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Cho SM, Hwang J, Chiarini G, Amer M, Antonini MV, Barrett N, Belohlavek J, Brodie D, Dalton HJ, Diaz R, Elhazmi A, Tahsili-Fahadan P, Fanning J, Fraser J, Hoskote A, Jung JS, Lotz C, MacLaren G, Peek G, Polito A, Pudil J, Raman L, Ramanathan K, Dos Reis Miranda D, Rob D, Salazar Rojas L, Taccone FS, Whitman G, Zaaqoq AM, Lorusso R. Neurological monitoring and management for adult extracorporeal membrane oxygenation patients: Extracorporeal Life Support Organization consensus guidelines. Crit Care 2024; 28:296. [PMID: 39243056 DOI: 10.1186/s13054-024-05082-z] [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: 07/17/2024] [Accepted: 08/28/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support. METHODS These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels. RESULTS We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts. CONCLUSIONS The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.
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Affiliation(s)
- Sung-Min Cho
- Divisions of Neuroscience Critical Care and Cardiac Surgery Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jaeho Hwang
- Divisions of Neuroscience Critical Care and Cardiac Surgery Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Giovanni Chiarini
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Division of Anaesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Marwa Amer
- Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, 11564, Al Mathar Ash Shamali, Riyadh, Saudi Arabia
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | | | - Nicholas Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Jan Belohlavek
- 2nd Department of Medicine, Cardiology and Angiologiy, General University Hospital and 1st School of Medicine, Charles University, Prague, Czech Republic
| | - Daniel Brodie
- Division of Pulmonary, and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heidi J Dalton
- Departments of Surgery and Pediatrics, Creighton University, Omaha, NE, USA
| | - Rodrigo Diaz
- Programa de Oxigenación Por Membrana Extracorpórea, Hospital San Juan de Dios Santiago, Santiago, Chile
| | - Alyaa Elhazmi
- Medical/Critical Pharmacy Division, King Faisal Specialist Hospital and Research Center, 11564, Al Mathar Ash Shamali, Riyadh, Saudi Arabia
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | - Pouya Tahsili-Fahadan
- Divisions of Neuroscience Critical Care and Cardiac Surgery Departments of Neurology, Neurosurgery, and Anaesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA
- Medical Critical Care Service, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Jonathon Fanning
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital and University of Queensland, Rode Rd, Chermside, QLD, 4032, Australia
| | - John Fraser
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital and University of Queensland, Rode Rd, Chermside, QLD, 4032, Australia
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for, Children National Health Service Foundation Trust, London, UK
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea
| | - Christopher Lotz
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
| | - Angelo Polito
- Pediatric Intensive Care Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Jan Pudil
- 2nd Department of Medicine, Cardiology and Angiologiy, General University Hospital and 1st School of Medicine, Charles University, Prague, Czech Republic
| | - Lakshmi Raman
- Department of Pediatrics, Section Critical Care Medicine, Children's Medical Center at Dallas, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daniel Rob
- 2nd Department of Medicine, Cardiology and Angiologiy, General University Hospital and 1st School of Medicine, Charles University, Prague, Czech Republic
| | - Leonardo Salazar Rojas
- ECMO Department, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Chiarini G, Mariani S, Schaefer AK, van Bussel BCT, Di Mauro M, Wiedemann D, Saeed D, Pozzi M, Botta L, Boeken U, Samalavicius R, Bounader K, Hou X, Bunge JJH, Buscher H, Salazar L, Meyns B, Herr D, Matteucci S, Sponga S, Ramanathan K, Russo C, Formica F, Sakiyalak P, Fiore A, Camboni D, Raffa GM, Diaz R, Wang IW, Jung JS, Belohlavek J, Pellegrino V, Bianchi G, Pettinari M, Barbone A, Garcia JP, Shekar K, Whitman GJR, Lorusso R. Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study. Crit Care 2024; 28:265. [PMID: 39113082 PMCID: PMC11304572 DOI: 10.1186/s13054-024-05047-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/27/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications. METHODS This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models. RESULTS This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar. CONCLUSIONS In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.
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Affiliation(s)
- Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands.
- Intensive Care Unit, Spedali Civili University Hospital, Brescia, Italy.
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands
- Cardiac Surgery Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Bas C T van Bussel
- Department of Intensive Care Medicine, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Department of Cardiac Surgery, Karl Landsteiner University, University Clinic St, Pölten, St. Pölten, Austria
| | - Diyar Saeed
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Cardiologic Hospital, Lyon, France
| | - Luca Botta
- Division of Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Robertas Samalavicius
- II Department of Anesthesiology, Centre of Anesthesia, Intensive Care and Pain Management, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessels Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jeroen J H Bunge
- Department of Intensive Care Adults and Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Hergen Buscher
- Department of Intensive Care Medicine, Center of Applied Medical Research, St Vincent's Hospital, Darlinghurs, NSW, Australia
- University of New South Wales, Sydney, Australia
| | - Leonardo Salazar
- Department of Cardiology, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Bart Meyns
- Department of Cardiac Surgery, Department of Cardiovascular Sciences, University of Leuven, Louvain, Belgium
| | - Daniel Herr
- Departments of Medicine and Surgery, University of Maryland, Baltimore, USA
| | - Sacha Matteucci
- SOD Cardiochirurgia Ospedali Riuniti 'Umberto I - Lancisi - Salesi' Università Politecnica delle Marche, Ancona, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Claudio Russo
- Cardiac Surgery Unit, Cardiac Thoracic and Vascular Department, Niguarda Hospital, Milan, Italy
| | - Francesco Formica
- Cardiac Surgery Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Department of Medicine and Surgery, Cardiac Surgery Unit, University of Parma, University Hospital of Parma, Parma, Italy
| | - Pranya Sakiyalak
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo Per I Trapianti e Terapie Ad Alta Specializzazione), Palermo, Italy
| | - Rodrigo Diaz
- Departamento de Anestesia, ECMO Unit, Clínica Las Condes, Las Condes, Santiago, Chile
| | - I-Wen Wang
- Division of Cardiac Surgery, Memorial Healthcare System, Hollywood, FL, 33021, USA
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, South Korea
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Vin Pellegrino
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia
| | - Giacomo Bianchi
- Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Alessandro Barbone
- Cardiac Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - José P Garcia
- IU Health Advanced Heart and Lung Care, Indiana University Methodist Hospital, Indianapolis, IN, USA
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Glenn J R Whitman
- Cardiac Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, P. Debyelaan, 25-6202AZ, Maastricht, The Netherlands
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3
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Kobata H, Sugie A, Kawakami M, Tanaka S, Sarapuddin G, Tucker A. Treatment strategies for patients with out-of-hospital cardiac arrest associated with traumatic brain injury: A case series. Am J Emerg Med 2024; 82:8-14. [PMID: 38749373 DOI: 10.1016/j.ajem.2024.05.006] [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: 12/12/2023] [Revised: 04/04/2024] [Accepted: 05/06/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION Collapse after out-of-hospital cardiac arrest (OHCA) can cause severe traumatic brain injury (TBI). We aimed to investigate the clinical characteristics and treatment strategies for patients with OHCA and TBI. METHODS We analyzed a consecutive cohort of patients with intrinsic OHCA retrospectively treated between January 2011 and December 2021 at a single critical care center, and presented a case series of seven patients. Patients with collapse-related TBI were examined for the causes and situations of cardiac arrest, laboratory data, radiological images, targeted temperature management (TTM), coronary angiography (CAG), percutaneous coronary intervention (PCI), and extracorporeal cardiopulmonary resuscitation (ECPR). RESULTS Of the 197 patients with intrinsic OHCA, 7 (3.6%) had TBI (age range: 49-70 years; 6 men). All seven patients presented with ventricular fibrillation in the initial electrocardiograms, with four refractory cases treated with ECPR. All patients underwent CAG under heparinization, and four underwent PCI with antiplatelet administration. Initial head computed tomography indicated an intracranial hemorrhage (ICH) in three patients. ICH appeared or was exacerbated in six patients after CAG with or without PCI, except in one who underwent delayed PCI. All patients displayed elevated plasma D-dimer levels, and four underwent neurosurgical procedures. Four patients survived (three with cerebral performance category [CPC] 2, one with CPC 3) and three died; two had hypoxic-ischemic brain injury and one had severe TBI. CONCLUSION Delayed ICH occurred frequently. Individualized management is required based on the extent of brain and cardiac damage, including optimal TTM, PCI procedures, and antiplatelet medications. Early detection of ICH and emergency treatment are critical for multi-disciplinary collaboration.
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Affiliation(s)
- Hitoshi Kobata
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Department of Neurosurgery, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan; Deparment of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan.
| | - Akira Sugie
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Emergency Medical Center, Ijinkai Takeda General Hospital, 28-1 Isidamoriminamicho, Fushimiku, Kyoto, 601-1495, Japan.
| | - Makiko Kawakami
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Department of Anesthesiology, Osaka Saiseikai Suita Hospital, 1-2 Kawazonocho, Suita, Suita, Osaka 564-0013, Japan.
| | - Suguru Tanaka
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Deparment of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka 569-8686, Japan.
| | - Gemmalynn Sarapuddin
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Neurology Department, Institute of Neurosciences, The Medical City, Ortigas Avenue, Pasig, Metro Manila, Philippines.
| | - Adam Tucker
- Osaka Mishima Emergency Critical Center, 11-1 Minami-akutagawacho, Takatsuki, Osaka 569-1124, Japan; Department of Neurosurgery, Japanese Red Cross Kitami Hospital, 2-1 Kita 6-jo, higashi, Kitami, Hokkaido 090-8666, Japan.
