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Zhang M, Li S, Ying J, Qu Y. Neutrophils: a key component in ECMO-related acute organ injury. Front Immunol 2024; 15:1432018. [PMID: 39346902 PMCID: PMC11427252 DOI: 10.3389/fimmu.2024.1432018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 08/27/2024] [Indexed: 10/01/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), as an extracorporeal life support technique, can save the lives of reversible critically ill patients when conventional treatments fail. However, ECMO-related acute organ injury is a common complication that increases the risk of death in critically ill patients, including acute kidney injury, acute brain injury, acute lung injury, and so on. In ECMO supported patients, an increasing number of studies have shown that activation of the inflammatory response plays an important role in the development of acute organ injury. Cross-cascade activation of the complement system, the contact system, and the coagulation system, as well as the mechanical forces of the circuitry are very important pathophysiological mechanisms, likely leading to neutrophil activation and the production of neutrophil extracellular traps (NETs). NETs may have the potential to cause organ damage, generating interest in their study as potential therapeutic targets for ECMO-related acute organ injury. Therefore, this article comprehensively summarized the mechanism of neutrophils activation and NETs formation following ECMO treatment and their actions on acute organ injury.
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Affiliation(s)
- Mingfu Zhang
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Chronobiology (National Health Commission), West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shiping Li
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Chronobiology (National Health Commission), West China Second University Hospital, Sichuan University, Chengdu, China
| | - Junjie Ying
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Chronobiology (National Health Commission), West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yi Qu
- Department of Pediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Chronobiology (National Health Commission), West China Second University Hospital, Sichuan University, Chengdu, China
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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 2024; 39:1238-1246. [PMID: 37387124 PMCID: PMC10756925 DOI: 10.1177/02676591231187548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 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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Zhang LQ, Chang H, Kalra A, Humayun M, Rosenblatt KR, Shah VA, Geocadin RG, Brown CH, Kim BS, Whitman GJR, Rivera-Lara L, Cho SM. Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation. Neurocrit Care 2024; 41:185-193. [PMID: 38326536 PMCID: PMC11303590 DOI: 10.1007/s12028-023-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/21/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Impaired cerebral autoregulation (CA) is one of several proposed mechanisms of acute brain injury in patients supported by extracorporeal membrane oxygenation (ECMO). The primary aim of this study was to determine the feasibility of continuous CA monitoring in adult ECMO patients. Our secondary aims were to describe changes in cerebral oximetry index (COx) and other metrics of CA over time and in relation to functional neurologic outcomes. METHODS This is a single-center prospective observational study. We measured COx, a surrogate measurement of cerebral blood flow measured by near-infrared spectroscopy, which is an index of CA derived from the moving correlation between mean arterial pressure (MAP) and slow waves of regional cerebral oxygen saturation. A COx value that approaches 1 indicates impaired CA. Using COx, we determined the optimal MAP (MAPOPT) and lower and upper limits of autoregulation for individual patients. These measurements were examined in relation to modified Rankin Scale (mRS) scores. RESULTS Fifteen patients (median age 57 years [interquartile range 47-69]) with 150 autoregulation measurements were included for analysis. Eleven were on veno-arterial ECMO (VA-ECMO), and four were on veno-venous ECMO (VV-ECMO). Mean COx was higher on postcannulation day 1 than on day 2 (0.2 vs. 0.09, p < 0.01), indicating improved CA over time. COx was higher in VA-ECMO patients than in VV-ECMO patients (0.12 vs. 0.06, p = 0.04). Median MAPOPT for the entire cohort was highly variable, ranging from 55 to 110 mm Hg. Patients with mRS scores 0-3 (good outcome) at 3 and 6 months spent less time outside MAPOPT compared with patients with mRS scores 4-6 (poor outcome) (74% vs. 82%, p = 0.01). The percentage of time when observed MAP was outside the limits of autoregulation was higher on postcannulation day 1 than on day 2 (18.2% vs. 3.3%, p < 0.01). CONCLUSIONS In ECMO patients, it is feasible to monitor CA continuously at the bedside. CA improved over time, most significantly between postcannulation days 1 and 2. CA was more impaired in VA-ECMO patients than in VV-ECMO patients. Spending less time outside MAPOPT may be associated with achieving a good neurologic outcome.
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Affiliation(s)
- Lucy Q Zhang
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Henry Chang
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariyam Humayun
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Kathryn R Rosenblatt
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- Department of Neurology and Center for Academic Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA.
