Care, The Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
9
|
Hadano H, Kamio T, Fukaguchi K, Sato M, Tsunano Y, Koyama H. Analysis of adverse events related to extracorporeal membrane oxygenation from a nationwide database of patient-safety accidents in Japan. J Artif Organs 2024; 27:15-22. [PMID: 36795227 PMCID: PMC9933024 DOI: 10.1007/s10047-023-01386-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/24/2023] [Indexed: 02/17/2023]
Abstract
Although adverse events related to extracorporeal membrane oxygenation have been reported, epidemiological data on life-threatening events are insufficient to study the causes of such adverse events. Data from the Japan Council for Quality Health Care database were retrospectively analyzed. The adverse events extracted from this national database included events associated with extracorporeal membrane oxygenation reported between January 2010 and December 2021. We identified 178 adverse events related to extracorporeal membrane oxygenation. At least 41 (23%) and 47 (26%) accidents resulted in death and residual disability, respectively. The most common adverse events were cannula malposition (28%), decannulation (19%), and bleeding (15%). Among patients with cannula malposition, 38% did not undergo fluoroscopy-guided or ultrasound-guided cannulation, 54% required surgical treatment, and 18% required trans-arterial embolization. In this epidemiological study in Japan, 23% of the adverse events related to extracorporeal membrane oxygenation had fatal outcomes. Our findings suggest that a training system for cannulation techniques may be needed, and hospitals offering extracorporeal membrane oxygenation should perform emergency surgeries.
Collapse
Affiliation(s)
- Hiroki Hadano
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura-shi, Kanagawa, 247-8533, Japan.
| | - Tadashi Kamio
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura-shi, Kanagawa, 247-8533, Japan
| | - Kiyomitsu Fukaguchi
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura-shi, Kanagawa, 247-8533, Japan
| | - Mizuki Sato
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura-shi, Kanagawa, 247-8533, Japan
| | - Yumiko Tsunano
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura-shi, Kanagawa, 247-8533, Japan
| | - Hiroshi Koyama
- Division of Critical Care, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura-shi, Kanagawa, 247-8533, Japan
| |
Collapse
|
10
|
Michel A, Vedrenne-Cloquet M, Kossorotoff M, Thy M, Levy R, Pouletty M, De Marcellus C, Grimaud M, Moulin F, Hully M, Simonnet H, Desguerre I, Renolleau S, Oualha M, Chareyre J. Neurologic Outcomes and Quality of Life in Children After Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2024; 25:e158-e167. [PMID: 38088764 DOI: 10.1097/pcc.0000000000003419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
RATIONALE Use of life support with extracorporeal membrane oxygenation (ECMO) is associated with brain injury. However, the consequences of these injuries on subsequent neurologic development and health-related quality of life (HRQoL) are poorly described in children. OBJECTIVES The aim of this preliminary study was to describe short- and long-term neurologic outcomes in survivors of ECMO, as well as their HRQoL. DESIGN Retrospective identified cohort with contemporary evaluations. SETTING Necker Children's Hospital academic PICU. PATIENTS Forty survivors who underwent ECMO (October 2014 to January 2020) were included in follow-up assessments in May 2021. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS We first reviewed the outcomes of ECMO at the time of PICU discharge, which included a summary of neurology, radiology, and Pediatric Overall/Cerebral Performance Category (POPC/PCPC) scores. Then, in May 2021, we interviewed parents and patients to assess HRQoL (Pediatric Quality of Life Inventory [PedsQL]) and POPC/PCPC for children 3 years old or older, and Denver II test (DTII) for younger children. An evaluation of DTII in the youngest patients 1 year after ECMO decannulation was also added. Median age at ECMO was 1.4 years (interquartile range [IQR], 0.4-6 yr). Thirty-five children (88%) underwent a venoarterial ECMO. At PICU discharge, 15 of 40 patients (38%) had neurologic impairment. Assessment of HRQoL was carried out at median of 1.6 years (IQR, 0.7-3.3 yr) after PICU discharge. PedsQL scores were over 70 of 100 for all patients (healthy peers mean results: 80/100), and scores were like those published in patients suffering with chronic diseases. In May 2021, seven of 15 patients had a normal DTII, and 36 of 40 patients had a POPC/PCPC score less than or equal to 3. CONCLUSIONS None of our patients presented severe disability at long term, and HRQoL evaluation was reassuring. Considering the risk of neurologic impairment after ECMO support, a systematic follow-up of these high-risk survivor patients would be advisable.
Collapse
Affiliation(s)
- Alizée Michel
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Meryl Vedrenne-Cloquet
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | | | - Michaël Thy
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Raphaël Levy
- Radiologie Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marie Pouletty
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Charles De Marcellus
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marion Grimaud
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Florence Moulin
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marie Hully
- Neurologie Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Hina Simonnet
- Service de Rééducation Pédiatrique Hôpital Trousseau, Paris, France
| | | | - Sylvain Renolleau
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Mehdi Oualha
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Judith Chareyre
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| |
Collapse
|
11
|
Bartlett R, Arachichilage DJ, Chitlur M, Hui SKR, Neunert C, Doyle A, Retter A, Hunt BJ, Lim HS, Saini A, Renné T, Kostousov V, Teruya J. The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation. Semin Thromb Hemost 2024; 50:81-90. [PMID: 36750217 DOI: 10.1055/s-0043-1761488] [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: 02/09/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.
Collapse
Affiliation(s)
- Robert Bartlett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Deepa J Arachichilage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Meera Chitlur
- Division of Hematology/Oncology, Central Michigan University School of Medicine, Children's Hospital of Michigan, Michigan
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Cindy Neunert
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Arun Saini
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Vadim Kostousov
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| |
Collapse
|
12
|
Tridon C, Bachelet D, El Baied M, Eloy P, Ortuno S, Para M, Wicky PH, Vellieux G, de Montmollin E, Bouadma L, Manceau H, Timsit JF, Peoc'h K, Sonneville R. Association of Sepsis With Neurologic Outcomes of Adult Patients Treated With Venoarterial Extracorporeal Membrane Oxygnenation. Crit Care Explor 2024; 6:e1042. [PMID: 38333077 PMCID: PMC10852385 DOI: 10.1097/cce.0000000000001042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVES Neurologic outcomes of patients under venoarterial extracorporeal membrane oxygenation (VA-ECMO) may be worsened by secondary insults of systemic origin. We aimed to assess whether sepsis, commonly observed during ECMO support, is associated with brain injury and outcomes. DESIGN Single-center cohort study of the "exposed-non-exposed" type on consecutive adult patients treated by VA-ECMO. SETTING Medical ICU of a university hospital, France, 2013-2020. PATIENTS Patients with sepsis at the time of VA-ECMO cannulation ("sepsis" group) were compared with patients without sepsis ("no sepsis" group). The primary outcome measure was poor functional outcome at 90 days, defined by a score greater than or equal to 4 on the modified Rankin scale (mRS), indicating severe disability or death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 196 patients were included ("sepsis," n = 128; "no sepsis," n = 68), of whom 87 (44.4%) had presented cardiac arrest before VA-ECMO cannulation. A poor functional outcome (mRS ≥ 4) was observed in 99 of 128 patients (77.3%) of the "sepsis" group and 46 of 68 patients (67.6%) of the "no sepsis" group (adjusted logistic regression odds ratio (OR) 1.21, 95% CI, 0.58-2.47; inverse probability of treatment weighting (IPTW) OR 1.24; 95% CI, 0.79-1.95). Subsequent analyses performed according to pre-ECMO cardiac arrest status suggested that sepsis was independently associated with poorer functional outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest (adjusted logistic regression OR 3.44; 95% CI, 1.06-11.40; IPTW OR 3.52; 95% CI, 1.68-7.73), whereas no such association was observed in patients without pre-ECMO cardiac arrest (adjusted logistic regression OR 0.69; 95% CI, 0.27-1.69; IPTW OR 0.76; 95% CI, 0.42-1.35). Compared with the "no sepsis" group, "sepsis" patients presented a significant increase in S100 calcium-binding protein beta concentrations at day 1 (0.94 μg/L vs. 0.52 μg/L, p = 0.03), and more frequent EEG alterations (i.e., severe slowing, discontinuous background, and a lower prevalence of sleep patterns), suggesting brain injury. CONCLUSION We observed a detrimental role of sepsis on neurologic outcomes in the subgroup of patients who had experienced pre-ECMO cardiac arrest, but not in other patients.
Collapse
Affiliation(s)
- Chloé Tridon
- Médecine intensive-réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Delphine Bachelet
- Physiologie-Explorations Fonctionnelles, FHU APOLLO, DMU DREAM, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Majda El Baied
- Physiologie-Explorations Fonctionnelles, FHU APOLLO, DMU DREAM, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Philippine Eloy
- Physiologie-Explorations Fonctionnelles, FHU APOLLO, DMU DREAM, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Sofia Ortuno
- Médecine intensive-réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Marylou Para
- Service de Chirurgie Cardiaque, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France. Université de Paris Cité, INSERM U1148, Paris, France
| | - Paul-Henri Wicky
- Médecine intensive-réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Geoffroy Vellieux
- Neurophysiologie clinique, service de Physiologie-Explorations Fonctionnelles, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Etienne de Montmollin
- Médecine intensive-réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, IAME, INSERM, UMR1137, Paris, France
| | - Lila Bouadma
- Médecine intensive-réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, IAME, INSERM, UMR1137, Paris, France
| | - Hana Manceau
- Université de Paris, IAME, INSERM, UMR1137, Paris, France
- Biochimie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Jean-François Timsit
- Médecine intensive-réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, IAME, INSERM, UMR1137, Paris, France
| | - Katell Peoc'h
- Université de Paris, IAME, INSERM, UMR1137, Paris, France
- Biochimie, Assistance Publique Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Romain Sonneville
- Médecine intensive-réanimation, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
- Université de Paris, IAME, INSERM, UMR1137, Paris, France
| |
Collapse
|
13
|
Davies MG, Hart JP. Current status of ECMO for massive pulmonary embolism. Front Cardiovasc Med 2023; 10:1298686. [PMID: 38179509 PMCID: PMC10764581 DOI: 10.3389/fcvm.2023.1298686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
Massive pulmonary embolism (MPE) carries significant 30-day mortality and is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Given the continued high mortality associated with MPE, there has been ongoing interest in utilizing extracorporeal membrane oxygenation (ECMO) to provide oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and RV pressure will improve outcomes. Two modalities can be employed: Veno-arterial-ECMO is a reliable process to decrease RV overload and improve RV function, thus allowing for hemodynamic stability and restoration of tissue oxygenation. Veno-venous ECMO can support oxygenation but is not designed to help circulation. Several societal guidelines now suggest using ECMO in MPE with interventional therapy. There are three strategies for ECMO utilization in MPE: bridge to definitive interventional therapy, sole therapy, and recovery after interventional treatment. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Considerable heterogeneity in studies is a significant weakness of the available literature. Applying ECMO is also associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, which must be factored into the outcomes. The application of ECMO in MPE should be combined with an aggressive pulmonary interventional program and should strictly adhere to the current selection criteria.