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Cho SM, Gusdon AM. Assessing Acute Brain Injury after Rapid Reduction of PaCO 2 using Plasma Biomarkers in Patients Undergoing ECMO. Neurocrit Care 2024; 41:6-8. [PMID: 38356080 DOI: 10.1007/s12028-024-01944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Aaron M Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
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Ahmad SA, Kapoor S, Muquit S, Gusdon A, Khanduja S, Ziai W, Everett AD, Whitman G, Cho SM, On Behalf Of Herald Investigators. Brain injury plasma biomarkers in patients on veno-arterial extracorporeal membrane oxygenation: A pilot prospective observational study. Perfusion 2024:2676591241256006. [PMID: 38757156 DOI: 10.1177/02676591241256006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Early diagnosis of acute brain injury (ABI) is critical for patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) to guide anticoagulation strategy; however, neurological assessment in ECMO is often limited by patient sedation. METHODS In this pilot study of adults from June 2018 to May 2019, plasma samples of glial fibrillary acidic protein (GFAP), neurofilament light chain (NFL), and tubulin associated unit (Tau) were collected daily after V-A ECMO cannulation and measured using a multiplex platform. Primary outcomes were occurrence of ABI, assessed clinically, and neurologic outcome, assessed by modified Rankin Scale (mRS). RESULTS Of 20 consented patients (median age = 48.5°years; 55% female), 8 (40%) had ABI and 15 (75%) had unfavorable neurologic outcome at discharge. 10 (50%) patients were centrally cannulated. Median duration on ECMO was 4.5°days (IQR: 2.5-9.5). Peak GFAP, NFL, and Tau levels were higher in patients with ABI vs. without (AUC = 0.77; 0.85; 0.57, respectively) and in patients with unfavorable vs. favorable neurologic outcomes (AUC = 0.64; 0.59; 0.73, respectively). GFAP elevated first, NFL elevated to the highest degree, and Tau showed limited change regardless of ABI. CONCLUSION Further studies are warranted to determine how plasma biomarkers may facilitate early detection of ABIs in V-A ECMO to assist timely clinical decision-making.
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Affiliation(s)
- Syed Ameen Ahmad
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shrey Kapoor
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Siam Muquit
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen D Everett
- Department of Pediatrics, Blalock-Taussig-Thomas Congenital Heart Center, Johns Hopkins University, Baltimore, MD, USA
| | - Glenn Whitman
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Tabet M, Custer C, Khan IR, Sanford E, Sharma J, Choe R, Singh S, Sirsi D, Olson DM, Morriss MC, Raman L, Busch DR. Neuromonitoring of Pediatric and Adult Extracorporeal Membrane Oxygenation Patients: The Importance of Continuous Bedside Tools in Driving Neuroprotective Clinical Care. ASAIO J 2024; 70:167-176. [PMID: 38051987 DOI: 10.1097/mat.0000000000002107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of temporary cardiopulmonary bypass for patients with acute respiratory or cardiac failure refractory to conventional therapy. Its usage has become increasingly widespread and while reported survival after ECMO has increased in the past 25 years, the incidence of neurological injury has not declined, leading to the pressing question of how to improve time-to-detection and diagnosis of neurological injury. The neurological status of patients on ECMO is clinically difficult to evaluate due to multiple factors including illness, sedation, and pharmacological paralysis. Thus, increasing attention has been focused on developing tools and techniques to measure and monitor the brain of ECMO patients to identify dynamic risk factors and monitor patients' neurophysiological state as a function in time. Such tools may guide neuroprotective interventions and thus prevent or mitigate brain injury. Current means to continuously monitor and prevent neurological injury in ECMO patients are rather limited; most techniques provide indirect or postinsult recognition of irreversible brain injury. This review will explore the indications, advantages, and disadvantages of standard-of-care, emerging, and investigational technologies for neurological monitoring on ECMO, focusing on bedside techniques that provide continuous assessment of neurological health.
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Affiliation(s)
- Margherita Tabet
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Chasity Custer
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Imad R Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ethan Sanford
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Jayesh Sharma
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Regine Choe
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, New York
| | - Sumit Singh
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Deepa Sirsi
- Division of Pediatric Neurology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Department of Pediatrics, The University of Texas Southwestern medical center
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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Cho SM, Khanduja S, Wilcox C, Dinh K, Kim J, Kang JK, Chinedozi ID, Darby Z, Acton M, Rando H, Briscoe J, Bush E, Sair HI, Pitts J, Arlinghaus LR, Wandji ACN, Moreno E, Torres G, Akkanti B, Gavito-Higuera J, Keller S, Choi HA, Kim BS, Gusdon A, Whitman GJ. Clinical Use of Bedside Portable Low-field Brain Magnetic Resonance Imaging in Patients on ECMO: The Results from Multicenter SAFE MRI ECMO Study. RESEARCH SQUARE 2024:rs.3.rs-3858221. [PMID: 38313271 PMCID: PMC10836091 DOI: 10.21203/rs.3.rs-3858221/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: 02/06/2024]
Abstract
Purpose Early detection of acute brain injury (ABI) is critical for improving survival for patients with extracorporeal membrane oxygenation (ECMO) support. We aimed to evaluate the safety of ultra-low-field portable MRI (ULF-pMRI) and the frequency and types of ABI observed during ECMO support. Methods We conducted a multicenter prospective observational study (NCT05469139) at two academic tertiary centers (August 2022-November 2023). Primary outcomes were safety and validation of ULF-pMRI in ECMO, defined as exam completion without adverse events (AEs); secondary outcomes were ABI frequency and type. Results ULF-pMRI was performed in 50 patients with 34 (68%) on venoarterial (VA)-ECMO (11 central; 23 peripheral) and 16 (32%) with venovenous (VV)-ECMO (9 single lumen; 7 double lumen). All patients were imaged successfully with ULF-pMRI, demonstrating discernible intracranial pathologies with good quality. AEs occurred in 3 (6%) patients (2 minor; 1 serious) without causing significant clinical issues.ABI was observed in ULF-pMRI scans for 22 patients (44%): ischemic stroke (36%), intracranial hemorrhage (6%), and hypoxic-ischemic brain injury (4%). Of 18 patients with both ULF-pMRI and head CT (HCT) within 24 hours, ABI was observed in 9 patients with 10 events: 8 ischemic (8 observed on ULF-oMRI, 4 on HCT) and 2 hemorrhagic (1 observed on ULF-pMRI, 2 on HCT). Conclusions ULF-pMRI was shown to be safe and valid in ECMO patients across different ECMO cannulation strategies. The incidence of ABI was high, and ULF-pMRI may more sensitive to ischemic ABI than HCT. ULF-pMRI may benefit both clinical care and future studies of ECMO-associated ABI.
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Affiliation(s)
| | | | | | - Kha Dinh
- UTHSC: The University of Texas Health Science Center at Houston
| | - Jiah Kim
- Johns Hopkins Hospital: Johns Hopkins Medicine
| | | | | | | | | | | | | | - Errol Bush
- Johns Hopkins Hospital: Johns Hopkins Medicine
| | | | | | | | | | - Elena Moreno
- UTHSC: The University of Texas Health Science Center at Houston
| | - Glenda Torres
- UTHSC: The University of Texas Health Science Center at Houston
| | - Bindu Akkanti
- UTHSC: The University of Texas Health Science Center at Houston
| | | | | | - HuiMahn A Choi
- UTHSC: The University of Texas Health Science Center at Houston
| | - Bo Soo Kim
- Johns Hopkins Hospital: Johns Hopkins Medicine
| | - Aaron Gusdon
- UTHSC: The University of Texas Health Science Center at Houston
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Su Y, Teng J, Pan S, Jiang W, Wang F, Tian F, Jing J, Huang H, Cao J, Hu H, Liu L, Li W, Liang C, Ma L, Meng X, Tian L, Wang C, Wang L, Wang Y, Wang Z, Wang Z, Xie Z, You M, Yuan J, Zeng C, Zeng L, Zhang L, Zhang L, Zhang X, Zhang Y, Zhao B, Zhou S, Zhou Z. The development of the neurocritical care specialty in China based on the analysis of neurocritical care unit volume and quality. Brain Circ 2024; 10:67-76. [PMID: 38655441 PMCID: PMC11034439 DOI: 10.4103/bc.bc_71_23] [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: 08/25/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 04/26/2024] Open
Abstract
PURPOSE Through three neurocritical care unit (NCCU) surveys in China, we tried to understand the development status of neurocritical care and clarify its future development. METHODS Using a cross-sectional survey method and self-report questionnaires, the number and quality of NCCUs were investigated through three steps: administering the questionnaire, sorting the survey data, and analyzing the survey data. RESULTS At the second and third surveys, the number of NCCUs (76/112/206) increased by 47% and 84%, respectively. The NCCUs were located in tertiary grade A hospitals or teaching hospitals (65/100/181) in most provinces (24/28/29). The numbers of full-time doctors (359/668/1337) and full-time nurses (904/1623/207) in the NCCUs increased, but the doctor-bed ratio and nurse-bed ratio were still insufficient (0.4:1 and 1.3:1). CONCLUSION In the past 20 years, the growth rate of NCCUs in China has accelerated, while the allocation of medical staff has been insufficient. Although most NCCU hospital bed facilities and instruments and equipment tend to be adequate, there are obvious defects in some aspects of NCCUs.