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Feng CY, Kolchinski A, Kapoor S, Khanduja S, Hwang J, Suarez JI, Geocadin RG, Kim BS, Whitman G, Cho SM. Prevalence and Neurological Outcomes of Comatose Patients With Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00449-X. [PMID: 39060155 DOI: 10.1053/j.jvca.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 07/02/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVES To investigate prevalence, risk factors, and in-hospital outcomes of comatose extracorporeal membrane oxygenation (ECMO) patients. DESIGN Retrospective observational. SETTING Tertiary academic hospital. PARTICIPANTS Adults received venoarterial (VA) or venovenous (VV) ECMO support between November 2017 and April 022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined 24-hour off sedation as no sedative infusion (except dexmedetomidine) or paralytics administration over a continuous 24-hour period while on ECMO. Off-sedation coma (comaoff) was defined as a Glasgow Coma Scale score of ≤8 after achieving 24-hour off sedation. On-sedation coma (comaon) was defined as a Glasgow Coma Scale score of ≤8 during the entire ECMO course without off sedation for 24 hours. Neurological outcomes were assessed at discharge using the modified Rankin scale (good, 0-3; poor, 4-6). We included 230 patients (VA-ECMO 143, 65% male); 24-hour off sedation was achieved in 32.2% VA-ECMO and 26.4% VV-ECMO patients. Among all patients off sedation for 24 hours (n = 69), 56.5% VA-ECMO and 52.2% VV-ECMO patients experienced comaoff. Among those unable to be sedation free for 24 hours (n = 161), 50.5% VA-ECMO and 17.2% VV-ECMO had comaon. Comaoff was associated with poor outcomes (p < 0.05) in VA-ECMO and VV-ECMO groups, whereas comaon only impacted the VA-ECMO group outcomes. In a multivariable analysis, requirement of renal replacement therapy was an independent risk factor for comaoff after adjusting for ECMO configuration, after adjusting for ECMO configuration, acute brain injury, pre-ECMO partial pressure of oxygen in arterial blood, partial pressure of carbon dioxide in arterial blood, pH, and bicarbonate level (worst value within 24 hours before cannulation). CONCLUSIONS Comaoff was common and associated with poor outcomes at discharge. Requirement of renal replacement therapy was an independent risk factor.
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Affiliation(s)
- Cheng-Yuan Feng
- Division of Neurosciences Critical Care, Departments of Neurology and Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Critical Care Medicine and TriHealth Neuroscience Institute, Cincinnati, OH
| | | | - Shrey Kapoor
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jaeho Hwang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Neurology and Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Neurology and Neurosurgery, and Anesthesiology and Critical Care Medicine, 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
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Neurosciences Critical Care, Departments of Neurology and Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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García-Montoto F, Paz-Martín D, Pestaña D, Soro M, Marcos Vidal JM, Badenes R, Suárez de la Rica A, Bardi T, Pérez-Carbonell A, García C, Cervantes JA, Martínez MP, Guerrero JL, Lorente JV, Veganzones J, Murcia M, Belda FJ. Guidelines for inhaled sedation in the ICU. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:90-111. [PMID: 38309642 DOI: 10.1016/j.redare.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/29/2023] [Indexed: 02/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES Sedation is used in intensive care units (ICU) to improve comfort and tolerance during mechanical ventilation, invasive interventions, and nursing care. In recent years, the use of inhalation anaesthetics for this purpose has increased. Our objective was to obtain and summarise the best evidence on inhaled sedation in adult patients in the ICU, and use this to help physicians choose the most appropriate approach in terms of the impact of sedation on clinical outcomes and the risk-benefit of the chosen strategy. METHODOLOGY Given the overall lack of literature and scientific evidence on various aspects of inhaled sedation in the ICU, we decided to use a Delphi method to achieve consensus among a group of 17 expert panellists. The processes was conducted over a 12-month period between 2022 and 2023, and followed the recommendations of the CREDES guidelines. RESULTS The results of the Delphi survey form the basis of these 39 recommendations - 23 with a strong consensus and 15 with a weak consensus. CONCLUSION The use of inhaled sedation in the ICU is a reliable and appropriate option in a wide variety of clinical scenarios. However, there are numerous aspects of the technique that require further study.
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Affiliation(s)
- F García-Montoto
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain.