Collapse
Affiliation(s)
- Mark G. Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
- Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX, United States
| | - Joseph P. Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| |
Collapse
|
14
|
Zhao J, Cui P, Zhou Z, Niu B, Pan C. Treatment of malignant airway stenosis with extracorporeal membrane oxygenation under low-dose anticoagulation: A case report. Heliyon 2023; 9:e23210. [PMID: 38144268 PMCID: PMC10746480 DOI: 10.1016/j.heliyon.2023.e23210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
The occurrence of airway obstruction due to severe stenosis from lung cancer poses a significant risk of asphyxia. Although the placement of a metallic stent may relieve the obstruction, the procedure is associated with a high risk of asphyxia. To mitigate this risk, extracorporeal membrane pulmonary oxygenation (ECMO) has been proposed to temporarily substitute for cardiopulmonary function during the procedure. However, the use of systemic anticoagulation with heparin during ECMO may increase the likelihood of bleeding during surgery. This case report describes a successful treatment of a patient with malignant central airway obstruction through low-dose heparin veno-venous ECMO. This approach resulted in reduced intraoperative bleeding and invasive operation time, allowing for prompt postoperative withdrawal and recovery.
Collapse
Affiliation(s)
- Jingsha Zhao
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
- Department of Intensive Care Unit, Pujiang People's Hospital, Chengdu, Sichuan, China
| | - Peng Cui
- Department of Cardiovascular, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Ziwei Zhou
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Bin Niu
- Department of Respiratory, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Chuanliang Pan
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| |
Collapse
|
15
|
Zhao D, Shou BL, Caturegli G, Whitman GJR, Kim BS, Cho SM. Trends on Near-Infrared Spectroscopy Associated With Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:1083-1089. [PMID: 37556554 PMCID: PMC10843160 DOI: 10.1097/mat.0000000000002032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
We aimed to determine the association between cerebral regional oxygen saturation (rSO 2 ) trends from cerebral near-infrared spectroscopy (cNIRS) and acute brain injury (ABI) in adult venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. ABI was defined as intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, or brain death during ECMO. rSO 2 values were collected from left and right cerebral oximetry sensors every hour from ECMO cannulation. Cerebral desaturation was defined as consecutive hours of rSO 2 < 40%. rSO 2 asymmetry was determined by (a) averaging left/right rSO 2 difference over the entire ECMO run; (b) consecutive hours of rSO 2 asymmetry. Sixty-nine VA-ECMO patients (mean age 56 years, 65% male) underwent cNIRS. Eighteen (26%) experienced ABI. When the mean rSO 2 asymmetry was >8% there was significantly increased odds of ABI (aOR = 39.4; 95% CI = 4.1-381.4). Concurrent rSO 2 < 40% and rSO 2 asymmetry >10% for >10 consecutive hours (asymmetric desaturation) was also significantly associated with ABI (aOR = 5.2; 95% CI = 1.2-22.2), but neither criterion alone were. Mean rSO 2 asymmetry>8% exhibited 39% sensitivity and 98% specificity for detecting ABI, with an area under the curve (AUC) of 0.86, and asymmetric desaturation had 33% sensitivity and 88% specificity, with an AUC of 0.72. These trends on NIRS monitoring may help detect ABI in VA-ECMO patients.
Collapse
Affiliation(s)
- David Zhao
- From the Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Benjamin L Shou
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Giorgio Caturegli
- From the Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Glenn J R Whitman
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sung-Min Cho
- From the Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
16
|
Chen W, Pei M, Chen C, Wang B, Shi L, Qiu G, Duan W, Chen S, Wei Q, Zeng X, Pang H, Wei Y, Wu R, Zhu R, Ji Q, Lyu L. One-Year Survival for Developing Acute Kidney Injury in Adult Patients with AMI Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation. Int J Gen Med 2023; 16:4537-4548. [PMID: 37818108 PMCID: PMC10561759 DOI: 10.2147/ijgm.s427999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/13/2023] [Indexed: 10/12/2023] Open
Abstract
Objective The incidence of cardiogenic shock cases treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support has been on the rise. Acute kidney injury (AKI) is a significant complication of cardiogenic shock and a frequent serious complication in patients requiring ECMO-supported therapy. AKI is strongly associated with unfavorable patient prognosis. However, there is a paucity of data on the influence of AKI on the prognosis of patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) who are receiving ECMO support, particularly with regard to long-term outcomes. Methods This retrospective observational study included 103 patients in the People's Hospital of Guangxi Zhuang Autonomous Region from January 2017 and June 2022. AKI was defined according to Kidney Disease Improving Global Outcome (KDIGO) criteria. Cox regression and logistic regression were used to identify risk factors. Results In this study, the incidence of AKI was 63.11%, with AKI stage 1, 2, and 3 accounting for 21.36%, 12.62%, and 29.13%, respectively. Patients with severe AKI had significantly higher in-hospital mortality (43.33% vs 27.40%, P < 0.001), 30-day mortality (60.00% vs 31.51%, P = 0.001), and 1-year mortality (63.67% vs 34.25%, P<0.001) than those without severe AKI. Furthermore, severe AKI significantly increased the risk of one-year mortality (HR 10.816, CI 3.118-37.512, P<0.001). Baseline serum creatinine, baseline platelet, and active cardiopulmonary resuscitation were independent predictors of one-year mortality. In addition, baseline white blood cell count, baseline aspartate aminotransferase, baseline alanine aminotransferase (ALT), baseline serum creatinine, preoperative lactate, and postoperative mean arterial pressure were independent risk factors of severe AKI during hospitalization. Conclusion In patients with AMI-CS receiving ECMO support, AKI is highly prevalent. Development of severe AKI significantly increased the risk of one-year mortality.
Collapse
Affiliation(s)
- Wan Chen
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Mingyu Pei
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Chunxia Chen
- Department of Pharmacy, the People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
| | - Bo Wang
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Lei Shi
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Guozheng Qiu
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Wenlong Duan
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Shengxin Chen
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Qiao Wei
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Xi Zeng
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Huifeng Pang
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Yanlin Wei
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Ruihua Wu
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Ruikai Zhu
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| | - Qingwei Ji
- Department of Cardiovascular Medicine, The People’s Hospital of Guang Xi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guangxi Academy of Medical Sciences Nanning, Nanning, People’s Republic of China
| | - Liwen Lyu
- Department of Emergency, the People’s Hospital of Guangxi Zhuang Autonomous Region& Research Center of Cardiovascular Disease, Guang Xi Academy of Medical Sciences, Nanning, People’s Republic of China
| |
Collapse
|
17
|
Zhang LQ, Chang H, Kalra A, Humayun M, Rosenblatt KR, Shah VA, Geocadin RG, Brown CH, Kim BS, Whitman GJR, Rivera-Lara L, Cho SM. Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation. RESEARCH SQUARE 2023:rs.3.rs-3300834. [PMID: 37790309 PMCID: PMC10543291 DOI: 10.21203/rs.3.rs-3300834/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background Impaired cerebral autoregulation (CA) is one of several proposed mechanisms of acute brain injury in patients supported by extracorporeal membrane oxygenation (ECMO). The primary aim of this study was to determine the feasibility of continuous CA monitoring in adult ECMO patients. Our secondary aims were to describe changes in cerebral oximetry index (COx) and other metrics of CA over time and in relation to functional neurologic outcomes. Methods This is a single-center prospective observational study. We measured Cox, a surrogate measurement of cerebral blood flow, measured by near-infrared spectroscopy, which is an index of CA derived from the moving correlation between mean arterial pressure and slow waves of regional cerebral oxygen saturation. A COx value that approaches 1 indicates impaired CA. Using COx, we determined the optimal MAP (MAPOPT), lower and upper limits of autoregulation for individual patients. These measurements were examined in relation to modified Rankin Scale (mRS) scores. Results Fifteen patients (median age=57 years [IQR=47-69]) with 150 autoregulation measurements were included for analysis. Eleven were on veno-arterial ECMO and 4 on veno-venous. Mean COx was higher on post-cannulation day 1 than on day 2 (0.2 vs 0.09, p<0.01), indicating improved CA over time. COx was higher in VA-ECMO patients than in VV-ECMO (0.12 vs 0.06, p=0.04). Median MAPOPT for entire cohort was highly variable, ranging 55-110 mmHg. Patients with mRS 0-3 (good outcome) at 3 and 6 months spent less time outside of MAPOPT compared to patients with mRS 4-6 (poor outcome) (74% vs 82%, p=0.01). The percentage of time when observed MAP was outside the limits of autoregulation was higher on post-cannulation day 1 than on day 2 (18.2% vs 3.3%, p<0.01). Conclusions In ECMO patients, it is feasible to monitor CA continuously at the bedside. CA improved over time, most significantly between post-cannulation days 1 and 2. CA was more impaired in VA-ECMO than VV-ECMO. Spending less time outside of MAPOPT may be associated with achieving a good neurologic outcome.