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Affiliation(s)
- Yingying Su
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Junfang Teng
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Suyue Pan
- Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Wen Jiang
- Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Furong Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Tian
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huijin Huang
- Departments of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Cao
- The First Hospital of Jilin University, Changchun, China
| | - Huaiqiang Hu
- The 960(th) Hospital of Joint Logistics Support, PLA, Jinan, China
| | - Liping Liu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Daping Hospital, The Army Military Medical University, Chongqing, China
| | - Cheng Liang
- The Second Hospital of Lanzhou University, Lanzhou, China
| | - Liansheng Ma
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xuegang Meng
- The Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Linyu Tian
- West China Hospital, Sichuan University, Chengdu, China
| | - Changqing Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lihua Wang
- The Second Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Yan Wang
- Tangshan People's Hospital of Hebei Province, Tangshan, China
| | - Zhenhai Wang
- Neurology Center, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Zhiqiang Wang
- The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zunchun Xie
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Mingyao You
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jun Yuan
- Inner Mongolia People's Hospital, Hohhot, China
| | - Chaosheng Zeng
- The Second Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Li Zeng
- The Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Le Zhang
- Xiangya Hospital, Central South University, Changsha, China
| | - Lei Zhang
- The First People's Hospital of Yunnan Province, Kunming, China
| | - Xin Zhang
- Nanjing Drum Tower Hospital, Nanjing, China
| | - Yongwei Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bin Zhao
- Tianjin Medical University General Hospital, Tianjin, China
| | - Saijun Zhou
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhonghe Zhou
- General Hospital of Northern Theater Command, Shenyang, China
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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10
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Zhao DX, Caturegli G, Wilcox C, Stephens RS, Kim BS, Keller S, Geocadin RG, Suarez JI, Whitman GJR, Cho SM. Challenges in determining death by neurologic criteria in extracorporeal membrane oxygenation - A single center experience. Perfusion 2023:2676591231187548. [PMID: 37387124 PMCID: PMC10756925 DOI: 10.1177/02676591231187548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Apnea test (AT) in patients on extracorporeal membrane oxygenation (ECMO) support is challenging, leading to variation in determining death by neurologic criteria (DNC). We aim to describe the diagnostic criteria and barriers for DNC in adults on ECMO in a tertiary care center. METHODS A retrospective review of a prospective observational standardized neuromonitoring study was conducted in adult VA- and VV-ECMO patients at a tertiary center from June 2016 to March 2022. Brain death was defined according to the 2010 American Academy of Neurology guidelines and following the 2020 World Brain Death Project recommendations for performing AT in ECMO patients. RESULTS Eight (2.7%) ECMO patients (median age = 44 years, 75% male, 50% VA-ECMO) met criteria for DNC, six (75%) of whom were determined with AT. In the other two patients who did not undergo AT due to safety concerns, ancillary tests (transcranial doppler and electroencephalography) were consistent with DNC. An additional seven (2.3%) patients (median age = 55 years, 71% male, 86% VA-ECMO) were noted to have absent brainstem reflexes but failed to complete determination of DNC as they underwent withdrawal of life-sustaining treatment (WLST) before a full evaluation was completed. In these patients, AT was never performed, and ancillary tests were inconsistent with either neurological exam findings and/or neuroimaging supporting DNC, or with each other. CONCLUSION AT was used safely and successfully in 6 of the 8 ECMO patients diagnosed with DNC and was always consistent with the neurological exam and imaging findings, as opposed to ancillary tests alone.
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Affiliation(s)
- David X Zhao
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Wilcox
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - R. Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Romergryko G. Geocadin
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn JR Whitman
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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11
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Wang Y, Deng K, Qian J, Tan L. Use of extracorporeal membrane oxygenation in children with burn injury: Case report and literature review. Medicine (Baltimore) 2023; 102:e34029. [PMID: 37327291 PMCID: PMC10270491 DOI: 10.1097/md.0000000000034029] [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: 04/10/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023] Open
Abstract
RATIONALE Burns are one of the most debilitating injuries in the world and one of the major causes of accidental disability and death among children. Severe burns can result in irreversible brain damage, placing patients at high risk of brain failure and high mortality. Therefore, timely diagnosis and treatment of burn encephalopathy are crucial for improving prognosis. In recent years, extracorporeal membrane oxygenation (ECMO) has been increasingly used to improve the prognosis of patients with burns. Here, we report a case of ECMO treatment in a child with burns and review the relevant literature. PATIENT CONCERNS A 7-year-old boy with a modified Baux score of 24 presented with asphyxia, loss of consciousness, refractory hypoxemia, and malignant arrhythmia after smoke inhalation for 1 day. Fiberoptic bronchoscopy revealed a large amount of black carbon-like substances aspirated from the trachea. DIAGNOSES Considering that the boy inhaled a large amount of smoke, the clinical manifestation was unclear consciousness, laboratory examination revealed continuous low blood oxygen saturation, and bronchoscopy revealed a large amount of black carbon-like substances in the trachea, thereby leading to the diagnosis of asphyxia, inhalation pneumonia, burn encephalopathy, multiple organ dysfunction syndrome, and malignant arrhythmia. In addition, pulmonary edema and carbon monoxide poisoning are caused by chemical agents, gas fumes, and vapors. INTERVENTIONS The boy's blood oxygen saturation and blood circulation remained unstable despite various ventilation methods and medications, thus we decided to use ECMO. After 8 days of ECMO support, the patient was successfully weaned from the machine. OUTCOMES Under the application of ECMO, the respiratory and circulatory systems significantly improved. Nevertheless, due to the progressive brain injury caused by burns and the poor prognosis, the parents ceased all treatment and the boy passed away. LESSONS This case report demonstrates that brain edema and herniation can arise as phenotypes of burn encephalopathy, which is a challenge to treat in children. Children with confirmed or suspected burn encephalopathy should undergo diagnostic tests completed as soon as possible to confirm the diagnosis. After receiving ECMO treatment, the respiratory and circulatory systems of the burn victims reported significantly improved. Hence, ECMO is a viable alternative for supporting patients with burns.
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Affiliation(s)
- Yanfei Wang
- Department of Surgical intensive care, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Kelei Deng
- Department of Surgical intensive care, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Junjie Qian
- Department of Surgical intensive care, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Linhua Tan
- Department of Surgical intensive care, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
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12
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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] [Grants] [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.
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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;
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13
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Sun PYW, Fanning J, Peeler A, Shou B, Lindsley J, Caturegli G, Whitman G, Cha S, Kim BS, Cho SM. Characteristics of delirium and its association with sedation and in-hospital mortality in patients with COVID-19 on veno-venous extracorporeal membrane oxygenation. Front Med (Lausanne) 2023; 10:1172063. [PMID: 37305142 PMCID: PMC10248255 DOI: 10.3389/fmed.2023.1172063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Background Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used in patients with COVID-19 acute respiratory distress syndrome (ARDS). We aim to assess the characteristics of delirium and describe its association with sedation and in-hospital mortality. Methods We retrospectively reviewed adult patients on VV-ECMO for severe COVID-19 ARDS in the Johns Hopkins Hospital ECMO registry in 2020-2021. Delirium was assessed by the Confusion Assessment Method for the ICU (CAM-ICU) when patients scored-3 or above on the Richmond Agitation-Sedation Scale (RASS). Primary outcomes were delirium prevalence and duration in the proportion of days on VV-ECMO. Results Of 47 patients (median age = 51), 6 were in a persistent coma and 40 of the remaining 41 patients (98%) had ICU delirium. Delirium in the survivors (n = 21) and non-survivors (n = 26) was first detected at a similar time point (VV-ECMO day 9.5(5,14) vs. 8.5(5,21), p = 0.56) with similar total delirium days on VV-ECMO (9.5[3.3, 16.8] vs. 9.0[4.3, 28.3] days, p = 0.43). Non-survivors had numerically lower RASS scores on VV-ECMO days (-3.72[-4.42, -2.96] vs. -3.10[-3.91, -2.21], p = 0.06) and significantly prolonged delirium-unassessable days on VV-ECMO with a RASS of -4/-5 (23.0[16.3, 38.3] vs. 17.0(6,23), p = 0.03), and total VV-ECMO days (44.5[20.5, 74.3] vs. 27.0[21, 38], p = 0.04). The proportion of delirium-present days correlated with RASS (r = 0.64, p < 0.001), the proportions of days on VV-ECMO with a neuromuscular blocker (r = -0.59, p = 0.001), and with delirium-unassessable exams (r = -0.69, p < 0.001) but not with overall ECMO duration (r = 0.01, p = 0.96). The average daily dosage of delirium-related medications on ECMO days did not differ significantly. On an exploratory multivariable logistic regression, the proportion of delirium days was not associated with mortality. Conclusion Longer duration of delirium was associated with lighter sedation and shorter paralysis, but it did not discern in-hospital mortality. Future studies should evaluate analgosedation and paralytic strategies to optimize delirium, sedation level, and outcomes.
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Affiliation(s)
- Philip Young-woo Sun
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathon Fanning
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Anna Peeler
- King's College London, Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, London, United Kingdom
| | - Benjamin Shou
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - John Lindsley
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Giorgio Caturegli
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Glenn Whitman
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Stephanie Cha
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Bo Soo Kim
- Department of Pulmonary Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
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14
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Cho SM, Geocadin R, Whitman GJ. Extracorporeal CPR for Out-of-Hospital Cardiac Arrest. N Engl J Med 2023; 388:1915-1916. [PMID: 37195956 PMCID: PMC10564385 DOI: 10.1056/nejmc2302405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Affiliation(s)
- Sung-Min Cho
- Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Yan J, Xu Z, Fang X, You J, Niu J, Xu M, Zhang J, Hu J, He X, Li T. Cerebral Neural Changes in Venous-Arterial Extracorporeal Membrane Oxygenation Survivors. Brain Sci 2023; 13:brainsci13040630. [PMID: 37190595 DOI: 10.3390/brainsci13040630] [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: 02/12/2023] [Revised: 03/15/2023] [Accepted: 03/31/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in patients with critical ailments, but very little is known about the functional cerebral changes in ECMO survivors. Degree centrality (DC), a graph-based assessment of network organization, was performed to explore the neural connectivity changes in ECMO survivors compared to controls and their correlation with cognitive and neurological measures. METHODS This exploratory observational study was conducted from August 2020 to May 2022. ECMO survivors and controls underwent functional magnetic resonance imaging (fMRI) of the brain. We performed DC analysis to identify voxels that showed changes in whole-brain functional connectivity with other voxels. DC was measured by the fMRI graph method and comparisons between the two groups were performed. All participants underwent neuropsychological assessment (Montreal Cognitive Assessment, MoCA). Blood serum neuron-specific enolase and the Glasgow Coma Scale (GCS) were assessed in ECMO survivors. RESULTS DC values in the right insula and right precuneus gyrus were lower in ECMO survivors and higher in the right medial superior frontal gyrus compared to controls (all p < 0.001). Decreased connectivity in the right insular and right precuneus gyrus correlated with total MoCA scores, delayed recollection, and calculation (all p < 0.05). Increased serum NSE levels, GCS score, and GCS-motor response correlated with decreased connectivity in the right insular and right precuneus gyrus and increased connectivity in the right medial superior frontal gyrus (all p < 0.05). CONCLUSIONS We showed that both functional impairment and adaptation were observed in survivors of ECMO, suggesting that neural connectivity changes may provide insights into the mechanisms that may potentially link ECMO survivors to neurological and cognitive disorders.
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Affiliation(s)
- Jueyue Yan
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Zhipeng Xu
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Xing Fang
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Jingyu You
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Jianhua Niu
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Mi Xu
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Jingchen Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Jia Hu
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Xujian He
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
| | - Tong Li
- Department of Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou 310003, China
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16
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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.