| | - D Paz-Martín
- UCI, Departamento de Anestesia y Cuidados Intensivos, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
| | - D Pestaña
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain; Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain
| | - M Soro
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - J M Marcos Vidal
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de León, León, Spain
| | - R Badenes
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain; UCI de Anestesia, Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Valencia, Valencia, Spain; INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
| | - A Suárez de la Rica
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
| | - T Bardi
- UCI de Anestesia, Servicio de Anestesiología y Reanimación, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - A Pérez-Carbonell
- UCI Quirúrgica, Servicio de Anestesiología, UCI Quirúrgica y Unidad del Dolor, Hospital General Universitario de Elche, Elche, Alicante, Spain
| | - C García
- UCI Quirúrgica, Servicio de Anestesiología y Reanimación, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | - J A Cervantes
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Torrecárdenas, Almería, Spain
| | - M P Martínez
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J L Guerrero
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Universidad de Málaga, Málaga, Spain; Instituto Biomédico de Málaga, Málaga, Spain
| | - J V Lorente
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Juan Ramón Jiménez, Huelva, Spain
| | - J Veganzones
- Unidad de Reanimación, Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - M Murcia
- UCI, Servicio de Anestesiología y Cuidados Intensivos, Hospital IMED, Valencia, Spain
| | - F J Belda
- Departamento Cirugía, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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Zhang LQ, Chang H, Kalra A, Humayun M, Rosenblatt KR, Shah VA, Geocadin RG, Brown CH, Kim BS, Whitman GJR, Rivera-Lara L, Cho SM. Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation. RESEARCH SQUARE 2023:rs.3.rs-3300834. [PMID: 37790309 PMCID: PMC10543291 DOI: 10.21203/rs.3.rs-3300834/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background Impaired cerebral autoregulation (CA) is one of several proposed mechanisms of acute brain injury in patients supported by extracorporeal membrane oxygenation (ECMO). The primary aim of this study was to determine the feasibility of continuous CA monitoring in adult ECMO patients. Our secondary aims were to describe changes in cerebral oximetry index (COx) and other metrics of CA over time and in relation to functional neurologic outcomes. Methods This is a single-center prospective observational study. We measured Cox, a surrogate measurement of cerebral blood flow, measured by near-infrared spectroscopy, which is an index of CA derived from the moving correlation between mean arterial pressure and slow waves of regional cerebral oxygen saturation. A COx value that approaches 1 indicates impaired CA. Using COx, we determined the optimal MAP (MAPOPT), lower and upper limits of autoregulation for individual patients. These measurements were examined in relation to modified Rankin Scale (mRS) scores. Results Fifteen patients (median age=57 years [IQR=47-69]) with 150 autoregulation measurements were included for analysis. Eleven were on veno-arterial ECMO and 4 on veno-venous. Mean COx was higher on post-cannulation day 1 than on day 2 (0.2 vs 0.09, p<0.01), indicating improved CA over time. COx was higher in VA-ECMO patients than in VV-ECMO (0.12 vs 0.06, p=0.04). Median MAPOPT for entire cohort was highly variable, ranging 55-110 mmHg. Patients with mRS 0-3 (good outcome) at 3 and 6 months spent less time outside of MAPOPT compared to patients with mRS 4-6 (poor outcome) (74% vs 82%, p=0.01). The percentage of time when observed MAP was outside the limits of autoregulation was higher on post-cannulation day 1 than on day 2 (18.2% vs 3.3%, p<0.01). Conclusions In ECMO patients, it is feasible to monitor CA continuously at the bedside. CA improved over time, most significantly between post-cannulation days 1 and 2. CA was more impaired in VA-ECMO than VV-ECMO. Spending less time outside of MAPOPT may be associated with achieving a good neurologic outcome.
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Affiliation(s)
- Lucy Q Zhang
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Henry Chang
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Andrew Kalra
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Mariyam Humayun
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Kathryn R Rosenblatt
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Vishank A Shah
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | | | - Charles H Brown
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Bo Soo Kim
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Glenn J R Whitman
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Lucia Rivera-Lara
- Stanford University Department of Neurology and Neurological Sciences
| | - Sung-Min Cho
- Johns Hopkins Department of Anesthesiology and Critical Care Medicine: Johns Hopkins Medicine Department of Anesthesiology and Critical Care Medicine
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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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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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9
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Extracorporeal Membrane Oxygenation During Pregnancy. Clin Obstet Gynecol 2023; 66:151-162. [PMID: 36044634 DOI: 10.1097/grf.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.
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10
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Characterization of Cerebral Hemodynamics with TCD in Patients Undergoing VA-ECMO and VV-ECMO: a Prospective Observational Study. Neurocrit Care 2022; 38:407-413. [PMID: 36510107 PMCID: PMC9744662 DOI: 10.1007/s12028-022-01653-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation has a high risk of acute brain injury and resultant mortality. Transcranial Doppler characterizes cerebral hemodynamics in real time, but limited data exist on its interpretation in ECMO. Here, we report TCD mean flow velocity and pulsatility index in a large ECMO population. METHODS This was a prospective cohort study at a tertiary care center. The patients were adults on venoarterial ECMO or venovenous ECMO undergoing TCD studies. RESULTS A total of 135 patients underwent a total of 237 TCD studies while on VA-ECMO (n = 95, 70.3%) or VV-ECMO (n = 40, 29.6%). MFVs were captured reliably (approximately 90%) and were similar to a published healthy cohort in all vessels except the internal carotid artery. Presence of a recordable PI was strongly associated with ECMO mode (57% in VA vs. 95% in VV, p < 0.001). Absence of TCD pulsatility was associated with intraparenchymal hemorrhage (14.7 vs. 1.6%, p = 0.03) in VA-ECMO patients. CONCLUSIONS Transcranial Doppler analysis in a single-center cohort of VA-ECMO and VV-ECMO patients demonstrates similar MFVs and PIs. Absence of PIs was associated with a higher frequency of intraparenchymal hemorrhage and a composite bleeding event. However, cautious interpretation and external validation is necessary for these findings with a multicenter study with a larger sample size.