Collapse
Affiliation(s)
- Lucy Q Zhang
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Henry Chang
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Andrew Kalra
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Mariyam Humayun
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Kathryn R Rosenblatt
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Vishank A Shah
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | | | - Charles H Brown
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Bo Soo Kim
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Glenn J R Whitman
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Lucia Rivera-Lara
- Stanford University Department of Neurology and Neurological Sciences
| | - Sung-Min Cho
- Johns Hopkins Department of Anesthesiology and Critical Care Medicine: Johns Hopkins Medicine Department of Anesthesiology and Critical Care Medicine
| |
Collapse
|
18
|
Thatch KA, Kays DW. Advances in pulmonary management and weaning from ECLS. Semin Pediatr Surg 2023; 32:151329. [PMID: 37866170 DOI: 10.1016/j.sempedsurg.2023.151329] [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: 10/24/2023]
Abstract
ECMO for neonatal and pediatric respiratory failure provides gas exchange to allow lung recovery from reversible pulmonary ailments. This is a comprehensive discussion on the various strategies and advances utilized by pediatric ECLS specialists today. ECMO patients require continual monitoring, serial gasses and radiographs, near-infrared spectroscopy (NIRS - to monitor oxygen delivery to regional tissue beds), and more quality ECLS directed care. As the foundation to lung recovery, good EMCO closely monitors ECLS flow rates, sweep gasses, and membrane lung function. Mixed venous oxygen saturation (Sv02) greater than 65% indicates good oxygen delivery and sweep gas adjustments maintain PaCO2 of 40-45 mm Hg. Lung recovery ventilatory settings do not fully rest the lungs but maintain normal or nontoxic pressure and oxygen levels. Neonatal recovery settings are PIP (cm H20) of 15-20, PEEP of 5-10, ventilator rate of 12-20 and an inspiratory time of 0.5-1 s, and FiO2 of 0.3-0.5. Pediatric recovery settings are PIP (cm H20) < 25, PEEP of 5-15, ventilator rate of 10-20 and an inspiratory time of 0.8-1 s, and FiO2 of <0.5. Some studies demonstrate a higher recovery PEEP level decreases duration of ECMO, but do not demonstrate a mortality difference. Multiple adjunctive therapies such as surfactant, routine pulmonary clearance and respiratory physiotherapy, iNO, prone positioning, bronchoscopy, POCUS, CT imaging, and extubation or "awake ECLS" can significantly affect pulmonary recovery. Patience is necessary as lung recovery may take weeks or even months on the nontoxic settings. On these settings, dynamic recovery will be revealed by improvement in tidal volume, minute ventilation and radiographic pulmonary aeration, prompting discussion about weaning. When this pulmonary compliance recovery becomes evident, decreasing ECLS flow while also decreasing circuit FiO2 and/or sweep gas are common components to ECMO weaning strategies.
Collapse
Affiliation(s)
- Keith A Thatch
- Department of Pediatric Surgery, John Hopkins All Children's Hospital, St. Petersburg, FL, USA.
| | - David W Kays
- Department of Pediatric Surgery, John Hopkins All Children's Hospital, St. Petersburg, FL, USA
| |
Collapse
|
19
|
Callier K, Dantes G, Johnson K, Linden AF. Pediatric ECLS Neurologic Management and Outcomes. Semin Pediatr Surg 2023; 32:151331. [PMID: 37944407 DOI: 10.1016/j.sempedsurg.2023.151331] [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: 11/12/2023]
Abstract
Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.
Collapse
Affiliation(s)
- Kylie Callier
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Kevin Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Allison F Linden
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| |
Collapse
|
20
|
Khanduja S, Kim J, Kang JK, Feng CY, Vogelsong MA, Geocadin RG, Whitman G, Cho SM. Hypoxic-Ischemic Brain Injury in ECMO: Pathophysiology, Neuromonitoring, and Therapeutic Opportunities. Cells 2023; 12:1546. [PMID: 37296666 PMCID: PMC10252448 DOI: 10.3390/cells12111546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), in conjunction with its life-saving benefits, carries a significant risk of acute brain injury (ABI). Hypoxic-ischemic brain injury (HIBI) is one of the most common types of ABI in ECMO patients. Various risk factors, such as history of hypertension, high day 1 lactate level, low pH, cannulation technique, large peri-cannulation PaCO2 drop (∆PaCO2), and early low pulse pressure, have been associated with the development of HIBI in ECMO patients. The pathogenic mechanisms of HIBI in ECMO are complex and multifactorial, attributing to the underlying pathology requiring initiation of ECMO and the risk of HIBI associated with ECMO itself. HIBI is likely to occur in the peri-cannulation or peri-decannulation time secondary to underlying refractory cardiopulmonary failure before or after ECMO. Current therapeutics target pathological mechanisms, cerebral hypoxia and ischemia, by employing targeted temperature management in the case of extracorporeal cardiopulmonary resuscitation (eCPR), and optimizing cerebral O2 saturations and cerebral perfusion. This review describes the pathophysiology, neuromonitoring, and therapeutic techniques to improve neurological outcomes in ECMO patients in order to prevent and minimize the morbidity of HIBI. Further studies aimed at standardizing the most relevant neuromonitoring techniques, optimizing cerebral perfusion, and minimizing the severity of HIBI once it occurs will improve long-term neurological outcomes in ECMO patients.
Collapse
Affiliation(s)
- Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Jiah Kim
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Cheng-Yuan Feng
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Melissa Ann Vogelsong
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Romergryko G. Geocadin
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| |
Collapse
|
21
|
Morris NA, Sarwal A. Neurologic Complications of Critical Medical Illness. Continuum (Minneap Minn) 2023; 29:848-886. [PMID: 37341333 DOI: 10.1212/con.0000000000001278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE This article reviews the neurologic complications encountered in patients admitted to non-neurologic intensive care units, outlines various scenarios in which a neurologic consultation can add to the diagnosis or management of a critically ill patient, and provides advice on the best diagnostic approach in the evaluation of these patients. LATEST DEVELOPMENTS Increasing recognition of neurologic complications and their adverse impact on long-term outcomes has led to increased neurology involvement in non-neurologic intensive care units. The COVID-19 pandemic has highlighted the importance of having a structured clinical approach to neurologic complications of critical illness as well as the critical care management of patients with chronic neurologic disabilities. ESSENTIAL POINTS Critical illness is often accompanied by neurologic complications. Neurologists need to be aware of the unique needs of critically ill patients, especially the nuances of the neurologic examination, challenges in diagnostic testing, and neuropharmacologic aspects of commonly used medications.
Collapse
|
22
|
Mainali S. Neurologic Complications of Cardiac and Pulmonary Disease. Continuum (Minneap Minn) 2023; 29:684-707. [PMID: 37341327 DOI: 10.1212/con.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE The heart and lungs work as a functional unit through a complex interplay. The cardiorespiratory system is responsible for the delivery of oxygen and energy substrates to the brain. Therefore, diseases of the heart and lungs can lead to various neurologic illnesses. This article reviews various cardiac and pulmonary pathologies that can lead to neurologic injury and discusses the relevant pathophysiologic mechanisms. LATEST DEVELOPMENTS We have lived through unprecedented times over the past 3 years with the emergence and rapid spread of the COVID-19 pandemic. Given the effects of COVID-19 on the lungs and heart, an increased incidence of hypoxic-ischemic brain injury and stroke associated with cardiorespiratory pathologies has been observed. Newer evidence has questioned the benefit of induced hypothermia in patients with out-of-hospital cardiac arrest. Further, global collaborative initiatives such as the Curing Coma Campaign are underway with the goal of improving the care of patients with coma and disorders of consciousness, including those resulting from cardiac and pulmonary pathologies. ESSENTIAL POINTS The neurologic complications of cardiorespiratory disorders are common and present in various forms such as stroke or hypoxic and anoxic injury related to cardiac or respiratory failure. With the emergence of the COVID-19 pandemic, neurologic complications have increased in recent years. Given the intimate and interdependent dynamics of the heart, lungs, and brain, it is crucial for neurologists to be aware of the interplay between these organs.
Collapse
|
23
|
Masi P, Bagate F, Tuffet S, Piscitelli M, Folliguet T, Razazi K, De Prost N, Carteaux G, Mekontso Dessap A. Dual titration of minute ventilation and sweep gas flow to control carbon dioxide variations in patients on venovenous extracorporeal membrane oxygenation. Ann Intensive Care 2023; 13:45. [PMID: 37225933 DOI: 10.1186/s13613-023-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The implantation of venovenous extracorporeal membrane oxygenation (VV-ECMO) support to manage severe acute respiratory distress syndrome generates large variations in carbon dioxide partial pressure (PaCO2) that are associated with intracranial bleeding. We assessed the feasibility and efficacy of a pragmatic protocol for progressive dual titration of sweep gas flow and minute ventilation after VV-ECMO implantation in order to limit significant PaCO2 variations. PATIENTS AND METHODS A protocol for dual titration of sweep gas flow and minute ventilation following VV-ECMO implantation was implemented in our unit in September 2020. In this single-centre retrospective before-after study, we included patients who required VV-ECMO from March, 2020 to May, 2021, which corresponds to two time periods: from March to August, 2020 (control group) and from September, 2020 to May, 2021 (protocol group). The primary endpoint was the mean absolute change in PaCO2 in consecutive arterial blood gases samples drawn over the first 12 h following VV-ECMO implantation. Secondary endpoints included large (> 25 mmHg) initial variations in PaCO2, intracranial bleedings and mortality in both groups. RESULTS Fifty-one patients required VV-ECMO in our unit during the study period, including 24 in the control group and 27 in the protocol group. The protocol was proved feasible. The 12-h mean absolute change in PaCO2 was significantly lower in patients of the protocol group as compared with their counterparts (7 mmHg [6-12] vs. 12 mmHg [6-24], p = 0.007). Patients of the protocol group experienced less large initial variations in PaCO2 immediately after ECMO implantation (7% vs. 29%, p = 0.04) and less intracranial bleeding (4% vs. 25%, p = 0.04). Mortality was similar in both groups (35% vs. 46%, p = 0.42). CONCLUSION Implementation of our protocol for dual titration of minute ventilation and sweep gas flow was feasible and associated with less initial PaCO2 variation than usual care. It was also associated with less intracranial bleeding.