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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
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17
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Abstract
OBJECTIVES Critically ill patients are at high risk of acute brain injury. Bedside multimodality neuromonitoring techniques can provide a direct assessment of physiologic interactions between systemic derangements and intracranial processes and offer the potential for early detection of neurologic deterioration before clinically manifest signs occur. Neuromonitoring provides measurable parameters of new or evolving brain injury that can be used as a target for investigating various therapeutic interventions, monitoring treatment responses, and testing clinical paradigms that could reduce secondary brain injury and improve clinical outcomes. Further investigations may also reveal neuromonitoring markers that can assist in neuroprognostication. We provide an up-to-date summary of clinical applications, risks, benefits, and challenges of various invasive and noninvasive neuromonitoring modalities. DATA SOURCES English articles were retrieved using pertinent search terms related to invasive and noninvasive neuromonitoring techniques in PubMed and CINAHL. STUDY SELECTION Original research, review articles, commentaries, and guidelines. DATA EXTRACTION Syntheses of data retrieved from relevant publications are summarized into a narrative review. DATA SYNTHESIS A cascade of cerebral and systemic pathophysiological processes can compound neuronal damage in critically ill patients. Numerous neuromonitoring modalities and their clinical applications have been investigated in critically ill patients that monitor a range of neurologic physiologic processes, including clinical neurologic assessments, electrophysiology tests, cerebral blood flow, substrate delivery, substrate utilization, and cellular metabolism. Most studies in neuromonitoring have focused on traumatic brain injury, with a paucity of data on other clinical types of acute brain injury. We provide a concise summary of the most commonly used invasive and noninvasive neuromonitoring techniques, their associated risks, their bedside clinical application, and the implications of common findings to guide evaluation and management of critically ill patients. CONCLUSIONS Neuromonitoring techniques provide an essential tool to facilitate early detection and treatment of acute brain injury in critical care. Awareness of the nuances of their use and clinical applications can empower the intensive care team with tools to potentially reduce the burden of neurologic morbidity in critically ill patients.
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Affiliation(s)
- Swarna Rajagopalan
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ
| | - Aarti Sarwal
- Department of Neurology, Atrium Wake Forest School of Medicine, Winston-Salem, NC
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18
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Lin G, Li Y, Zhuang Y, Fan Q, Luo Y, Zeng H. Seizures in children undergoing extracorporeal membrane oxygenation: a systematic review and meta-analysis. Pediatr Res 2023; 93:755-762. [PMID: 35906308 PMCID: PMC9336161 DOI: 10.1038/s41390-022-02187-5] [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: 03/01/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the incidence of seizures and short-term mortality associated with seizures in children undergoing extracorporeal membrane oxygenation (ECMO). METHODS PubMed, Embase, and Web of Science were searched from inception to September 2021. Study quality was assessed using the Newcastle-Ottawa Scale. Random effects meta-analysis was conducted. RESULTS Fourteen studies met the inclusion criteria for quantitative meta-analysis. The cumulative estimate of seizure incidence was 15% (95% CI: 12-17%). Studies using electroencephalography reported a higher incidence of seizures compared with those using electro-clinical criteria (19% vs. 9%, P = 0.034). Furthermore, 75% of seizures were subclinical. Children receiving extracorporeal cardiopulmonary resuscitation (ECPR) exhibited a higher incidence of seizures compared to children with respiratory and cardiac indications. Seizure incidence was higher in patients undergoing venoarterial (VA) ECMO compared with venovenous (VV) ECMO. The pooled odds ratio of mortality was 2.58 (95% CI: 2.25-2.95) in those developed seizures. CONCLUSION The incidence of seizures in children requiring ECMO was 15% and majority of seizures were subclinical. The incidence of seizures was higher in patients receiving ECPR than in those with respiratory and cardiac indications. Seizures were more frequent in patients undergoing VA ECMO than VV ECMO. Seizures were associated with increased short-term mortality. IMPACT The incidence of seizures in children undergoing extracorporeal membrane oxygenation (ECMO) was ~15% and majority of the seizures were subclinical. Seizures were associated with increased short-term mortality. Risk factors for seizures were extracorporeal cardiopulmonary resuscitation and venoarterial ECMO. Electroencephalography (EEG) monitoring is recommended in children undergoing ECMO and further studies on the optimal protocol for EEG monitoring are necessary.
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Affiliation(s)
- Guisen Lin
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Yaowen Li
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Yijiang Zhuang
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Qimeng Fan
- Department of Pediatric Intensive Care Unit, Shenzhen Children's Hospital, Shenzhen, China
| | - Yi Luo
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Hongwu Zeng
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China.
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19
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Prokupets R, Kannapadi N, Chang H, Caturegli G, Bush EL, Kim BS, Keller S, Geocadin RG, Whitman GJR, Cho SM. Management of Anticoagulation Therapy in ECMO-Associated Ischemic Stroke and Intracranial Hemorrhage. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:49-57. [PMID: 36628944 DOI: 10.1177/15569845221141702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Despite the common occurrence of extracorporeal membrane oxygenation (ECMO)-associated acute ischemic stroke (AIS) and intracranial hemorrhage (ICH), there are little data to guide optimal anticoagulation management. We sought to describe antithrombotic therapy management after stroke and outcomes. METHODS A retrospective analysis was conducted of venoarterial (VA) and venovenous (VV) ECMO patients treated at a tertiary care center from June 2016 to February 2021. Patients with image-confirmed diagnosis of AIS or ICH while receiving ECMO were included for study with data collected regarding anticoagulation management and clinical outcomes. RESULTS Overall, 216 patients (153 VA-ECMO, 63 VV-ECMO) were included in this study. Of the 153 patients on VA-ECMO, 13 (8.4%) had AIS and 6 (3.9%) had ICH. Of the 63 patients on VV-ECMO, none had AIS and 5 (7.9%) had ICH. One patient (9%) received anticoagulation reversal after ICH. Anticoagulation was discontinued and later resumed in all 5 ICH survivors (median cessation time, 30 h) and 1 of 2 (50%) AIS survivors (median cessation time, 96 h). While off anticoagulation, 2 of 11 patients (18%) had thromboembolic events and none had new AIS. Upon resumption, there were no cases of hemorrhagic transformation of AIS or ICH expansion. There was no difference in in-hospital mortality between patients with ICH and those without in both the VA-ECMO and VV-ECMO cohorts nor between VA-ECMO patients with AIS and those without. CONCLUSIONS Early cessation and judicious resumption of anticoagulation appeared feasible in the cohort of patients with ECMO-associated AIS and ICH.
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Affiliation(s)
- Rochelle Prokupets
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nivedha Kannapadi
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Henry Chang
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Giorgio Caturegli
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bo Soo Kim
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology 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
| | - Sung-Min Cho
- Neuroscience Critical Care Division, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [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: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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21
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Jiao G, Ye S, Zhang J, Wu B, Wei D, Liu D, Liu F, Hu C, Chen J. Association of cardiac disease with the risk of post-lung transplantation mortality in Chinese recipients aged over 65 years. Front Med 2022; 17:58-67. [PMID: 36536194 PMCID: PMC9762646 DOI: 10.1007/s11684-022-0937-y] [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: 11/20/2021] [Accepted: 05/10/2022] [Indexed: 12/23/2022]
Abstract
The current organ allocation rules prioritize elderly and urgent patients on the lung transplantation (LT) waiting list. A steady increase in the threshold at which age is taken into consideration for LT has been observed. This retrospective cohort study recruited 166 lung transplant recipients aged ≽ 65 years between January 2016 and October 2020 in the largest LT center in China. In the cohort, subgroups of patients aged 65-70 years (111 recipients, group 65-70) and ≽ 70 years (55 recipients, group ≽ 70) were included. Group D restrictive lung disease was the main indication of a lung transplant in recipients over 65 years. A significantly higher percentage of coronary artery stenosis was observed in the group ≽ 70 (30.9% vs. 14.4% in group 65-70, P = 0.014). ECMO bridging to LT was performed in 5.4% (group 65-70) and 7.3% (group ≽ 70) of patients. Kaplan-Meier estimates showed that recipients with cardiac abnormalities had a significantly increased risk of mortality. After adjusting for potential confounders, cardiac abnormality was shown to be independently associated with the increased risk of post-LT mortality (HR 6.37, P = 0.0060). Our result showed that LT can be performed in candidates with an advanced age and can provide life-extending benefits.
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Affiliation(s)
- Guohui Jiao
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Shugao Ye
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Ji Zhang
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Bo Wu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Dong Wei
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Dong Liu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Feng Liu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Chunxiao Hu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China
| | - Jingyu Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, 214023, China.
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22
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Arterial Carbon Dioxide and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:1501-1507. [PMID: 35671442 PMCID: PMC9477972 DOI: 10.1097/mat.0000000000001699] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Acute brain injury (ABI) occurs frequently in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We examined the association between peri-cannulation arterial carbon dioxide tension (PaCO 2 ) and ABI with granular blood gas data. We retrospectively analyzed adult patients who underwent VA-ECMO at a tertiary care center with standardized neuromonitoring. Pre- and post-cannulation PaCO 2 were defined as the mean of all PaCO 2 values in the 12 hours before and after cannulation, respectively. Peri-cannulation PaCO 2 drop (∆PaCO 2 ) equaled pre- minus post-cannulation PaCO 2 . ABI included intracranial hemorrhage (ICH), ischemic stroke, hypoxic-ischemic brain injury, cerebral edema, seizure, and brain death. Univariable logistic regression analysis was performed for the presence of ABI. Out of 129 VA-ECMO patients (median age = 60, 63% male), 43 (33%) patients experienced ABI. Patients had a median of 11 (interquartile range: 8-14) peri-cannulation PaCO 2 values. Comparing patients with and without ABI, pre-cannulation (39 vs. 42 mm Hg; p = 0.38) and post-cannulation (37 vs. 36 mm Hg; p = 0.82) PaCO 2 were not different. However, higher pre-cannulation PaCO 2 (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.10-4.00; p = 0.02) and larger ∆PaCO 2 (OR = 2.69; 95% CI = 1.18-6.13; p = 0.02) were associated with ICH. In conclusion, in a cohort with granular arterial blood gas (ABG) data and a standardized neuromonitoring protocol, higher pre-cannulation PaCO 2 and larger ∆PaCO 2 were associated with increased prevalence of ICH.