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11
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Transcranial Doppler microemboli and acute brain injury in extracorporeal membrane oxygenation: A prospective observational study. JTCVS Tech 2022; 15:111-122. [PMID: 36276670 PMCID: PMC9579875 DOI: 10.1016/j.xjtc.2022.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/14/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Extracorporeal membrane oxygenation (ECMO) carries a high morbidity of acute brain injury (ABI) with resultant mortality increase. Transcranial Doppler (TCD) allows real-time characterization of regional cerebral hemodynamics, but limited data exist on the interpretation of microembolic signals (MES) in ECMO. Methods This prospective cohort study was conducted at a single tertiary care center, November 2017 through February 2022, and included all adult patients receiving venoarterial (VA) and venovenous (VV) ECMO undergoing TCD examinations, which all included MES monitoring. Results Of 145 patients on ECMO who underwent at least 1 TCD examination, 100 (68.9%) patients on VA-ECMO received 187 examinations whereas 45 (31.1%) patients on VV-ECMO received 65 examinations (P = .81). MES were observed in 35 (35.0%) patients on VA-ECMO and 2 (4.7%) patients on VV-ECMO (P < .001), corresponding to 46 (24.6%) and 2 (3.1%) TCD examinations, respectively. MES were present in 29.4% of patients on VA-ECMO without additional cardiac support, compared with 38.1% with intra-aortic balloon pump and 57.1% with left ventricular assist device, but these differences were not statistically significant (P = .39; P = .20, respectively). Presence or number of MES was not associated with VA-ECMO cannulation mode (23.4% MES presence in peripheral cannulation vs 25.8% in central cannulation, P = .80). In both VA- and VV-ECMO, MES presence or number was not associated with presence of clot or fibrin in the ECMO circuit or with any studied hemodynamic, laboratory, or ECMO parameters at the time of TCD. ABI occurred in 38% and 31.1% of patients on VA- and VV-ECMO, respectively. In multivariable logistic regression analyses, neither ABI nor a composite outcome of arterial thromboembolic events was associated with presence or number of MES in VA- ECMO. Conclusions TCD analysis in a large cohort of patients on ECMO demonstrates a significant number of MES, especially in patients on VA-ECMO with intra-aortic balloon pump, and/or left ventricular assist device. However, clinical associations and significance of TCD MES remain unresolved and warrant further correlation with systematic imaging and long-term neurologic follow-up.
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12
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Brasil S, Solla DJF, Nogueira RDC, Teixeira MJ, Malbouisson LMS, Paiva WDS. A Novel Noninvasive Technique for Intracranial Pressure Waveform Monitoring in Critical Care. J Pers Med 2021; 11:1302. [PMID: 34945774 PMCID: PMC8707681 DOI: 10.3390/jpm11121302] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We validated a new noninvasive tool (B4C) to assess intracranial pressure waveform (ICPW) morphology in a set of neurocritical patients, correlating the data with ICPW obtained from invasive catheter monitoring. MATERIALS AND METHODS Patients undergoing invasive intracranial pressure (ICP) monitoring were consecutively evaluated using the B4C sensor. Ultrasound-guided manual internal jugular vein (IJV) compression was performed to elevate ICP from the baseline. ICP values, amplitudes, and time intervals (P2/P1 ratio and time-to-peak [TTP]) between the ICP and B4C waveform peaks were analyzed. RESULTS Among 41 patients, the main causes for ICP monitoring included traumatic brain injury, subarachnoid hemorrhage, and stroke. Bland-Altman's plot indicated agreement between the ICPW parameters obtained using both techniques. The strongest Pearson's correlation for P2/P1 and TTP was observed among patients with no cranial damage (r = 0.72 and 0.85, respectively) to the detriment of those who have undergone craniotomies or craniectomies. P2/P1 values of 1 were equivalent between the two techniques (area under the receiver operator curve [AUROC], 0.9) whereas B4C cut-off 1.2 was predictive of intracranial hypertension (AUROC 0.9, p < 000.1 for ICP > 20 mmHg). CONCLUSION B4C provided biometric amplitude ratios correlated with ICPW variation morphology and is useful for noninvasive critical care monitoring.