Collapse
Affiliation(s)
- Paul Masi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France.
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France.
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France.
| | - François Bagate
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Mariantonietta Piscitelli
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Nicolas De Prost
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| |
Collapse
|
24
|
McDevitt WM, Farley M, Martin-Lamb D, Jones TJ, Morris KP, Seri S, Scholefield BR. Feasibility of non-invasive neuro-monitoring during extracorporeal membrane oxygenation in children. Perfusion 2023; 38:547-556. [PMID: 35212252 DOI: 10.1177/02676591211066804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Detection of neurological complications during extracorporeal membrane oxygenation (ECMO) may be enhanced with non-invasive neuro-monitoring. We investigated the feasibility of non-invasive neuro-monitoring in a paediatric intensive care (PIC) setting. METHODS In a single centre, prospective cohort study we assessed feasibility of recruitment, and neuro-monitoring via somatosensory evoked potentials (SSEP), electroencephalography (EEG) and near infrared spectroscopy (NIRS) during venoarterial (VA) ECMO in paediatric patients (0-15 years). Measures were obtained within 24h of cannulation, during an intermediate period, and finally at decannulation or echo stress testing. SSEP/EEG/NIRS measures were correlated with neuro-radiology findings, and clinical outcome assessed via the Pediatric cerebral performance category (PCPC) scale 30 days post ECMO cannulation. RESULTS We recruited 14/20 (70%) eligible patients (median age: 9 months; IQR:4-54, 57% male) over an 18-month period, resulting in a total of 42 possible SSEP/EEG/NIRS measurements. Of these, 32/42 (76%) were completed. Missed recordings were due to lack of access/consent within 24 h of cannulation (5/42, 12%) or PIC death/discharge (5/42, 12%). In each patient, the majority of SSEP (8/14, 57%), EEG (8/14, 57%) and NIRS (11/14, 79%) test results were within normal limits. All patients with abnormal neuroradiology (4/10, 40%), and 6/7 (86%) with poor outcome (PCPC ≥4) developed indirect SSEP, EEG or NIRS measures of neurological complications prior to decannulation. No study-related adverse events or neuro-monitoring data interpreting issues were experienced. CONCLUSION Non-invasive neuro-monitoring (SSEP/EEG/NIRS) during ECMO is feasible and may provide early indication of neurological complications in this high-risk population.
Collapse
Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Margaret Farley
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK
| | - Darren Martin-Lamb
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Timothy J Jones
- Department of Cardiac Surgery, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Stefano Seri
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK.,Aston Brain Centre, School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| |
Collapse
|
25
|
Cai J, Abudou H, Chen Y, Wang H, Wang Y, Li W, Li D, Niu Y, Chen X, Liu Y, Li Y, Liu Z, Meng X, Fan H. The effects of ECMO on neurological function recovery of critical patients: A double-edged sword. Front Med (Lausanne) 2023; 10:1117214. [PMID: 37064022 PMCID: PMC10098123 DOI: 10.3389/fmed.2023.1117214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/16/2023] [Indexed: 04/01/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) played an important role in the treatment of patients with critical care such as cardiac arrest (CA) and acute respiratory distress syndrome. ECMO is gradually showing its advantages in terms of speed and effectiveness of circulatory support, as it provides adequate cerebral blood flow (CBF) to the patient and ensures the perfusion of organs. ECMO enhances patient survival and improves their neurological prognosis. However, ECMO-related brain complications are also important because of the high risk of death and the associated poor outcomes. We summarized the reported complications related to ECMO for patients with CA, such as north–south syndrome, hypoxic–ischemic brain injury, cerebral ischemia–reperfusion injury, impaired intracranial vascular autoregulation, embolic stroke, intracranial hemorrhage, and brain death. The exact mechanism of ECMO on the role of brain function is unclear. Here we review the pathophysiological mechanisms associated with ECMO in the protection of neurologic function in recent years, as well as the ECMO-related complications in brain and the means to improve it, to provide ideas for the treatment of brain function protection in CA patients.
Collapse
Affiliation(s)
- Jinxia Cai
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Halidan Abudou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yuansen Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Haiwang Wang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yiping Wang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Wenli Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Duo Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanxiang Niu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Xin Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yongmao Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- *Correspondence: Ziquan Liu,
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- Xiangyan Meng,
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- Haojun Fan,
| |
Collapse
|
26
|
Cvetkovic M, Chiarini G, Belliato M, Delnoij T, Zanatta P, Taccone FS, Miranda DDR, Davidson M, Matta N, Davis C, IJsselstijn H, Schmidt M, Broman LM, Donker DW, Vlasselaers D, David P, Di Nardo M, Muellenbach RM, Mueller T, Barrett NA, Lorusso R, Belohlavek J, Hoskote A. International survey of neuromonitoring and neurodevelopmental outcome in children and adults supported on extracorporeal membrane oxygenation in Europe. Perfusion 2023; 38:245-260. [PMID: 34550013 DOI: 10.1177/02676591211042563] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Adverse neurological events during extracorporeal membrane oxygenation (ECMO) are common and may be associated with devastating consequences. Close monitoring, early identification and prompt intervention can mitigate early and late neurological morbidity. Neuromonitoring and neurocognitive/neurodevelopmental follow-up are critically important to optimize outcomes in both adults and children. OBJECTIVE To assess current practice of neuromonitoring during ECMO and neurocognitive/neurodevelopmental follow-up after ECMO across Europe and to inform the development of neuromonitoring and follow-up guidelines. METHODS The EuroELSO Neurological Monitoring and Outcome Working Group conducted an electronic, web-based, multi-institutional, multinational survey in Europe. RESULTS Of the 211 European ECMO centres (including non-ELSO centres) identified and approached in 23 countries, 133 (63%) responded. Of these, 43% reported routine neuromonitoring during ECMO for all patients, 35% indicated selective use, and 22% practiced bedside clinical examination alone. The reported neuromonitoring modalities were NIRS (n = 88, 66.2%), electroencephalography (n = 52, 39.1%), transcranial Doppler (n = 38, 28.5%) and brain injury biomarkers (n = 33, 24.8%). Paediatric centres (67%) reported using cranial ultrasound, though the frequency of monitoring varied widely. Before hospital discharge following ECMO, 50 (37.6%) reported routine neurological assessment and 22 (16.5%) routinely performed neuroimaging with more paediatric centres offering neurological assessment (65%) as compared to adult centres (20%). Only 15 (11.2%) had a structured longitudinal follow-up pathway (defined followup at regular intervals), while 99 (74.4%) had no follow-up programme. The majority (n = 96, 72.2%) agreed that there should be a longitudinal structured follow-up for ECMO survivors. CONCLUSIONS This survey demonstrated significant variability in the use of different neuromonitoring modalities during and after ECMO. The perceived importance of neuromonitoring and follow-up was noted to be very high with agreement for a longitudinal structured follow-up programme, particularly in paediatric patients. Scientific society endorsed guidelines and minimum standards should be developed to inform local protocols.
Collapse
Affiliation(s)
- Mirjana Cvetkovic
- Cardiac Intensive Care and ECMO, Great Ormond Street Hospital for Children NHS Foundation Trust & UCL Great Ormond Street Institute of Child Health, London, UK
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,2nd Intensive Care Unit, Spedali Civili, University of Brescia, Brescia, Italy
| | - Mirko Belliato
- Second Anaesthesia and Intensive Care Unit, S. Matteo Hospital, IRCCS, Pavia, Italy
| | - Thijs Delnoij
- Department of Cardiology and Department of Intensive Care Unit, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paolo Zanatta
- Anaesthesia and Multi-Speciality Intensive Care, Integrated University Hospital of Verona, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Bruxelles, Belgium
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Nashwa Matta
- Neonatal Unit, Princess Royal Maternity, Glasgow, Scotland
| | - Carl Davis
- Surgery Unit, Royal Hospital for Children, Glasgow, Scotland
| | - Hanneke IJsselstijn
- Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthieu Schmidt
- Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Dirk W Donker
- Intensive Care Center, University Medical Centre, Utrecht, The Netherlands
| | - Dirk Vlasselaers
- Department Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Piero David
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matteo Di Nardo
- Paediatric Intensive Care, Bambino Gesù Children's Hospital, Rome, Italy
| | - Ralf M Muellenbach
- Department of Anaesthesia and Intensive Care, Klinikum Kassel GmbH, Kassel, Germany
| | | | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital and 1st Medical School, Charles University in Prague, Praha, Czech Republic
| | - Aparna Hoskote
- Cardiac Intensive Care and ECMO, Great Ormond Street Hospital for Children NHS Foundation Trust & UCL Great Ormond Street Institute of Child Health, London, UK
| |
Collapse
|
27
|
Ohira S, Dhand A, Hirani R, Martinez S, Lanier GM, Levine A, Pan S, Aggarwal-Gupta C, Gass AL, Wolfe K, Spielvogel D, Kai M. Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation. Clin Transplant 2023; 37:e14871. [PMID: 36468757 DOI: 10.1111/ctr.14871] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/14/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal. METHODS From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). RESULTS Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA-ECMO cannulation-related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications. CONCLUSIONS Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.