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23
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Hwang J, Bronder J, Martinez NC, Geocadin R, Kim BS, Bush E, Whitman G, Choi CW, Ritzl EK, Cho SM. Continuous Electroencephalography Markers of Prognostication in Comatose Patients on Extracorporeal Membrane Oxygenation. Neurocrit Care 2022; 37:236-245. [DOI: 10.1007/s12028-022-01482-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/01/2022] [Indexed: 01/21/2023]
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24
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Podell JE, Krause EM, Rector R, Hassan M, Reddi A, Jaffa MN, Morris NA, Herr DL, Parikh GY. Neurologic Outcomes After Extracorporeal Cardiopulmonary Resuscitation: Recent Experience at a Single High-Volume Center. ASAIO J 2022; 68:247-254. [PMID: 33927083 DOI: 10.1097/mat.0000000000001448] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR)-veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest-has grown rapidly, but its widespread adoption has been limited by frequent neurologic complications. With individual centers developing best practices, utilization may be increasing with an uncertain effect on outcomes. This study describes the recent ECPR experience at the University of Maryland Medical Center from 2016 through 2018, with attention to neurologic outcomes and predictors thereof. The primary outcome was dichotomized Cerebral Performance Category (≤2) at hospital discharge; secondary outcomes included rates of specific neurologic complications. From 429 ECMO runs over 3 years, 57 ECPR patients were identified, representing an increase in ECPR utilization compared with 41 cases over the previous 6 years. Fifty-two (91%) suffered in-hospital cardiac arrest, and 36 (63%) had an initial nonshockable rhythm. Median low-flow time was 31 minutes. Overall, 26 (46%) survived hospitalization and 23 (88% of survivors, 40% overall) had a favorable discharge outcome. Factors independently associated with good neurologic outcome included lower peak lactate, initial shockable rhythm, and higher initial ECMO mean arterial pressure. Neurologic complications occurred in 18 patients (32%), including brain death in 6 (11%), hypoxic-ischemic brain injury in 11 (19%), ischemic stroke in 6 (11%), intracerebral hemorrhage in 1 (2%), and seizure in 4 (7%). We conclude that good neurologic outcomes are possible for well-selected ECPR patients in a high-volume program with increasing utilization and evolving practices. Markers of adequate peri-resuscitation tissue perfusion were associated with better outcomes, suggesting their importance in neuroprognostication.
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Affiliation(s)
- Jamie E Podell
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eric M Krause
- Division of Thoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Raymond Rector
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mubariz Hassan
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashwin Reddi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew N Jaffa
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicholas A Morris
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel L Herr
- Division of Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gunjan Y Parikh
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
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25
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Mathon B, Favreau M, Degos V, Amelot A, Le Joncour A, Weiss N, Rohaut B, Le Guennec L, Boch AL, Carpentier A, Bielle F, Mokhtari K, Idbaih A, Touat M, Combes A, Demoule A, Shotar E, Navarro V, Raux M, Demeret S, Pineton De Chambrun M. Brain Biopsy for Neurological Diseases of Unknown Etiology in Critically Ill Patients: Feasibility, Safety, and Diagnostic Yield. Crit Care Med 2022; 50:e516-e525. [PMID: 34995211 DOI: 10.1097/ccm.0000000000005439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Brain biopsy is a useful surgical procedure in the management of patients with suspected neoplastic lesions. Its role in neurologic diseases of unknown etiology remains controversial, especially in ICU patients. This study was undertaken to determine the feasibility, safety, and the diagnostic yield of brain biopsy in critically ill patients with neurologic diseases of unknown etiology. We also aimed to compare these endpoints to those of non-ICU patients who underwent a brain biopsy in the same clinical context. DESIGN Monocenter, retrospective, observational cohort study. SETTING A French tertiary center. PATIENTS All adult patients with neurologic diseases of unknown etiology under mechanical ventilation undergoing in-ICU brain biopsy between January 2008 and October 2020 were compared with a cohort of non-ICU patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 2,207 brain-biopsied patients during the study period, 234 biopsies were performed for neurologic diseases of unknown etiology, including 29 who were mechanically ventilated and 205 who were not ICU patients. Specific histological diagnosis and final diagnosis rates were 62.1% and 75.9%, respectively, leading to therapeutic management modification in 62.1% of cases. Meningitis on prebiopsy cerebrospinal fluid analysis was the sole predictor of obtaining a final diagnosis (2.3 [1.4-3.8]; p = 0.02). ICU patients who experienced therapeutic management modification after the biopsy had longer survival (p = 0.03). The grade 1 to 4 (mild to severe) complication rates were: 24.1%, 3.5%, 0%, and 6.9%, respectively. Biopsy-related mortality was significantly higher in ICU patients compared with non-ICU patients (6.9% vs 0%; p = 0.02). Hematological malignancy was associated with biopsy-related mortality (1.5 [1.01-2.6]; p = 0.04). CONCLUSIONS Brain biopsy in critically ill patients with neurologic disease of unknown etiology is associated with high diagnostic yield, therapeutic modifications and postbiopsy survival advantage. Safety profile seems acceptable in most patients. The benefit/risk ratio of brain biopsy in this population should be carefully weighted.
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Affiliation(s)
- Bertrand Mathon
- Department of Neurosurgery, AP-HP, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France. Paris Brain Institute, ICM, INSERM U 1127, CNRS UMR 7225, Sorbonne Université, UMRS 1127, Paris, France. Department of Neurosurgical Anesthesiology and Critical Care, AP-HP, Sorbonne University, La Pitié Salpêtrière Hospital, Paris, France. Department of Internal Medicine and Clinical Immunology, AP-HP, Sorbonne University, La Pitié Salpêtrière Hospital, Paris, France. Department of Neurology, Neuro-ICU, AP-HP, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France. Brain Liver Pitié-Salpêtrière Study Group, INSERM UMR S 938, Centre de Recherche Saint-Antoine, Sorbonne University, Paris, France. Department of Neuropathology, AP-HP, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France. Department of Neurology, Sorbonne University, DMU Neurosciences, AP-HP, La Pitié-Salpêtrière Hospital, Paris, France. Intensive Care Medicine Department, AP-HP, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France. Intensive Care Medicine Department (R3S Department), AP-HP, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France. INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France. Department of Neuroradiology, AP-HP, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France. Department of Neurology, Epileptology Unit, AP-HP, Sorbonne University, La Pitié Salpêtrière Hospital, Paris, France. Department of Anesthesiology and Critical Care, AP-HP, Sorbonne University, La Pitié Salpêtrière Hospital, Paris, France. Department of Internal Medicine 2, AP-HP, Sorbonne University, La Pitié-Salpêtrière Hospital, Paris, France. INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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26
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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.
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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
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Ong CS, Etchill E, Dong J, Shou BL, Shelley L, Giuliano K, Al-Kawaz M, Ritzl EK, Geocadin RG, Kim BS, Bush EL, Choi CW, Whitman GJR, Cho SM. Neuromonitoring detects brain injury in patients receiving extracorporeal membrane oxygenation support. J Thorac Cardiovasc Surg 2021; 165:2104-2110.e1. [PMID: 34865837 DOI: 10.1016/j.jtcvs.2021.09.063] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 09/08/2021] [Accepted: 09/21/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE There is limited evidence on standardized protocols for optimal neurological monitoring methods in patients receiving extracorporeal membrane oxygenation (ECMO). We previously introduced protocolized noninvasive multimodal neuromonitoring using serial neurological examinations, electroencephalography, transcranial Doppler ultrasound, and somatosensory evoked potentials. The purpose of this study was to examine if standardized neuromonitoring is associated with detection of acute brain injury (ABI) and improved patient outcomes. METHODS A retrospective analysis of ECMO patients who received neurocritical care consultation was performed and outcomes were reviewed. The cohort was stratified according to those who did not receive standardized neuromonitoring (era 1: 2016-2017) and those who received standardized neuromonitoring (era 2: 2017-2020). Multivariable logistic regression was used to evaluate the association between standardized neuromonitoring and ABI. RESULTS A total of 215 patients (mean age, 54 years; 60% male) underwent ECMO (71% venoarterial-ECMO) in our institution, 70 in era 1 and 145 in era 2. The proportion of patients diagnosed with ABI were 23% in era 1 and 33% in era 2 (P = .12). In multivariable logistic regression, standardized neuromonitoring (odds ratio, 2.24; 95% CI, 1.12-4.48; P = .02) and pre-ECMO cardiac arrest (odds ratio, 2.17; 95% CI, 1.14-4.14; P = .02) were independently associated with ABI. There was a greater proportion of patients with good neurological outcomes when discharged alive in era 2 (54% vs 30%; P = .04). CONCLUSIONS Standardized neuromonitoring was associated with increased ABIs in ECMO patients. Although neuromonitoring does not prevent ABI from occurring, it might prevent worsening with timely interventions (eg, anticoagulation management, optimizing oxygen delivery and blood pressure), leading to improved neurological outcomes at discharge.
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Affiliation(s)
- Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Jie Dong
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Leah Shelley
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Katherine Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Mais Al-Kawaz
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Eva K Ritzl
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Romergryko G Geocadin
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Errol L Bush
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Chun Woo Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md.
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Wilcox C, Choi CW, Cho SM. Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short- and long-term neurological outcomes are warranted.
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Kietaibl C, Horvat Menih I, Engel A, Ullrich R, Klein KU, Erdoes G. Cerebral microemboli during extracorporeal life support: a single-centre cohort study. Eur J Cardiothorac Surg 2021; 61:172-179. [PMID: 34406372 DOI: 10.1093/ejcts/ezab353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate the load and composition of cerebral microemboli in adult patients undergoing venoarterial extracorporeal life support (ECLS). METHODS Adult ECLS patients were investigated for the presence of cerebral microemboli and compared to critically ill, pressure-controlled ventilated controls and healthy volunteers. Cerebral microemboli were detected in both middle cerebral arteries for 30 min using transcranial Doppler ultrasound. Neurological outcome (ischaemic stroke, global brain ischaemia, intracerebral haemorrhage, seizure, metabolic encephalopathy, sensorimotor sequelae and neuropsychiatric disorders) was additionally evaluated. RESULTS Twenty ECLS patients (cannulations: 15 femoro-femoral, 4 femoro-subclavian, 1 femoro-aortic), 20 critically ill controls and 20 healthy volunteers were analysed. ECLS patients had statistically significantly more cerebral microemboli than critically ill controls {123 (43-547) [median (interquartile range)] vs 35 (16-74), difference: 88 [95% confidence interval (CI) 19-320], P = 0.023} and healthy volunteers [11 (5-12), difference: 112 (95% CI 45-351), P < 0.0001]. In ECLS patients, 96.5% (7346/7613) of cerebral microemboli were of gaseous composition, while solid cerebral microemboli [1 (0-5)] were detected in 12 out of 20 patients. ECLS patients had more neurological complications than critically ill controls (12/20 vs 3/20, P = 0.003). In ECLS patients, a high microembolic rate (>100/30 min) tended to be associated with neurological complications including ischaemic stroke, neuropsychiatric disorders, sensorimotor sequelae and non-convulsive status epilepticus (odds ratio 4.5, 95% CI 0.46-66.62; P = 0.559). CONCLUSIONS Our results indicate that adult ECLS patients are continuously exposed to many gaseous and, frequently, to few solid cerebral microemboli. Prolonged cerebral microemboli formation may contribute to neurological morbidity related to ECLS treatment. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02020759, https://clinicaltrials.gov/ct2/show/NCT02020759?term=erdoes&rank=1.