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Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | | | - Wellingson da Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
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13
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Cerecedo-Lopez CD, Ng I, Nguyen HB, Lai PMR, Gormley WB, Patel N, Frerichs KU, Aziz-Sultan MA, Du R. Incidence and Outcomes of Registry-Based Acute Myocardial Infarction After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:772-780. [PMID: 34697769 DOI: 10.1007/s12028-021-01365-3] [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: 02/03/2021] [Accepted: 09/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) is the rarest and least studied cardiac complication of aneurysmal subarachnoid hemorrhage (aSAH). Precise estimates of the incidence of AMI after aSAH are unavailable. Our goal was to estimate the incidence of registry-based AMI (rb-AMI) after aSAH and determine its association with clinical outcomes. METHODS Adult patients with aSAH in the National Inpatient Samples from 2002 to 2014 were included in the study. We evaluated risk factors for rb-AMI using univariate and multivariate regression models. Clinical outcomes that were assessed included functional status at discharge, in-patient mortality, length of stay, and total hospitalization cost, adjusting for patient demographics and cardiovascular risk factors through an inverse probability weighted analysis. Subgroup analyses were further performed stratified by rb-AMI type (ST-segment elevation myocardial infarction [STEMI] vs. non-STEMI [NSTEMI]). RESULTS A total of 139,734 patients with aSAH were identified, 3.6% of whom had rb-AMI. NSTEMI was the most common type of rb-AMI occurring after aSAH (71% vs. 29% for NSTEMI vs. STEMI, respectively). Patient characteristics associated with higher odds of rb-AMI included age, female sex, poor aSAH grade, and various cardiovascular risk factors. Rb-AMI was also associated with poor functional status at discharge, higher in-hospital mortality, and a longer and more costly hospital stay. CONCLUSIONS Rb-AMI occurs in 3.6% of patients with aSAH and is associated with poor functional status at discharge, higher in-patient mortality, and a longer and more costly hospitalization. Differentiating between different types of rb-AMI would be important in optimizing the management of patients with aSAH. Our definition of rb-AMI likely includes patients with neurogenic stress cardiomyopathy, which may confound the results.
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Affiliation(s)
- Christian D Cerecedo-Lopez
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Issac Ng
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Hillary B Nguyen
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Nirav Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - M Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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14
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Al-Kawaz MN, Canner J, Caturegli G, Kannapadi N, Balucani C, Shelley L, Kim BS, Choi CW, Geocadin RG, Whitman G, Cho SM. Duration of Hyperoxia and Neurologic Outcomes in Patients Undergoing Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 49:e968-e977. [PMID: 33935164 DOI: 10.1097/ccm.0000000000005069] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the impact of duration of hyperoxia on neurologic outcome and mortality in patients undergoing venoarterial extracorporeal membrane oxygenation. DESIGN A retrospective analysis of venoarterial extracorporeal membrane oxygenation patients admitted to the Johns Hopkins Hospital. The primary outcome was neurologic function at discharge defined by modified Rankin Scale, with a score of 0-3 defined as a good neurologic outcome, and a score of 4-6 defined as a poor neurologic outcome. Multivariable logistic regression analysis was performed to evaluate the association between hyperoxia and neurologic outcomes. SETTING The Johns Hopkins Hospital Cardiovascular ICU and Cardiac Critical Care Unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We measured first and maximum Pao2 values, area under the curve per minute over the first 24 hours, and duration of mild, moderate, and severe hyperoxia. Of 132 patients on venoarterial extracorporeal membrane oxygenation, 127 (96.5%) were exposed to mild hyperoxia in the first 24 hours. Poor neurologic outcomes were observed in 105 patients (79.6%) (102 with vs 3 without hyperoxia; p = 0.14). Patients with poor neurologic outcomes had longer exposure to mild (19.1 vs 15.2 hr; p = 0.01), moderate (14.6 vs 9.2 hr; p = 0.003), and severe hyperoxia (9.1 vs 4.0 hr; p = 0.003). In a multivariable analysis, patients with worse neurologic outcome experienced longer durations of mild (adjusted odds ratio, 1.10; 95% CI, 1.01-1.19; p = 0.02), moderate (adjusted odds ratio, 1.12; 95% CI, 1.04-1.22; p = 0.002), and severe (adjusted odds ratio, 1.19; 95% CI, 1.06-1.35; p = 0.003) hyperoxia. Additionally, duration of severe hyperoxia was independently associated with inhospital mortality (adjusted odds ratio, 1.18; 95% CI, 1.08-1.29; p < 0.001). CONCLUSIONS In patients undergoing venoarterial extracorporeal membrane oxygenation, duration and severity of early hyperoxia were independently associated with poor neurologic outcomes at discharge and mortality.
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Affiliation(s)
- Mais N Al-Kawaz
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph Canner
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Giorgio Caturegli
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nivedha Kannapadi
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Clotilde Balucani
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leah Shelley
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chun Woo Choi
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Neurosciences Critical Care Division, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Cardiac Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Zhang H, Xu J, Yang X, Zou X, Shu H, Liu Z, Shang Y. Narrative Review of Neurologic Complications in Adults on ECMO: Prevalence, Risks, Outcomes, and Prevention Strategies. Front Med (Lausanne) 2021; 8:713333. [PMID: 34660625 PMCID: PMC8513760 DOI: 10.3389/fmed.2021.713333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/02/2021] [Indexed: 01/18/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.