Collapse
Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
| | - Abhay Dhand
- New York Medical College, Valhalla, New York, USA.,Transplant Infectious Disease, Department of Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Rahim Hirani
- New York Medical College, Valhalla, New York, USA
| | | | - Gregg M Lanier
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Avi Levine
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Stephen Pan
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Chhaya Aggarwal-Gupta
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Alan L Gass
- New York Medical College, Valhalla, New York, USA.,Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Kevin Wolfe
- Division of Data Compliance, Transplant Services, Westchester Medical Center, Valhalla, New York, USA
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, Valhalla, New York, USA.,New York Medical College, Valhalla, New York, USA
| |
Collapse
|
28
|
Kohli G, George DD, Grenga A, Santangelo G, Gosev I, Schartz D, Kessler A, Khan I, Barrus B, Gu Y, Bhalla T, Mattingly TK, Bender MT. Mechanical Thrombectomy for Ischemic Stroke Secondary to Large Vessel Occlusions in Patients on Extracorporeal Membrane Oxygenation. Cerebrovasc Dis 2023; 52:532-538. [PMID: 36716722 DOI: 10.1159/000528218] [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: 07/03/2022] [Accepted: 10/20/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The use of short-term mechanical circulatory support (MCS) devices and procedures for function- and life-sustaining therapy is becoming a routine practice at many centers. Concomitant with the increasing use of MCS is the increasing recognition of acute brain injuries, including acute ischemic stroke, which may be caused by a myriad of MCS-driven factors. The aim of this case series was to document our experience with mechanical thrombectomy (MT) for ischemic stroke in extracorporeal membrane oxygenation (ECMO) patients. METHODS We retrospectively reviewed a prospectively maintained database of patients undergoing endovascular thrombectomy for large vessel occlusion at our institution. We identified patients that were on ECMO and underwent thrombectomy. Baseline demographics and procedural and functional outcomes were collected. RESULTS Three patients on ECMO were identified to have a large vessel occlusion and underwent thrombectomy. Two patients had an internal carotid artery terminus occlusion and one had a basilar artery occlusion. An mTICI 3 recanalization was achieved in all patients without postoperative hemorrhagic complications. Two patients achieved a 3-month mRS of 1, while one had mRS 4. CONCLUSION Ischemic stroke can be associated with significant morbidity in MCS patients. We demonstrate that MT can be safely performed in this patient population with good outcomes.
Collapse
Affiliation(s)
- Gurkirat Kohli
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Derek D George
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Audrey Grenga
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Gabrielle Santangelo
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Imad Khan
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Bryan Barrus
- Baptist Health Cardiothoracic Surgery Clinic, Little Rock, Arkansas, USA
| | - Yang Gu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| |
Collapse
|
29
|
Shi X, Zhang L, Zeng X, Li Y, Hu W, Xi S. NEUROLOGIC IMPAIRMENT IN PATIENTS WITH EXTRACORPOREAL CARDIOPULMONARY RESUSCITATION SUPPORT: CLINICAL FEATURES AND LONG-TERM OUTCOMES. Shock 2023; 59:41-48. [PMID: 36703277 DOI: 10.1097/shk.0000000000002041] [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: 01/28/2023]
Abstract
ABSTRACT Introduction: The present study aimed to explore the clinical features and long-term outcomes associated with neurologic impairment in patients with cardiac arrest (CA) who received extracorporeal cardiopulmonary resuscitation (ECPR). Methods: A total of 37 adult CA patients who underwent venoarterial extracorporeal membrane oxygenation and were admitted to our department between January 2015 and February 2022 were divided according to neurologic impairment. Baseline and CPR- and ECMO-related characteristics were compared between the two groups. Long-term neurologic outcomes were collected via telephone follow-ups. Results: Twenty-four (64.9%) ECPR-supported patients developed neurologic impairments. The two groups differed significantly in median age (P = 0.026), proportion of intra-aortic balloon pump (IABP) support (P = 0.011), proportion of continuous renal replacement therapy (P = 0.025), and median serum creatinine (Cr) level (P = 0.012) pre-ECMO. The 28-day mortality (P = 0.001), hospital mortality (P = 0.003), median duration from CA to restoration of spontaneous circulation (P = 0.029), proportion of patients with nonpulsatile perfusion (NP) >12 hours (P = 0.040), and median ECMO duration (P = 0.047) were higher in the neurologic impairment group. In contrast, the group without neurologic impairment exhibited a longer median intensive care unit length of stay (P = 0.047), longer median hospital LOS (P = 0.031), and more successful ECMO weaning (P = 0.049). Moreover, NP >12 hours combined with IABP support (odds ratio [OR], 14.769; 95% confidence interval [CI], 1.417~153.889; P = 0.024) and serum Cr level (OR, 1.028; 95% CI, 1.001~1.056; P = 0.043) were independent risk factors for neurologic impairment. Furthermore, neurologic impairment was associated with significantly worse 90-day survival (hazards ratio, 4.218; 95% CI, 1.745~10.2; P = 0.0014). Conclusions: The incidence of neurologic impairment was higher in patients who received ECPR and was closely related to 28-day mortality and discharge survival. NP >12 hours combined with IABP support and serum Cr levels were independent risk factors for neurologic impairments in ECPR-supported patients. Neurologic impairment significantly adversely affected the long-term outcomes of ECPR-supported patients after discharge.
Collapse
Affiliation(s)
- Xiaobei Shi
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lili Zhang
- Intensive Care Unit, Beijing First Hospital of Integrated Chinese and Western Medicine, Beijing, China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yiwei Li
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| |
Collapse
|
30
|
Characterization of Cerebral Hemodynamics with TCD in Patients Undergoing VA-ECMO and VV-ECMO: a Prospective Observational Study. Neurocrit Care 2022; 38:407-413. [PMID: 36510107 PMCID: PMC9744662 DOI: 10.1007/s12028-022-01653-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation has a high risk of acute brain injury and resultant mortality. Transcranial Doppler characterizes cerebral hemodynamics in real time, but limited data exist on its interpretation in ECMO. Here, we report TCD mean flow velocity and pulsatility index in a large ECMO population. METHODS This was a prospective cohort study at a tertiary care center. The patients were adults on venoarterial ECMO or venovenous ECMO undergoing TCD studies. RESULTS A total of 135 patients underwent a total of 237 TCD studies while on VA-ECMO (n = 95, 70.3%) or VV-ECMO (n = 40, 29.6%). MFVs were captured reliably (approximately 90%) and were similar to a published healthy cohort in all vessels except the internal carotid artery. Presence of a recordable PI was strongly associated with ECMO mode (57% in VA vs. 95% in VV, p < 0.001). Absence of TCD pulsatility was associated with intraparenchymal hemorrhage (14.7 vs. 1.6%, p = 0.03) in VA-ECMO patients. CONCLUSIONS Transcranial Doppler analysis in a single-center cohort of VA-ECMO and VV-ECMO patients demonstrates similar MFVs and PIs. Absence of PIs was associated with a higher frequency of intraparenchymal hemorrhage and a composite bleeding event. However, cautious interpretation and external validation is necessary for these findings with a multicenter study with a larger sample size.
Collapse
|
31
|
Complications Associated With Venovenous Extracorporeal Membrane Oxygenation-What Can Go Wrong? Crit Care Med 2022; 50:1809-1818. [PMID: 36094523 DOI: 10.1097/ccm.0000000000005673] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Despite increasing use and promising outcomes, venovenous extracorporeal membrane oxygenation (V-V ECMO) introduces the risk of a number of complications across the spectrum of ECMO care. This narrative review describes the variety of short- and long-term complications that can occur during treatment with ECMO and how patient selection and management decisions may influence the risk of these complications. DATA SOURCES English language articles were identified in PubMed using phrases related to V-V ECMO, acute respiratory distress syndrome, severe respiratory failure, and complications. STUDY SELECTION Original research, review articles, commentaries, and published guidelines from the Extracorporeal Life support Organization were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS Selecting patients for V-V ECMO exposes the patient to a number of complications. Adequate knowledge of these risks is needed to weigh them against the anticipated benefit of treatment. Timing of ECMO initiation and transfer to centers capable of providing ECMO affect patient outcomes. Choosing a configuration that insufficiently addresses the patient's physiologic deficit leads to consequences of inadequate physiologic support. Suboptimal mechanical ventilator management during ECMO may lead to worsening lung injury, delayed lung recovery, or ventilator-associated pneumonia. Premature decannulation from ECMO as lungs recover can lead to clinical worsening, and delayed decannulation can prolong exposure to complications unnecessarily. Short-term complications include bleeding, thrombosis, and hemolysis, renal and neurologic injury, concomitant infections, and technical and mechanical problems. Long-term complications reflect the physical, functional, and neurologic sequelae of critical illness. ECMO can introduce ethical and emotional challenges, particularly when bridging strategies fail. CONCLUSIONS V-V ECMO is associated with a number of complications. ECMO selection, timing of initiation, and management decisions impact the presence and severity of these potential harms.
Collapse
|
32
|
Sakibuzzaman M, Hassan A, Hayee S, Haque FA, Bushra SS, Maliha M, Tania MK, Sadat A, Akter F, Mazumder T, Razzaque J, Kapuria P, Jalal I, Shah-Riar P. Exacerbation of Pre-existing Neurological Symptoms With COVID-19 in Patients With Chronic Neurological Diseases: An Updated Systematic Review. Cureus 2022; 14:e29297. [PMID: 36277564 PMCID: PMC9578565 DOI: 10.7759/cureus.29297] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 01/08/2023] Open
Abstract
The neurotropism of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can potentially explain the worsening of symptoms in patients with a history of neurological conditions such as stroke, Parkinson's disease, Alzheimer's, and epilepsy. Several studies have reported that these pre-existing conditions may worsen with a higher frequency of flare-ups, thus resulting in a more significant risk of patient mortality. In this review, we sought to provide an overview of the relationship between pre-existing neurological disorders and COVID-19, focusing on whether the initial infection directly influenced the severity of symptoms. We systematically searched the electronic database PubMed (MEDLINE) and used specific keywords related to our aims from January 2020 to July 2022. All articles published on COVID-19 with keywords pertaining to pre-existing neurological diseases were retrieved and subsequently analyzed. After independent review, the data from 107 articles were selected and evaluated. After analyzing the data from selected articles reviewing the effect of COVID-19 on neurological conditions, we have documented the relationship between said pre-existing neurological diseases, showing an increased risk of hospitalization, admission length, worsening of symptoms, and even mortality in COVID-19 patients.