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Affiliation(s)
- Clemens Kietaibl
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Ines Horvat Menih
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Adrian Engel
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Klaus U Klein
- Department of Anaesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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The authors reply. Crit Care Med 2021; 49:e344-e345. [PMID: 33616369 DOI: 10.1097/ccm.0000000000004871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Luo Y, Gu Q, Wen X, Li Y, Peng W, Zhu Y, Hu W, Xi S. Neurological Complications of Veno-Arterial Extracorporeal Membrane Oxygenation: A Retrospective Case-Control Study. Front Med (Lausanne) 2021; 8:698242. [PMID: 34277671 PMCID: PMC8280317 DOI: 10.3389/fmed.2021.698242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background: To explore the epidemiology, clinical features, risk indicators, and long-term outcomes of neurological complications caused by veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Methods: We retrospectively analyzed 60 adult patients who underwent V-A ECMO support in our unit from February 2012 to August 2020. These patients were separated into the neurological complications group (NC group) and the non-neurological complications group (nNC group). The differences in basic data and ECMO data between the two groups were compared. The data of long-term neurological prognosis were collected by telephone follow-up. Results: Thirty-nine patients (65.0%) had neurological complications. There were significant differences between the two groups in terms of median age, hypertension, median blood urea nitrogen, median troponin I (TNI), median lactic acid, pre-ECMO percutaneous coronary intervention, continuous renal replacement therapy (CRRT), median Sequential Organ Failure Assessment score, median Acute Physiology and Chronic Health Evaluation II score, median peak inspiratory pressure, median positive end expiratory pressure, and median fresh frozen plasma (P < 0.05). The median Intensive Care Unit length of stay (ICU LOS), 28-day mortality, median post-ECMO vasoactive inotropic score, non-pulsate perfusion (NP), and median ECMO duration of the NC group were significantly higher than those of the nNC group (P < 0.05). Furthermore, multiple logistic regression analysis revealed that TNI (P = 0.043), CRRT (P = 0.047), and continuous NP > 12 h (P = 0.043) were independent risk indicators for neurological complications in patients undergoing ECMO. Forty-four patients (73.3%) survived after discharge, and 38 patients (63.3%) had Cerebral Performance Category score of 1–2. And there were significant differences between the two groups in long-term neurological outcomes after discharge for 6 months (P < 0.05). Conclusion: The incidence of neurological complications was higher in patients undergoing V-A ECMO and was closely related to adverse outcomes (including ICU LOS and 28-day mortality). TNI, CRRT, and continuous NP > 12 h were independent risk indicators for predicting neurological complications in ECMO supporting patients. And the neurological complications of patients during ECMO support had significant adverse effect on long-term surviving and neurological outcomes of patients after discharge for 6 months.
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Affiliation(s)
- Yinan Luo
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiao Gu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Wen
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiwei Li
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weihua Peng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Zhu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Huang M, Shoskes A, Migdady I, Amin M, Hasan L, Price C, Uchino K, Choi CW, Hernandez AV, Cho SM. Does Targeted Temperature Management Improve Neurological Outcome in Extracorporeal Cardiopulmonary Resuscitation (ECPR)? J Intensive Care Med 2021; 37:157-167. [PMID: 34114481 DOI: 10.1177/08850666211018982] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE Targeted temperature management (TTM) is a standard of care in patients after cardiac arrest for neuroprotection. Currently, the effectiveness and efficacy of TTM after extracorporeal cardiopulmonary resuscitation (ECPR) is unknown. We aimed to compare neurological and survival outcomes between TTM vs non-TTM in patients undergoing ECPR for refractory cardiac arrest. METHODS We searched PubMed and 5 other databases for randomized controlled trials and observational studies reporting neurological outcomes or survival in adult patients undergoing ECPR with or without TTM. Good neurological outcome was defined as cerebral performance category <3. Two independent reviewers extracted the data. Random-effects meta-analyses were used to pool data. RESULTS We included 35 studies (n = 2,643) with the median age of 56 years (interquartile range [IQR]: 52-59). The median time from collapse to ECMO cannulation was 58 minutes (IQR: 49-82) and the median ECMO duration was 3 days (IQR: 2.0-4.1). Of 2,643, 1,329 (50.3%) patients received TTM and 1,314 (49.7%) did not. There was no difference in the frequency of good neurological outcome at any time between TTM (29%, 95% confidence interval [CI]: 23%-36%) vs. without TTM (19%, 95% CI: 9%-31%) in patients with ECPR (P = 0.09). Similarly, there was no difference in overall survival between patients with TTM (30%, 95% CI: 22%-39%) vs. without TTM (24%, 95% CI: 14%-34%) (P = 0.31). A cumulative meta-analysis by publication year showed improved neurological and survival outcomes over time. CONCLUSIONS Among ECPR patients, survival and neurological outcome were not different between those with TTM vs. without TTM. Our study suggests that neurological and survival outcome are improving over time as ECPR therapy is more widely used. Our results were limited by the heterogeneity of included studies and further research with granular temperature data is necessary to assess the benefit and risk of TTM in ECPR population.
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Affiliation(s)
- Merry Huang
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Shoskes
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Ibrahim Migdady
- Division of Neurocritical Care, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Moein Amin
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Leen Hasan
- 7712University of Connecticut, Medicine Institute, Farmington, CT, USA
| | - Carrie Price
- Albert S. Cook Library, 1492Towson University, Towson, MD, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Chun Woo Choi
- Division of Cardiac Surgery, 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, 15504University of Connecticut School of Pharmacy, Storrs, CT, USA.,Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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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.
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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
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Khan IR, Saulle M, Oldham MA, Weber MT, Schifitto G, Lee HB. Cognitive, Psychiatric, and Quality of Life Outcomes in Adult Survivors of Extracorporeal Membrane Oxygenation Therapy: A Scoping Review of the Literature. Crit Care Med 2021; 48:e959-e970. [PMID: 32886470 DOI: 10.1097/ccm.0000000000004488] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To perform a scoping literature review of cognitive, psychiatric, and quality of life outcomes in adults undergoing extracorporeal membrane oxygenation for any indication. DATA SOURCES We searched PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL, and PsycINFO from inception to June 2019. STUDY SELECTION Observational studies, clinical trials, qualitative studies, and case series with at least 10 adult subjects were included for analysis. Outcomes of interest consisted of general or domain-specific cognition, psychiatric illness, and quality of life measures that included both mental and physical health. DATA EXTRACTION Study selection, data quality assessment, and interpretation of results were performed by two independent investigators in accordance with the PRISMA statement. DATA SYNTHESIS Twenty-two articles were included in this review. Six described cognitive outcomes, 12 described psychiatric outcomes of which two were qualitative studies, and 16 described quality of life outcomes. Cognitive impairment was detected in varying degrees in every study that measured it. Three studies examined neuroimaging results and found neurologic injury to be more frequent in venoarterial versus venovenous extracorporeal membrane oxygenation, but described a variable correlation with cognitive impairment. Rates of depression, anxiety, and post-traumatic stress disorder were similar to other critically ill populations and were related to physical disability after extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survivors' physical quality of life was worse than population norms but tended to improve with time, while mental quality of life did not differ significantly from the general population. Most studies did not include matched controls and instead compared outcomes to previously published values. CONCLUSIONS Extracorporeal membrane oxygenation survivors experience cognitive impairment, psychiatric morbidity, and worse quality of life compared with the general population and similar to other survivors of critical illness. Physical disability in extracorporeal membrane oxygenation patients plays a significant role in psychiatric morbidity. However, it remains unclear if structural brain injury plays a role in these outcomes and whether extracorporeal membrane oxygenation causes secondary brain injury.
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Affiliation(s)
- Imad R Khan
- Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Michael Saulle
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
| | - Miriam T Weber
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Hochang B Lee
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY
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Modifiable Risk Factors and Mortality From Ischemic and Hemorrhagic Strokes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Organization Registry. Crit Care Med 2021; 48:e897-e905. [PMID: 32931195 DOI: 10.1097/ccm.0000000000004498] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Although acute brain injury is common in patients receiving extracorporeal membrane oxygenation, little is known regarding the mechanism and predictors of ischemic and hemorrhagic stroke. We aimed to determine the risk factors and outcomes of each ischemic and hemorrhagic stroke in patients with venoarterial extracorporeal membrane oxygenation support. DESIGN Retrospective analysis. SETTING Data reported to the Extracorporeal Life Support Organization by 310 extracorporeal membrane oxygenation centers from 2013 to 2017. PATIENTS Patients more than 18 years old supported with a single run of venoarterial extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 10,342 venoarterial extracorporeal membrane oxygenation patients, 401 (3.9%) experienced ischemic stroke and 229 (2.2%) experienced hemorrhagic stroke. Reported acute brain injury during venoarterial extracorporeal membrane oxygenation decreased from 10% to 6% in 5 years. Overall in-hospital mortality was 56%, but rates were higher when ischemic stroke and hemorrhagic stroke were present (76% and 86%, respectively). In multivariable analysis, lower pre-extracorporeal membrane oxygenation pH (adjusted odds ratio, 0.21; 95% CI, 0.09-0.49; p < 0.001), higher PO2 on first day of extracorporeal membrane oxygenation (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.009), higher rates of extracorporeal membrane oxygenation circuit mechanical failure (adjusted odds ratio, 1.33; 95% CI, 1.02-1.74; p = 0.03), and renal replacement therapy (adjusted odds ratio, 1.49; 95% CI, 1.14-1.94; p = 0.004) were independently associated with ischemic stroke. Female sex (adjusted odds ratio, 1.61; 95% CI, 1.16-2.22; p = 0.004), extracorporeal membrane oxygenation duration (adjusted odds ratio, 1.01; 95% CI, 1.00-1.03; p = 0.02), renal replacement therapy (adjusted odds ratio, 1.81; 95% CI, 1.30-2.52; p < 0.001), and hemolysis (adjusted odds ratio, 1.87; 95% CI, 1.11-3.16; p = 0.02) were independently associated with hemorrhagic stroke. CONCLUSIONS Despite a decrease in the prevalence of acute brain injury in recent years, mortality rates remain high when ischemic and hemorrhagic strokes are present. Future research is necessary on understanding the timing of associated risk factors to promote prevention and management strategy.