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Affiliation(s)
- Hongling Zhang
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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16
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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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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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18
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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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Gusdon AM, Farrokh S, Grotta JC. Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease. Semin Neurol 2021; 41:365-387. [PMID: 33851394 DOI: 10.1055/s-0041-1726331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.
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Affiliation(s)
- Aaron M Gusdon
- Department of Neurosurgery, UTHealth Neurosciences, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas
| | - Salia Farrokh
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Texas Medical Center, Houston
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20
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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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21
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Caturegli G, Cho SM, White B, Chen LL. Acute Brain Injury in Infant Venoarterial Extracorporeal Membrane Oxygenation: An Autopsy Study. Pediatr Crit Care Med 2021; 22:297-302. [PMID: 33055528 DOI: 10.1097/pcc.0000000000002573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Characterization of the types and timing of acute brain injury in infant autopsy patients after extracorporeal membrane oxygenation. DESIGN Retrospective cohort study. SETTING Single tertiary-care center. PATIENTS Infants supported on extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS Clinical and pathologic records were reviewed for infant extracorporeal membrane oxygenation patients who had undergone brain autopsy in a single center between January 2009 and December 2018. Twenty-four patients supported on venoarterial extracorporeal membrane oxygenation had postmortem examination with brain autopsy. Median age at extracorporeal membrane oxygenation initiation was 82 days (interquartile range, 11-263 d), median age at time of death was 20 weeks (interquartile range, 5-44 wk), and median extracorporeal membrane oxygenation support duration was 108 hours (interquartile range, 35-366 hr). The most common acute brain injury found at autopsy was hypoxic-ischemic brain injury (58%) followed by intracranial hemorrhage (29%). The most common types of intracranial hemorrhage were intracerebral (17%), subarachnoid (17%), and subdural (8%). Only five infants (21%) did not have acute brain injury. Correlates of acute brain injury included low preextracorporeal membrane oxygenation oxygen saturation as well as elevated liver enzymes, total bilirubin, and lactate on days 1 and 3 of extracorporeal membrane oxygenation. Gestational age, Apgar scores, birth weight, extracorporeal membrane oxygenation duration, anticoagulation therapy, and renal and hepatic impairments were not associated with acute brain injury. CONCLUSIONS Acute brain injury was observed in 79% of autopsies conducted in infants supported on extracorporeal membrane oxygenation. Hypoxic-ischemic brain injury was the most common type of brain injury (58%), and further associations with preextracorporeal membrane oxygenation acute brain injury require additional exploration.
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Affiliation(s)
- Giorgio Caturegli
- Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bartholomew White
- Neurosciences Critical Care, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Liam L Chen
- Neurosciences Critical Care, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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22
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Tasker RC. Editor's Choice Articles for March. Pediatr Crit Care Med 2021; 22:229-230. [PMID: 33657610 DOI: 10.1097/pcc.0000000000002694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Selwyn College, Cambridge University, United Kington
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Thurnher MM, Boban J, Röggla M, Staudinger T. Distinct pattern of microsusceptibility changes on brain magnetic resonance imaging (MRI) in critically ill patients on mechanical ventilation/oxygenation. Neuroradiology 2021; 63:1651-1658. [PMID: 33646336 PMCID: PMC7917373 DOI: 10.1007/s00234-021-02663-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/28/2021] [Indexed: 01/30/2023]
Abstract
Purpose Over the years, interesting SWI abnormalities in patients from intensive care units (ICU) were observed, not attributable to a specific cause and with uncertain clinical significance. Recently, multiple SWI-hypointense foci were mentioned related to neurological complications of SARS-COV-2 infection. The purpose of the study was to describe the patterns of susceptibility brain changes in critically-ill patients who underwent mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO). Methods An institutional board-approved, retrospective study was conducted on 250 ICU patients in whom brain MRI was performed between January 2011 and May 2020. Out of 48 patients who underwent mechanical ventilation/ECMO, in fifteen patients (median age 47.7 years), the presence of SWI abnormalities was observed and described. Results Microsusceptibilities were located in white-gray matter interface, in subcortical white matter (U-fibers), and surrounding subcortical nuclei in 13/14 (92,8%) patients. In 8/14 (57,1%) patients, SWI foci were seen infratentorially. The corpus callosum was affected in ten (71,4%), internal capsule in five (35,7%), and midbrain/pons in six (42,8%) patients. Conclusion We showed distinct patterns of diffuse brain SWI susceptibilities in critically-ill patients who underwent mechanical ventilation/ECMO. The etiology of these foci remains uncertain, but the association with mechanical ventilation, prolonged respiratory failure, and hypoxemia seems probable explanations.