Collapse
|
33
|
Ratay CR, Doshi AA, Steinberg A, Kaczorowski D, Phillips DP, Rhinehart ZJ, Fozard J, Rivosecchi RM, Schatz KW, Bahl KD, Schwarm P, Coppler PJ. Amiodarone induced movement disorder after cardiac arrest – A case report. Resusc Plus 2022; 11:100272. [PMID: 35832320 PMCID: PMC9272379 DOI: 10.1016/j.resplu.2022.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
We describe a case of new onset movement disorder in a patient with ventricular tachycardia storm supported with peripheral VA ECMO. The differential diagnosis of abnormal movements in a post cardiac arrest patient requiring temporary mechanical circulatory support for cardiogenic shock is explored.
Collapse
Affiliation(s)
- Cecelia R. Ratay
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Corresponding author at: Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15213, USA.
| | - Ankur A. Doshi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexis Steinberg
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine Pittsburgh, PA, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dennis P. Phillips
- Departments of Anesthesiology-Cardiothoracic Division and Critical Care Medicine Excela Medical Center, Greensburg, PA, USA
| | - Zachary J. Rhinehart
- Department of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jessica Fozard
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine Pittsburgh, PA, USA
| | - Ryan M. Rivosecchi
- Department of Pharmacy and Therapeutics, University of Pittsburgh Medical Center, PA, USA
| | - Kimberly W. Schatz
- Department of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katherine D. Bahl
- Department of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Paul Schwarm
- UPMC Presbyterian Hospital, Cardiothoracic Intensive Care Unit, Pittsburgh, PA, USA
| | - Patrick J. Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
34
|
Transcranial Doppler microemboli and acute brain injury in extracorporeal membrane oxygenation: A prospective observational study. JTCVS Tech 2022; 15:111-122. [PMID: 36276670 PMCID: PMC9579875 DOI: 10.1016/j.xjtc.2022.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/14/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Extracorporeal membrane oxygenation (ECMO) carries a high morbidity of acute brain injury (ABI) with resultant mortality increase. Transcranial Doppler (TCD) allows real-time characterization of regional cerebral hemodynamics, but limited data exist on the interpretation of microembolic signals (MES) in ECMO. Methods This prospective cohort study was conducted at a single tertiary care center, November 2017 through February 2022, and included all adult patients receiving venoarterial (VA) and venovenous (VV) ECMO undergoing TCD examinations, which all included MES monitoring. Results Of 145 patients on ECMO who underwent at least 1 TCD examination, 100 (68.9%) patients on VA-ECMO received 187 examinations whereas 45 (31.1%) patients on VV-ECMO received 65 examinations (P = .81). MES were observed in 35 (35.0%) patients on VA-ECMO and 2 (4.7%) patients on VV-ECMO (P < .001), corresponding to 46 (24.6%) and 2 (3.1%) TCD examinations, respectively. MES were present in 29.4% of patients on VA-ECMO without additional cardiac support, compared with 38.1% with intra-aortic balloon pump and 57.1% with left ventricular assist device, but these differences were not statistically significant (P = .39; P = .20, respectively). Presence or number of MES was not associated with VA-ECMO cannulation mode (23.4% MES presence in peripheral cannulation vs 25.8% in central cannulation, P = .80). In both VA- and VV-ECMO, MES presence or number was not associated with presence of clot or fibrin in the ECMO circuit or with any studied hemodynamic, laboratory, or ECMO parameters at the time of TCD. ABI occurred in 38% and 31.1% of patients on VA- and VV-ECMO, respectively. In multivariable logistic regression analyses, neither ABI nor a composite outcome of arterial thromboembolic events was associated with presence or number of MES in VA- ECMO. Conclusions TCD analysis in a large cohort of patients on ECMO demonstrates a significant number of MES, especially in patients on VA-ECMO with intra-aortic balloon pump, and/or left ventricular assist device. However, clinical associations and significance of TCD MES remain unresolved and warrant further correlation with systematic imaging and long-term neurologic follow-up.
Collapse
|
35
|
Focused Management of Patients With Severe Acute Brain Injury and ARDS. Chest 2022; 161:140-151. [PMID: 34506794 PMCID: PMC8423666 DOI: 10.1016/j.chest.2021.08.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/04/2021] [Accepted: 08/25/2021] [Indexed: 02/04/2023] Open
Abstract
Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. Although there are trials and guidelines to support the mainstays of treatment for ARDS and sABI independently, guidance on concomitant management is limited. Treatment strategies aimed at managing severe ARDS may at times conflict with the management of sABI. In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.
Collapse
|
36
|
Wang M, Li L, Tan YD. Transcranial Doppler Ultrasound for Monitoring the Cerebral Hemodynamic Changes and Prognosticating Outcomes in Venoarterial Extracorporeal Membrane-Oxygenated Patients. Int J Clin Pract 2022; 2022:2912477. [PMID: 36052306 PMCID: PMC9423977 DOI: 10.1155/2022/2912477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/05/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) support may have cerebral hemodynamic changes whose impact on patient outcome are not fully elucidated. This study aims to evaluate the correlation between cerebral hemodynamic changes and prognostic outcome in patients during VA-ECMO. METHODS Transcranial Doppler (TCD) ultrasound examination was performed to attain the systolic velocity (Vs), diastolic velocity (Vd), mean velocity (Vm), and pulsatility index (PI) of patients undergoing VA-ECMO. Cardiac ultrasound was also performed to assess the correlation between the left ventricular outflow tract velocity time integral (LVOT VTI), left ventricular ejection fraction (LVEF), and middle cerebral artery (MCA) with the systolic peak. Moreover, we assessed the predictive value of LVOT VTI and LVEF in patients with the systolic peak. Patients were divided into survival and death groups according to the 28-day survival period. Clinical data were compared between the two groups to investigate the effects of cerebral hemodynamic changes on the prognosis of VA-ECMO patients. RESULTS We found that the patient's LVOT VTI and LVEF had high predictive values for the systolic peak of the right middle cerebral artery. The initial LVEF, Vs, Vd and PI, and lactate level as well as the MODS incidence rate difference were significantly different between the survival and death groups. In addition, the results showed that the initial Vs value was an independent risk factor for the prognosis of patients undergoing VA-ECMO. CONCLUSIONS Cerebral hemodynamic changes may occur in patients supported by VA-ECMO. In addition, a poor cerebral arterial pulsatile blood flow was closely correlated with an unfavorable outcome in these patients.
Collapse
Affiliation(s)
- Man Wang
- Emergency Department, Guigang City People's Hospital, Guigang 537100, Guangxi Zhuang Autonomous Region, China
| | - Le Li
- Emergency Department, Guigang City People's Hospital, Guigang 537100, Guangxi Zhuang Autonomous Region, China
| | - Yi-Dong Tan
- Emergency Department, Guigang City People's Hospital, Guigang 537100, Guangxi Zhuang Autonomous Region, China
| |
Collapse
|
37
|
Beck K, Vincent A, Cam H, Becker C, Gross S, Loretz N, Müller J, Amacher SA, Bohren C, Sutter R, Bassetti S, Hunziker S. Medical futility regarding cardiopulmonary resuscitation in in-hospital cardiac arrests of adult patients: A systematic review and Meta-analysis. Resuscitation 2021; 172:181-193. [PMID: 34896244 DOI: 10.1016/j.resuscitation.2021.11.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/29/2021] [Indexed: 11/19/2022]
Abstract
AIM For some patients, survival with good neurologic function after cardiopulmonary resuscitation (CPR) is highly unlikely, thus CPR would be considered medically futile. Yet, in clinical practice, there are no well-established criteria, guidelines or measures to determine futility. We aimed to investigate how medical futility for CPR in adult patients is defined, measured, and associated with do-not-resuscitate (DNR) code status as well as to evaluate the predictive value of clinical risk scores through meta-analysis. METHODS We searched Embase, PubMed, CINAHL, and PsycINFO from the inception of each database up to January 22, 2021. Data were pooled using a fixed-effects model. Data collection and reporting followed the PRISMA guidelines. RESULTS Thirty-one studies were included in the systematic review and 11 in the meta-analysis. Medical futility defined by risk scores was associated with a significantly higher risk of in-hospital mortality (5 studies, 3102 participants with Pre-Arrest Morbidity (PAM) and Prognosis After Resuscitation (PAR) score; overall RR 3.38 [95% CI 1.92-5.97]) and poor neurologic outcome/in-hospital mortality (6 studies, 115,213 participants with Good Outcome Following Attempted Resuscitation (GO-FAR) and Prediction of Outcome for In-Hospital Cardiac Arrest (PIHCA) score; RR 6.93 [95% CI 6.43-7.47]). All showed high specificity (>90%) for identifying patients with poor outcome. CONCLUSION There is no international consensus and a lack of specific definitions of CPR futility in adult patients. Clinical risk scores might aid decision-making when CPR is assumed to be futile. Future studies are needed to assess their clinical value and reliability as a measure of futility regarding CPR.