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Carlson JM, Etchill EW, Enriquez CAG, Peeler A, Whitman GJ, Choi CW, Geocadin RG, Cho SM. Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 36:833-839. [PMID: 34088552 DOI: 10.1053/j.jvca.2021.04.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/20/2021] [Accepted: 04/24/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE As survival with extracorporeal membrane oxygenation (ECMO) therapy improves, it is important to study patients who do not survive secondary to withdrawal of life-sustaining therapy (WLST). The purpose of the present study was to determine the population and clinical characteristics of those who experienced short latency to WLST. DESIGN Retrospective cohort study. SETTING Single academic hospital center. PARTICIPANTS Adult ECMO patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 150 patients (mean age 54.8 ± 15.9 y, 43.3% female) underwent ECMO (80% venoarterial ECMO and 20% venovenous ECMO). Seventy-three (48.7%) had WLST from ECMO support (median five days), and 33 of those (45.2%) had early WLST (≤five days). Patients who underwent WLST were older (60.3 ± 15.3 y v 49.6 ± 14.7 y; p < 0.001) than those who did not undergo WLST and had greater body mass index (31.7 ± 7.6 kg/m2v 28.3 ± 5.5 kg/m2; p = 0.002), longer ECMO duration (six v four days; p = 0.01), and higher Acute Physiology and Chronic Health Evaluation (25 v 21; p < 0.001) and Sequential Organ Failure Assessment (12 v 11; p = 0.037) scores. Family request frequently (91.7%) was cited as part of the WLST decision. WLST patients experienced more chaplaincy (89% v 65%; p < 0.001), palliative care consults (53.4% v 29.9%; p = 0.003), and code status change (do not resuscitate: 83.6% v 7.8%; p < 0.001). CONCLUSIONS Nearly 50% of ECMO patients underwent WLST, with approximately 25% occurring in the first 72 hours. These patients were older, sicker, and experienced a different clinical context. Unlike with other critical illnesses, neurologic injury was not a primary reason for WLST in ECMO patients.
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Affiliation(s)
- Julia M Carlson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Clare Angeli G Enriquez
- Department of Neurosciences, University of the Philippines Manila-Philippine General Hospital, Manila, Philippines
| | - Anna Peeler
- Johns Hopkins University School of Nursing, Baltimore, MD
| | - Glenn J Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chun Woo Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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Badenes R, Bogossian EG, Chisbert V, Robba C, Oddo M, Taccone FS, Matta BF. The role of non-invasive brain oximetry in adult critically ill patients without primary brain injury. Minerva Anestesiol 2021; 87:1226-1238. [PMID: 33938677 DOI: 10.23736/s0375-9393.21.15333-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A primary objective in intensive care and perioperative settings is to promote an adequate supply and delivery of oxygen to tissues and organs, particularly to the brain. Cerebral near infrared spectroscopy (NIRS) is a non-invasive, continuous monitoring technique, that can be used to assess cerebral oxygenation. Using NIRS to monitor cerebral oximetry is not new, and has been in widespread use in neonates and cardiac surgery for decades. In addition, it has become common to see NIRS being used in adult and pediatric cardiac surgery, acute neurological diseases, neurosurgical procedures, vascular surgery, severe trauma and other acute medical diseases. Furthermore, recent evidence suggests a role for NIRS in the perioperative settings; detecting and preventing episodes of cerebral desaturation aiming to reduce the development of post-operative delirium. NIRS is not without its limitations; these include the risk of extra-cranial contamination, spatial limitations and skin blood flow/volume changes, as well being a measure of localized blood oxygenation underneath the sensor. However, NIRS is a non-invasive technique and can, therefore, be used in those patients without indications or justification for invasive brain monitoring; non-neurosurgical procedures such as liver transplantation, major orthopedic surgery and critically illness where the brain is at risk. The aim of this manuscript was to discuss the physical principles of NIRS and to report the current evidence regarding its use in critically ill patients without primary non-anoxic brain injury.
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Affiliation(s)
- Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain - .,Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain - .,INCLIVA Health Research Institute, Valencia, Spain -
| | - Elisa G Bogossian
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Vicente Chisbert
- INCLIVA Health Research Institute, Valencia, Spain.,Escuela de Doctorado, Universidad Católica de Valencia, Valencia, Spain
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCSS S. Martino Hospital, Genoa, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Basil F Matta
- Trauma and NeuroCritical Care Unit, Cambridge University Hospital, Cambridge, UK
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Heinsar S, Raman S, Suen JY, Cho HJ, Fraser JF. The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis. Clin Exp Pediatr 2021; 64:188-195. [PMID: 32777915 PMCID: PMC8103038 DOI: 10.3345/cep.2020.00836] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.
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Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Sainath Raman
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Hwa Jin Cho
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Department of Pediatrics, Chonnam National University Children's Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - John F Fraser
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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40
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How Are We Monitoring Brain Injuries in Patients With Left Ventricular Assist Device? A Systematic Review of Literature. ASAIO J 2021; 67:149-156. [PMID: 33512913 DOI: 10.1097/mat.0000000000001204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Despite the common occurrence of brain injury in patients with left ventricular assist device (LVAD), optimal neuromonitoring methods are unknown. A systematic review of PubMed and six electronic databases from inception was conducted until June 5, 2019. Studies reporting methods of neuromonitoring while on LVAD were extracted. Of 5,190 records screened, 37 studies met the inclusion criteria. The neuromonitoring methods include Transcranial Doppler ultrasound for emboli monitoring (TCD-e) (n = 13) and cerebral autoregulation (n = 3), computed tomography and magnetic resonance imaging (n = 9), serum biomarkers (n = 7), carotid ultrasound (n = 3), and near-infrared spectroscopy (n = 2). Of 421 patients with TCD-e, thromboembolic events (TEs) were reported in 79 patients (20%) and microembolic signals (MES) were detected in 105 patients (27%). Ischemic stroke was more prevalent in patients with MES compared to patients without MES (43% vs.13%, p < 0.001). Carotid ultrasound for assessing carotid stenosis was unreliable after LVAD implantation. Elevated lactate dehydrogenase (LDH) levels were associated with TEs. Significant heterogeneity exists in timing, frequency, and types of neuromonitoring tools. TCD-e and serial LDH levels appeared to have potential for assessing the risk of ischemic stroke. Future prospective research incorporating protocolized TCD-e and LDH may assist in monitoring adverse events in patients with LVAD.
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Chiarini G, Cho SM, Whitman G, Rasulo F, Lorusso R. Brain Injury in Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach. Semin Neurol 2021; 41:422-436. [PMID: 33851392 DOI: 10.1055/s-0041-1726284] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents an established technique to provide temporary cardiac and/or pulmonary support. ECMO, in veno-venous, veno-arterial or in extracorporeal carbon dioxide removal modality, is associated with a high rate of brain injuries. These complications have been reported in 7 to 15% of adults and 20% of neonates, and are associated with poor survival. Thromboembolic events, loss of cerebral autoregulation, alteration of the blood-brain barrier, and hemorrhage related to anticoagulation represent the main causes of severe brain injury during ECMO. The most frequent forms of acute neurological injuries in ECMO patients are intracranial hemorrhage (2-21%), ischemic stroke (2-10%), seizures (2-6%), and hypoxic-ischemic brain injury; brain death may also occur in this population. Other frequent complications are infarction (1-8%) and cerebral edema (2-10%), as well as neuropsychological and psychiatric sequelae, including posttraumatic stress disorder.
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Affiliation(s)
- Giovanni Chiarini
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frank Rasulo
- Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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42
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Cho SM, Tahsili-Fahadan P, Kilic A, Choi CW, Starling RC, Uchino K. A Comprehensive Review of Risk Factor, Mechanism, and Management of Left Ventricular Assist Device-Associated Stroke. Semin Neurol 2021; 41:411-421. [PMID: 33851393 DOI: 10.1055/s-0041-1726328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The use of left ventricular assist devices (LVADs) has been increasing in the last decade, along with the number of patients with advanced heart failure refractory to medical therapy. Ischemic stroke and intracranial hemorrhage remain the leading causes of morbidity and mortality in LVAD patients. Despite the common occurrence and the significant outcome impact, underlying mechanisms and management strategies of stroke in LVAD patients are controversial. In this article, we review our current knowledge on pathophysiology and risk factors of LVAD-associated stroke, outline the diagnostic approach, and discuss treatment strategies.
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Affiliation(s)
- Sung-Min Cho
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pouya Tahsili-Fahadan
- Division of Neurocritical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Neuroscience Intensive Care Unit, Department of Medicine, Virginia Commonwealth University, Inova Fairfax Medical Campus, Falls Church, Virginia.,Neuroscience Research, Neuroscience and Spine Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ahmet Kilic
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun Woo Choi
- Department of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ken Uchino
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Noninvasive neurocritical care monitoring for neonates on extracorporeal membrane oxygenation: where do we stand? J Perinatol 2021; 41:830-835. [PMID: 32753710 DOI: 10.1038/s41372-020-0762-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/06/2020] [Accepted: 07/22/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine practice variation in the utilization of neuromonitoring modalities in neonatal extracorporeal membrane oxygenation (ECMO) patients across Level IV neonatal intensive care units (NICUs). STUDY DESIGN Cross-sectional survey design using electronic surveys sent to site sponsors of a multicenter collaborative of 34 Level IV NICUs of the Children's Hospitals Neonatal Consortium (CHNC) from June to August 2018. RESULTS We had 22 survey respondents from CHNC ECMO centers. Twenty-seven percent of respondents routinely monitored for seizures using electroencephalogram. Cerebral near infrared spectroscopy was used by 50%. Head ultrasound was performed by 95% but the frequency, duration, and type of views varied. Post ECMO screening brain MRI prior to hospital discharge was routinely performed by 77% of respondents. A majority of centers (95%) performed neurodevelopmental follow-up after hospital discharge. CONCLUSIONS There is variation in neuromonitoring practices in Level IV NICUs performing ECMO. Lack of evidence and clear outcome benefits has contributed to practice variation across institutions.