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Affiliation(s)
- Majda M Thurnher
- Department for Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
| | - Jasmina Boban
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, SR-21000, Serbia
| | - Martin Röggla
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Thomas Staudinger
- Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
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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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Khan IR, Gu Y, George BP, Malone L, Conway KS, Francois F, Donlon J, Quazi N, Reddi A, Ho CY, Herr DL, Johnson MD, Parikh GY. Brain Histopathology of Adult Decedents After Extracorporeal Membrane Oxygenation. Neurology 2021; 96:e1278-e1289. [PMID: 33472914 DOI: 10.1212/wnl.0000000000011525] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To test the hypothesis that brain injury is more common and varied in patients receiving extracorporeal membrane oxygenation (ECMO) than radiographically observed, we described neuropathology findings of ECMO decedents and associated clinical factors from 3 institutions. METHODS We conducted a retrospective multicenter observational study of brain autopsies from adult ECMO recipients. Pathology findings were examined for correlation with demographics, clinical data, ECMO characteristics, and outcomes. RESULTS Forty-three decedents (n = 13 female, median age 47 years) received autopsies after undergoing ECMO for acute respiratory distress syndrome (n = 14), cardiogenic shock (n = 14), and cardiac arrest (n = 15). Median duration of ECMO was 140 hours, most decedents (n = 40) received anticoagulants; 60% (n = 26) underwent venoarterial ECMO, and 40% (n = 17) underwent venovenous ECMO. Neuropathology was found in 35 decedents (81%), including microhemorrhages (37%), macrohemorrhages (35%), infarctions (47%), and hypoxic-ischemic brain injury (n = 17, 40%). Most pathology occurred in frontal neocortices (n = 43 occurrences), basal ganglia (n = 33), and cerebellum (n = 26). Decedents with hemorrhage were older (median age 57 vs 38 years, p = 0.01); those with hypoxic brain injury had higher Sequential Organ Failure Assessment scores (8.0 vs 2.0, p = 0.04); and those with infarction had lower peak Paco2 (53 vs 61 mm Hg, p = 0.04). Six of 9 patients with normal neuroimaging results were found to have pathology on autopsy. The majority underwent withdrawal of life-sustaining therapy (n = 32, 74%), and 2 of 8 patients with normal brain autopsy underwent withdrawal of life-sustaining therapy for suspected neurologic injury. CONCLUSION Neuropathological findings after ECMO are common, varied, and associated with various clinical factors. Further study on underlying mechanisms is warranted and may guide ECMO management.
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Affiliation(s)
- Imad R Khan
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY.
| | - Yang Gu
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Benjamin P George
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Laura Malone
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Kyle S Conway
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Fabienne Francois
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Jack Donlon
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Nadim Quazi
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Ashwin Reddi
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Cheng-Ying Ho
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Daniel L Herr
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Mahlon D Johnson
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Gunjan Y Parikh
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
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26
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Cho SM, Canner J, Caturegli G, Choi CW, Etchill E, Giuliano K, Chiarini G, Calligy K, Rycus P, Lorusso R, Kim BS, Sussman M, Suarez JI, Geocadin R, Bush EL, Ziai W, Whitman G. Risk Factors of Ischemic and Hemorrhagic Strokes During Venovenous Extracorporeal Membrane Oxygenation: Analysis of Data From the Extracorporeal Life Support Organization Registry. Crit Care Med 2021; 49:91-101. [PMID: 33148951 PMCID: PMC9513801 DOI: 10.1097/ccm.0000000000004707] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Stroke is commonly reported in patients receiving venovenous extracorporeal membrane oxygenation, but risk factors are not well described. We sought to determine preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors for both ischemic and hemorrhagic strokes in patients with venovenous extracorporeal membrane oxygenation support. DESIGN Retrospective analysis. SETTING Data reported to the Extracorporeal Life Support Organization by 366 extracorporeal membrane oxygenation centers from 2013 to 2019. PATIENTS Patients older than 18 years supported with a single run of venovenous extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 15,872 venovenous extracorporeal membrane oxygenation patients, 812 (5.1%) had at least one type of acute brain injury, defined as ischemic stroke, hemorrhagic stroke, or brain death. Overall, 215 (1.4%) experienced ischemic stroke and 484 (3.1%) experienced hemorrhagic stroke. Overall inhospital mortality was 36%, but rates were higher in those with ischemic or hemorrhagic stroke (68% and 73%, respectively). In multivariable analysis, preextracorporeal membrane oxygenation pH (adjusted odds ratio = 0.10; 95% CI, 0.03-0.35; p < 0.001), hemolysis (adjusted odds ratio = 2.27; 95% CI, 1.22-4.24; p = 0.010), gastrointestinal hemorrhage (adjusted odds ratio = 2.01; 95% CI 1.12-3.59; p = 0.019), and disseminated intravascular coagulation (adjusted odds ratio = 3.61; 95% CI, 1.51-8.66; p = 0.004) were independently associated with ischemic stroke. Pre-extracorporeal membrane oxygenation pH (adjusted odds ratio = 0.28; 95% CI, 0.12-0.65; p = 0.003), preextracorporeal membrane oxygenation Po2 (adjusted odds ratio = 0.96; 95% CI, 0.93-0.99; p = 0.021), gastrointestinal hemorrhage (adjusted odds ratio = 1.70; 95% CI, 1.15-2.51; p = 0.008), and renal replacement therapy (adjusted odds ratio=1.57; 95% CI, 1.22-2.02; p < 0.001) were independently associated with hemorrhagic stroke. CONCLUSIONS Among venovenous extracorporeal membrane oxygenation patients in the Extracorporeal Life Support Organization registry, approximately 5% had acute brain injury. Mortality rates increased two-fold when ischemic or hemorrhagic strokes occurred. Risk factors such as lower pH and hypoxemia during the pericannulation period and markers of coagulation disturbances were associated with acute brain injury. Further research on understanding preextracorporeal membrane oxygenation and on-extracorporeal membrane oxygenation risk factors and the timing of acute brain injury is necessary to develop appropriate prevention and management strategies.