Collapse
Affiliation(s)
- Katharina Beck
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Alessia Vincent
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Missionsstrasse 60/62, 4055 Basel, Switzerland
| | - Hasret Cam
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Department of Emergency Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Nina Loretz
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Jonas Müller
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Simon A Amacher
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Clinic of Intensive Care, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Chantal Bohren
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Raoul Sutter
- Clinic of Intensive Care, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Medical Faculty, University of Basel, Klingelbergstrasse 61, 4031 Basel, Switzerland; Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Medical Faculty, University of Basel, Klingelbergstrasse 61, 4031 Basel, Switzerland.
| |
Collapse
|
38
|
Ko JY, Lee MR, Ha EH, Kim A. Peripheral neuropathy after extra-corporeal membrane oxygenation therapy in children: A case report. Medicine (Baltimore) 2021; 100:e27735. [PMID: 34766582 PMCID: PMC10545386 DOI: 10.1097/md.0000000000027735] [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: 09/14/2021] [Revised: 10/14/2021] [Accepted: 10/22/2021] [Indexed: 11/25/2022] Open
Abstract
RATIONALE In recent years, the use of extracorporeal membrane oxygenation (ECMO) treatment for pediatric patients with cardiorespiratory failure has increased, with emphasis being given to the prevention of complications in ECMO-treated patients. Several studies have reported ECMO-related central nervous system complications, such as intracranial hemorrhage, cerebral infarction, and seizure. However, few cases of peripheral nerve injury have been reported in ECMO-treated adults; there have also been no reported cases of peripheral nerve injury in the pediatric population. PATIENT CONCERNS Two pediatric patients aged 16 and 6 experienced motor weakness in the extremities after the insertion of ECMO equipment. DIAGNOSES They were diagnosed with peripheral nerve injuries through an electrodiagnostic study that showed femoral/sciatic neuropathies and brachial plexopathy. Arteriography and doppler sonography was performed to find the cause of peripheral nerve injury, and this may be the results of vascular compromise and compressive injuries, respectively. INTERVENTIONS Surgical embolectomy was performed to remove thrombus in one patient. Two patients received orthosis, and physical therapy and occupational therapy were performed to prevent contracture and improve strength and functional use. OUTCOMES Two pediatric patients showed a gradual improvement in motor power and function. LESSONS Through this case report, we present rare ECMO-related complications and emphasize the importance of early diagnosis and monitoring of peripheral nerve injury in ECMO-treated children.
Collapse
Affiliation(s)
- Jun Young Ko
- Department of Rehabilitation Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Mi rim Lee
- Department of Rehabilitation Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Eun-Hye Ha
- Division of Pulmonary and Critical Care Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Aram Kim
- Department of Rehabilitation Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| |
Collapse
|
39
|
Layman AJ, Lin PT. Extracorporeal membrane oxygenation in the forensic setting: A series of 19 forensic cases. J Forensic Sci 2021; 67:243-250. [PMID: 34741312 DOI: 10.1111/1556-4029.14918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/04/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) employs vascular cannulation and a gas exchange circuit to provide support to patients with severely compromised cardiopulmonary function. ECMO is often the last intervention taken before death and thus presents a unique challenge to medical examiners. This study describes the characteristics of decedents on ECMO at the time of death, including clinical indications, types of circuit configurations, causes and manners of death, gross findings at autopsy, and therapeutic complications. Files of a regional medical examiner office within an academic medical center were searched for the period between 2013 and 2019. Nineteen cases were identified with a median age of 36 years. The circumstances surrounding the initial presentation included: sudden death, trauma, substance abuse, homicide, therapeutic complication, work-related injury, drowning, and hypothermia. The underlying causes of death included injury-related, as well as respiratory and cardiac-related natural diseases. The time spent on ECMO varied from less than 1 h to 10 months. Complications encountered due to ECMO included cannulation site bleeding, pneumohemopericardium, retroperitoneal hematoma, limb ischemia, clotting, and cannula dislodgement. The patient population likely to receive ECMO has significant overlap with death circumstances likely to be reported to the medical examiner. As ECMO therapy has become increasingly available, it is of importance for medical examiners and death investigators to be familiar with the procedure as well as its limitations. Familiarity with ECMO and its sequelae allows for the proper documentation of postmortem findings and fosters an informed determination of the cause and manner of death.
Collapse
Affiliation(s)
- Andrew J Layman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter T Lin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Southern Minnesota Regional Medical Examiner Office, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
40
|
Cho SM, Choi CW, Whitman G, Suarez JI, Martinez NC, Geocadin RG, Ritzl EK. Neurophysiological Findings and Brain Injury Pattern in Patients on ECMO. Clin EEG Neurosci 2021; 52:462-469. [PMID: 31823652 DOI: 10.1177/1550059419892757] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction. Brain injury is a major determinant of outcomes in extracorporeal membrane oxygenation (ECMO). Neurologic prognostication in ECMO has not been established. Absent electroencephalogram (EEG) reactivity and absent N20 on somatosensory evoked potential (SSEP) are associated with poor outcome in other types of brain injuries, especially following cardiopulmonary arrest. It is currently known if the same criteria are applicable in patients on ECMO. Methods. Continuous EEG (cEEG) was performed for patients with a Glasgow Coma Scale (GCS) <8 and SSEP data were performed for patients with a motor GCS < 4 in a prospective observational cohort undergoing ECMO at a tertiary center. EEG variables including reactivity were collected. SSEPs were categorized into absence, delay, or presence of N20. Poor outcome was defined as cerebral performance category 3 to 5 at discharge. Results. We present 13 consecutive patients who underwent both cEEG and SSEP. The median time from cannulation to EEG and SSEP were 3 (interquartile range [IQR] = 1-6) and 5 (IQR = 2-7) days, respectively. All patients were in coma and 12 (92%) had poor outcomes. Ten (77%) underwent brain computed tomography, the findings of which explained coma in only 2. Patients (n = 12) with poor outcome had poor variability, absent reactivity, and lack of sleep features with diffusely slow theta-delta background on the EEG. Despite poor outcomes, all had relatively preserved or normal N20 responses. One patient with preserved reactivity and sleep features on the EEG and intact SSEP had a good outcome. Conclusions. Absent EEG reactivity with the preservation of SSEP N20 was associated with poor outcome in comatose ECMO patients. We advise caution in interpreting electrophysiological tests in prognosticating ECMO patients until the patterns and outcomes are better understood.
Collapse
Affiliation(s)
- Sung-Min Cho
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Chun Woo Choi
- Cardiovascular Surgical Intensive Care, Heart and Vascular Institute, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Glenn Whitman
- Cardiovascular Surgical Intensive Care, Heart and Vascular Institute, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nirma Carballido Martinez
- Continuous Video EEG Service, Department of Neurology, School of Medicine, John Hopkins University, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Eva K Ritzl
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Continuous Video EEG Service, Department of Neurology, School of Medicine, John Hopkins University, Baltimore, MD, USA.,Intraoperative Monitoring Service, Department of Neurology, School of Medicine, John Hopkins University, Baltimore, MD, USA
| |
Collapse
|
41
|
Drewniak D, Brandi G, Buehler PK, Steiger P, Hagenbuch N, Stamm-Balderjahn S, Schenk L, Rosca A, Krones T. Key Factors in Decision Making for ECLS: A Binational Factorial Survey. Med Decis Making 2021; 42:313-325. [PMID: 34693802 PMCID: PMC8918869 DOI: 10.1177/0272989x211040815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Extracorporeal life support (ECLS) provides support to patients with cardiopulmonary failure refractory to conventional therapy. While ECLS is potentially life-saving, it is associated with severe complications; decision making to initiate ECLS must, therefore, carefully consider which patients ECLS potentially benefits despite its consequences. Objective To answer 2 questions: First, which medically relevant patient factors influence decisions to initiate ECLS? Second, what are factors relevant to decisions to withdraw a running ECLS treatment? Methods We conducted a factorial survey among 420 physicians from 111 hospitals in Switzerland and Germany. The study included 2 scenarios: 1 explored willingness to initiate ECLS, and 1 explored willingness to withdraw a running ECLS treatment. Each participant responded to 5 different vignettes for each scenario. Vignettes were analyzed using mixed-effects regression models with random intercepts. Results Factors in the vignettes such as patients’ age, treatment costs, therapeutic goal, comorbidities, and neurological outcome significantly influenced the decision to initiate ECLS. When it came to the decision to withdraw ECLS, patients’ age, days on ECLS, criteria for discontinuation, condition of the patient, comorbidities, and neurological outcome were significant factors. In both scenarios, patients’ age and neurological outcome were the most influential factors. Conclusions This study provided insights into physicians’ decision making processes about ECLS initiation and withdrawal. Patients’ age and neurological status were the strongest factors influencing decisions regarding initiation of ECLS as well as for ECLS withdrawal. The findings may contribute to a more refined understanding of complex decision making for ECLS.
Collapse
Affiliation(s)
- Daniel Drewniak
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Giovanna Brandi
- IInstitute of Intensive Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Karl Buehler
- IInstitute of Intensive Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Peter Steiger
- IInstitute of Intensive Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Niels Hagenbuch
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Sabine Stamm-Balderjahn
- IInstitute of Medical Sociology and Rehabilitation Science, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Liane Schenk
- IInstitute of Medical Sociology and Rehabilitation Science, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ana Rosca
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Tanja Krones
- IInstitute of Biomedical Ethics and History of Medicine, Clinical Ethics Unit, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
42
|
Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
| |
Collapse
|
43
|
Affiliation(s)
- Andrew J Doyle
- Centre for Thrombosis & Haemostasis, Department of Haematology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Andrew Retter
- Centre for Thrombosis & Haemostasis, Department of Haematology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
44
|
Zhang H, Xu J, Yang X, Zou X, Shu H, Liu Z, Shang Y. Narrative Review of Neurologic Complications in Adults on ECMO: Prevalence, Risks, Outcomes, and Prevention Strategies. Front Med (Lausanne) 2021; 8:713333. [PMID: 34660625 PMCID: PMC8513760 DOI: 10.3389/fmed.2021.713333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/02/2021] [Indexed: 01/18/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.