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez C, Shah A, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg 2021; 161:1287-1331. [PMID: 33039139 DOI: 10.1016/j.jtcvs.2020.09.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/03/2020] [Accepted: 04/21/2020] [Indexed: 12/26/2022]
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Md.
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia; Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy; Department of Anaesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, Wash
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Christian Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Ashish Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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Shoskes A, Whitman G, Cho SM. Neurocritical Care of Mechanical Circulatory Support Devices. Curr Neurol Neurosci Rep 2021; 21:20. [PMID: 33694065 DOI: 10.1007/s11910-021-01107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) devices have demonstrated improved survival outcomes in otherwise refractory cardiopulmonary failure but are associated with significant neurologic morbidity and mortality. This review aims to characterize MCS-associated brain injury and discuss the neurocritical care of this population. RECENT FINDINGS We found no practice guidelines or specific management strategies for the neurocritical care of patients with MCS devices. Acute brain injury was commonly observed in short-term and durable MCS devices. There is emerging evidence that a standardized neurological monitoring and management algorithm for MCS device-associated brain injury is feasible and potentially improves neurological outcomes. While MCS devices are associated with significant neurologic morbidity and mortality, there is scant evidence regarding optimal neuromonitoring and neurocritical care. With the increase in use of MCS devices for both short-term and durable applications, improved outcomes will depend on early identification and intervention of neurologic complications and further research into their pathophysiology.
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Affiliation(s)
- Aaron Shoskes
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Sung-Min Cho
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Division of Neuroscience Critical Care, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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Cerebral Microbleeds and Intracranial Hemorrhages in Adult Patients on Extracorporeal Membrane Oxygenation-Autopsy Study. Crit Care Explor 2021; 3:e0358. [PMID: 33681814 PMCID: PMC7929626 DOI: 10.1097/cce.0000000000000358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: Current studies lack robust information on the prevalence and associated factors of cerebral microbleeds in patients who underwent extracorporeal membrane oxygenation. Design: Retrospective analysis. Setting: We reviewed patients who underwent (extracorporeal membrane oxygenation) and subsequent brain autopsy with gross and microscopic examinations from January 2009 to December 2018 from a single tertiary center. Patients: Twenty-five extracorporeal membrane oxygenation patients (median age, 53 yr; interquartile range, 36–61 yr; 17 women and 8 men) underwent brain autopsy. Interventions: Descriptive analysis of neuropathologic findings. Cerebral microbleed was defined as a small focus (< 10 mm diameter) of accumulation of blood product in the brain tissue. Macrohemorrhage was defined as any of the grossly identifiable epidural, subdural, subarachnoid, or intraparenchymal hemorrhages larger than 10 mm. Measurement and Main Results: Of 25 (22 venoarterial extracorporeal membrane oxygenation; three venovenous extracorporeal membrane oxygenation), 15 patients (60%) were found to have cerebral microbleeds, whereas 13 (52%) had macrohemorrhages, of whom five (20%) had both. Overall, 92% of brains demonstrated the presence of either cerebral microbleeds or macrohemorrhages after extracorporeal membrane oxygenation support. Of the patients with cerebral microbleeds, lobar cerebral microbleeds (80%) occurred more frequently than deep cerebral microbleeds (60%), with 40% of patients having both types. The cases of macrohemorrhages consisted of one epidural (8%), two subdural (15%), and 10 subarachnoid hemorrhages (77%). In univariate analyses, the presence of macrohemorrhages was significantly associated with the presence of cerebral microbleeds (p = 0.03) with odds ratio of 0.13 (CI, 0.02–0.82). Age, sex, extracorporeal membrane oxygenation duration, extracorporeal membrane oxygenation type, use of aspirin or dialysis during extracorporeal membrane oxygenation support, bloodstream infections, hemoglobin, platelets, and coagulopathy profiles were not associated with cerebral microbleeds. Conclusions: In patients with postmortem neuropathologic evaluation, 92% sustained acute cerebral microbleeds or macrohemorrhages after extracorporeal membrane oxygenation support. Cerebral microbleeds were commonly present in the majority of extracorporeal membrane oxygenation nonsurvivors. Further research is necessary to study the long-term sequelae, such as cognitive outcome of extracorporeal membrane oxygenation-associated cerebral microbleeds in extracorporeal membrane oxygenation survivors.
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Cho SM, Farrokh S, Whitman G, Bleck TP, Geocadin R. The authors reply. Crit Care Med 2021; 48:e340-e341. [PMID: 32205635 DOI: 10.1097/ccm.0000000000004251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sung-Min Cho
- Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, and Neurosciences Critical Care, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, and Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Johns Hopkins University of Medicine, Baltimore, MD Department of Neurological Sciences, Rush Medical College, Chicago, IL, and Department of Neurosurgery, Rush Medical College, Chicago, IL, and Department of Internal Medicine, Rush Medical College, Chicago, IL, and Department of Anesthesiology, Rush Medical College, Chicago, IL Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, and Neurosciences Critical Care, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, and Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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48
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Intracranial Hemorrhage Occurs Early in Patients With Severe Respiratory Failure Requiring Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 48:e339-e340. [PMID: 32205634 DOI: 10.1097/ccm.0000000000004214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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49
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Wilcox C, Etchill E, Giuliano K, Mayasi Y, Gusdon AM, Cho I CW, Kim BS, Bush EL, Geocadin RG, Whitman GJ, Cho SM. Acute Brain Injury in Postcardiotomy Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 35:1989-1996. [PMID: 33593649 DOI: 10.1053/j.jvca.2021.01.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Acute brain injury (ABI) is common in venoarterial extracorporeal membrane oxygenation (VA-ECMO). One of the most common indications for use of VA-ECMO is postcardiotomy shock (PCS). The authors aimed to characterize the prevalence of ABI and its association with outcomes in this population. DESIGN prospective observational. SETTING Single-center tertiary care university hospital. PARTICIPANTS Fifty-two consecutive patients treated for PCS with VA-ECMO from November 2017 to March 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The median age of patients was 64 (interquartile range 44-84), 62% were male. Of 52 PCS patients treated with extracorporeal membrane oxygenation, 38% (n = 20) experienced acute brain injury. Ischemic stroke was the most common (n = 13, 25%). Patients with central versus peripheral cannulation experienced more ischemic and hemorrhagic strokes (8% v 38%, p = 0.04). Patients with intracardiac thrombus experienced more brain injury (n = 4, 8% p = 0.02). The in-hospital mortality in patients with brain injury was 90% (n = 18/20) compared to 78% (n = 25/32) in patients without brain injury. CONCLUSIONS ABI is common in postcardiotomy VA-ECMO and associated with worse outcome. Patients with central recanalization experienced the majority of acute strokes. Intracardiac thrombus was significantly associated with acute brain injury.
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Affiliation(s)
| | - Eric Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katherine Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yunis Mayasi
- Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurocritical Care, Avera Health, Sioux Falls, SD
| | - Aaron M Gusdon
- Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurosurgery, University of Texas Health Science Center, Houston, TX
| | - Chun Woo Cho I
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bo Soo Kim
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Errol L Bush
- Division of Thoracic Surgery, D epartment of Surgery, Heart, and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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50
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Prinz V, Manekeller L, Menk M, Hecht N, Weber-Carstens S, Vajkoczy P, Finger T. Clinical management and outcome of adult patients with extracorporeal life support device-associated intracerebral hemorrhage-a neurocritical perspective and grading. Neurosurg Rev 2021; 44:2879-2888. [PMID: 33483801 PMCID: PMC8490251 DOI: 10.1007/s10143-020-01471-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/14/2020] [Accepted: 12/30/2020] [Indexed: 01/10/2023]
Abstract
Intracerebral hemorrhage (ICH) is a devastating complication in patients treated with extracorporeal membrane oxygenation (ECMO) due to respiratory or cardiac issues. Neurosurgical evaluation and management of such cases has only insufficiently been studied. We conducted a retrospective, cohort study of adult patients treated with ECMO between January 2007 and January 2017 in a tertiary healthcare center. Demographics, clinical data, coagulation status, ICH characteristics, and treatment modalities were analyzed. The primary outcome parameter was defined as mortality caused by ICH during ECMO. 525 patients with ECMO therapy were eligible for analysis. An overall incidence for any type of intracranial bleeding of 12.3% was found. Small hemorrhages accounted for 6.4% and acute subdural and epidural hematoma for 1.2%. Twenty-four (4.6%) patients developed ICH, and 11 patients (46%) died due to the ICH. Mortality was significantly higher in patients with larger ICH volumes (86.8 ± 34.8 ml vs 9.9 ± 20.3 ml, p < 0.001), intraventricular hemorrhage (83% vs 8%, p = 0.01), and a fluid level inside the ICH (75% vs 31%, p = 0.04). All patients were classified according to the bleeding pattern on the initial CT scan into 3 types. Patients with type 1 bleeding were statistically more likely to die (p < 0.001). In 15 out of 24 patients (63%), correction of the coagulation status was possible within 12 h after ICH onset. Seven out of 9 patients (78%) without early coagulation correction died compared to 2 out of 15 patients (13%), in whom early coagulation correction was successful (p = 0.01). This is the first study evaluating the course and management of patients experiencing an ICH under ECMO therapy and establishing an ICH classification based on the bleeding patterns. Early correction of the coagulation is of paramount importance in the treatment of these patients.
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Affiliation(s)
- Vincent Prinz
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Germany
| | - Lisa Manekeller
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Germany
| | - Mario Menk
- Department of Anesthesiology and Operative Intensive Care Medicine, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Germany.
| | - Tobias Finger
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Germany
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