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Affiliation(s)
- Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joe Canner
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Giorgio Caturegli
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chun Woo Choi
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Etchill
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Katherine Giuliano
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
- Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Kate Calligy
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter Rycus
- Extracorporeal Life Support Organization (ELSO), Ann Arbor, Michigan
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Bo Soo Kim
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc Sussman
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose I. Suarez
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Romergryko Geocadin
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Errol L. Bush
- Division of Thoracic Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy Ziai
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Cardiovascular Surgical Intensive Care, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
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27
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Toivonen F, Biancari F, Dalén M, Dell'Aquila AM, Jónsson K, Fiore A, Mariscalco G, El-Dean Z, Gatti G, Zipfel S, Perrotti A, Bounader K, Alkhamees K, Loforte A, Lechiancole A, Pol M, Spadaccio C, Pettinari M, De Keyzer D, Welp H, Lichtenberg A, Saeed D, Ruggieri VG, Ragnarsson S. Neurologic Injury in Patients Treated With Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock. J Cardiothorac Vasc Anesth 2020; 35:2669-2680. [PMID: 33262035 DOI: 10.1053/j.jvca.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the frequency, predictors, and outcomes of neurologic injury in adults treated with postcardiotomy extracorporeal membrane oxygenation (PC-ECMO). DESIGN A retrospective multicenter registry study. SETTING Twenty-one European institutions where cardiac surgery is performed. PARTICIPANTS A total of 781 adult patients who required PC-ECMO during 2010 to 2018 were divided into patients with neurologic injury (NI) and patients without neurologic injury (NNI). MEASUREMENTS AND MAIN RESULTS Baseline and operative data, in-hospital outcomes, and long-term survival were compared between the NI and the NNI groups. Predictors of neurologic injury were identified. A subgroup analysis according to the type of neurologic injury was performed. Overall, NI occurred in 19% of patients in the overall series, but the proportion of patients with NI ranged from 0% to 65% among the centers. Ischemic stroke occurred in 84 patients and hemorrhagic stroke in 47 patients. Emergency procedure was the sole independent predictor of NI. In-hospital mortality was higher in the NI group than in the NNI group (79% v 61%, p < 0.001). The one-year survival was lower in the NI group (17%) compared with the NNI group (37%). Long-term survival did not differ between patients with ischemic stroke and those with hemorrhagic stroke. CONCLUSION Neurologic injury during PC-ECMO is common and associated with a dismal prognosis. There is considerable interinstitutional variation in the proportion of neurologic injury in PC-ECMO-treated adults. Well-known risk factors for stroke are not associated with neurologic injury in this setting.
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Affiliation(s)
- Fanni Toivonen
- Department of Cardiothoracic Surgery, Skane University Hospital and Lund University, Lund, Sweden
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Kristján Jónsson
- Department of Cardiac Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antonio Fiore
- Department of Cardiothoracic Surgery, Henri Mondor University Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Zein El-Dean
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | | | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | | | - Antonio Loforte
- Department of Cardiothoracic, Transplantation and Vascular Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Marek Pol
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Matteo Pettinari
- Department of Cardiovascular Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter De Keyzer
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Henryk Welp
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Diyar Saeed
- Department of Cardiovascular Surgery, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic Surgery, Skane University Hospital and Lund University, Lund, Sweden.
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28
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Brain Autopsy Findings in Adult Extracorporeal Membrane Oxygenation: Precipitating Event or Extracorporeal Membrane Oxygenation Treatment? Need More Data…. Crit Care Med 2020; 48:936-937. [PMID: 32433087 DOI: 10.1097/ccm.0000000000004319] [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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