Collapse
Affiliation(s)
- Hongling Zhang
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
45
|
Hou D, Wang H, Yang F, Hou X. Neurologic Complications in Adult Post-cardiotomy Cardiogenic Shock Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Cohort Study. Front Med (Lausanne) 2021; 8:721774. [PMID: 34458294 PMCID: PMC8385654 DOI: 10.3389/fmed.2021.721774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study aims to describe the prevalence of neurologic complications and hospital outcome in adult post-cardiotomy cardiogenic shock (PCS) patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support and factors associated with such adverse events. Methods: Four hundred and fifteen adult patients underwent cardiac surgery and received V-A ECMO for more than 24 h because of PCS. Patients were divided into two groups: those who developed a neurological complication and those who did not (control group). Multivariable logistic regression was performed to identify factors independently associated with neurologic complications. Results: Neurologic complications occurred in 87 patients (21.0%), including cerebral infarction in 33 patients (8.0%), brain death in 30 patients (7.2%), seizures in 14 patients (3.4%), and intracranial hemorrhage in 11 (2.7%) patients. In-hospital mortality in patients with neurologic complications was 90.8%, compared to 52.1% in control patients (p < 0.001). In a multivariable model, the lowest systolic blood pressure (SBP) level pre-ECMO (OR, 0.89; 95% CI: 0.86–0.93) and aortic surgery combined with coronary artery bypass grafting (OR, 9.22; 95% CI: 2.10–40.55) were associated with overall neurologic complications. Age (OR, 1.06; 95% CI: 1.01–1.12) and lowest SBP (OR, 0.81; 95% CI: 0.76–0.87) were correlative factors of brain death. Coagulation disorders (OR, 9.75; 95% CI: 1.83–51.89) and atrial fibrillation (OR, 12.19; 95% CI: 1.22–121.61) were shown to be associated independently with intracranial hemorrhage, whereas atrial fibrillation (OR, 8.15; 95% CI: 1.31–50.62) was also associated with cerebral infarction. Conclusions: Neurologic complications in adult PCS patients undergoing V-A ECMO support are frequent and associated with higher in-hospital mortality. Identified risk factors of neurologic complications might help to improve ECMO management and might reduce their occurrence.
Collapse
Affiliation(s)
- Dengbang Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
46
|
|
47
|
Abstract
OBJECTIVES To describe the incidence and outcomes of radiologically confirmed acute CNS complications in extracorporeal membrane oxygenation patients at an Australian extracorporeal membrane oxygenation referral center and identify associated patient characteristics. DESIGN Retrospective cohort study. SETTING Single-center tertiary institution. PATIENTS Four-hundred twelve consecutive adult patients supported with extracorporeal membrane oxygenation from 2009 to 2017. RESULTS Fifty-five patients (13.3%) had a CNS complication confirmed by CT or MRI, including ischemic stroke (7.0%), intracerebral hemorrhage (3.4%), hypoxic ischemic encephalopathy (3.6%), and spinal cord injury (1.2%). CNS complication rates in the venoarterial, venovenous, and veno-pulmonary artery extracorporeal membrane oxygenation subgroups were 18.0%, 4.6%, and 13.6%, respectively. Neurologic complications were independently associated with the use of venoarterial extracorporeal membrane oxygenation (p = 0.002) and renal replacement therapy (p = 0.04). Sixty-five percent of patients with a neurologic complication died during their hospital admission compared with 32% of patients without this complication (p < 0.001). Venoarterial extracorporeal membrane oxygenation, renal replacement therapy, and days of extracorporeal membrane oxygenation support were also associated with hospital mortality and remained so after adjustment in a multivariable regression model (p = 0.01, p < 0.001, and p = 0.003, respectively). CONCLUSIONS CNS complications appear to occur more frequently in patients requiring circulatory as opposed to respiratory support on extracorporeal membrane oxygenation and are independently associated with mortality. It remains unclear if these complications are causative of a poor outcome or a marker of severity of the underlying condition. Further research is required to better elucidate modifiable or preventable aspects through better patient selection and change in ongoing care.
Collapse
|
48
|
Kaso ER, Pan JA, Salerno M, Kadl A, Aldridge C, Haskal ZJ, Kennedy JLW, Mazimba S, Mihalek AD, Teman NR, Giri J, Aronow HD, Sharma AM. Venoarterial Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Embolism: a Meta-Analysis and Call to Action. J Cardiovasc Transl Res 2021; 15:258-267. [PMID: 34282541 PMCID: PMC8288068 DOI: 10.1007/s12265-021-10158-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/09/2021] [Indexed: 01/08/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63–2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment.
Collapse
Affiliation(s)
- Elona Rrapo Kaso
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Jonathan A Pan
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Michael Salerno
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.,Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.,Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
| | - Alexandra Kadl
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Chad Aldridge
- Department of Therapy Services, University of Virginia, Charlottesville, VA, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- Division of Cardiology, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Sula Mazimba
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Andrew D Mihalek
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jay Giri
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Herbert D Aronow
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aditya M Sharma
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.
| |
Collapse
|
49
|
Akoumianaki E, Jonkman A, Sklar MC, Georgopoulos D, Brochard L. A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea. Ann Intensive Care 2021; 11:107. [PMID: 34250563 PMCID: PMC8273031 DOI: 10.1186/s13613-021-00897-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/30/2021] [Indexed: 12/16/2022] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (ECMO) is a helpful intervention in patients with severe refractory hypoxemia either because mechanical ventilation cannot ensure adequate oxygenation or because lung protective ventilation is not feasible. Since ECMO is a highly invasive procedure with several, potentially devastating complications and its implementation is complex and expensive, simpler and less invasive therapeutic options should be first exploited. Low tidal volume and driving pressure ventilation, prone position, neuromuscular blocking agents and individualized ventilation based on transpulmonary pressure measurements have been demonstrated to successfully treat the vast majority of mechanically ventilated patients with severe hypoxemia. Veno-venous ECMO has a place in the small portion of severely hypoxemic patients in whom these strategies fail. A combined analysis of recent ARDS trials revealed that ECMO was used in only 2.15% of patients (n = 145/6736). Nevertheless, ECMO use has sharply increased in the last decade, raising questions regarding its thoughtful use. Such a policy could be harmful both for patients as well as for the ECMO technique itself. This narrative review attempts to describe together the practical approaches that can be offered to the sickest patients before going to ECMO, as well as the rationale and the limitations of ECMO. The benefit and the drawbacks associated with ECMO use along with a direct comparison with less invasive therapeutic strategies will be analyzed.
Collapse
Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Annemijn Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
50
|
Shoskes A, Migdady I, Rice C, Hassett C, Deshpande A, Price C, Hernandez AV, Cho SM. Brain Injury Is More Common in Venoarterial Extracorporeal Membrane Oxygenation Than Venovenous Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 48:1799-1808. [PMID: 33031150 DOI: 10.1097/ccm.0000000000004618] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Despite the common occurrence of brain injury in patients undergoing extracorporeal membrane oxygenation, it is unclear which cannulation method carries a higher risk of brain injury. We compared the prevalence of brain injury between patients undergoing venoarterial and venovenous extracorporeal membrane oxygenation. DATA SOURCES PubMed and six other databases from inception to April 2020. STUDY SELECTION Observational studies and randomized clinical trials in adult patients undergoing venoarterial extracorporeal membrane oxygenation or venovenous extracorporeal membrane oxygenation reporting brain injury. DATA EXTRACTION Two independent reviewers extracted the data from the studies. Random-effects meta-analyses were used to pool data. DATA SYNTHESIS Seventy-three studies (n = 16,063) met inclusion criteria encompassing 8,211 patients (51.2%) undergoing venoarterial extracorporeal membrane oxygenation and 7,842 (48.8%) undergoing venovenous extracorporeal membrane oxygenation. Venoarterial extracorporeal membrane oxygenation patients had more overall brain injury compared with venovenous extracorporeal membrane oxygenation (19% vs 10%; p = 0.002). Venoarterial extracorporeal membrane oxygenation patients had more ischemic stroke (10% vs 1%; p < 0.001), hypoxic-ischemic brain injury (13% vs 1%; p < 0.001), and brain death (11% vs 1%; p = 0.001). In contrast, rates of intracerebral hemorrhage (6% vs 8%; p = 0.35) did not differ. Survival was lower in venoarterial extracorporeal membrane oxygenation (48%) than venovenous extracorporeal membrane oxygenation (64%) (p < 0.001). After excluding studies that included extracorporeal cardiopulmonary resuscitation, no significant difference was seen in the rate of overall acute brain injury between venoarterial extracorporeal membrane oxygenation and venovenous extracorporeal membrane oxygenation (13% vs 10%; p = 0.4). However, ischemic stroke (10% vs 1%; p < 0.001), hypoxic-ischemic brain injury (7% vs 1%; p = 0.02), and brain death (9% vs 1%; p = 0.005) remained more frequent in nonextracorporeal cardiopulmonary resuscitation venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation. CONCLUSIONS Brain injury was more common in venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation. While ischemic brain injury was more common in venoarterial extracorporeal membrane oxygenation patients, the rates of intracranial hemorrhage were similar between venoarterial extracorporeal membrane oxygenation and venovenous extracorporeal membrane oxygenation. Further research on mechanism, timing, and effective monitoring of acute brain injury and its management is necessary.
Collapse
Affiliation(s)
- Aaron Shoskes
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Ibrahim Migdady
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Cory Rice
- Department of Neurology, Erlanger Medical Center, University of Tennessee-Chattanooga, Chattanooga, TN
| | - Catherine Hassett
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Abhishek Deshpande
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Carrie Price
- Welch Medical Library, Johns Hopkins University, Baltimore, MD
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, University of Connecticut School of Pharmacy, Storrs, CT.,Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Sung-Min Cho
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH.,Department of Neurology, Erlanger Medical Center, University of Tennessee-Chattanooga, Chattanooga, TN.,Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH.,Welch Medical Library, Johns Hopkins University, Baltimore, MD.,Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, University of Connecticut School of Pharmacy, Storrs, CT.,Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru.,Division of Neuroscience Critical Care, Department of Neurology, Johns Hopkins University, Baltimore, MD.,Division of Neuroscience Critical Care, Department of Neurosurgery, Johns Hopkins University, Baltimore, MD.,Division of Neuroscience Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| |
Collapse
|