Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation

Web-based Dashboard on ECMO Utilization in Germany: An Interactive Visualization, Analyses, and Prediction Based on Real-life Data

In Germany, a comprehensive reimbursement policy for extracorporeal membrane oxygenation (ECMO) results in the highest per capita use worldwide, although benefits remain controversial. Public ECMO data is unstructured and poorly accessible to healthcare professionals, researchers, and policymakers. In addition, there are no uniform policies for ECMO allocation which confronts medical personnel with ethical considerations during health crises such as respiratory virus outbreaks.Retrospective information on adult and pediatric ECMO support performed in German hospitals was extracted from publicly available reimbursement data and hospital quality reports and processed to create the web-based ECMO Dashboard built on Open-Source software. Patient-level and hospital-level data were merged resulting in a solid base for ECMO use analysis and ECMO demand forecasting with high spatial granularity at the level of 413 county and city districts in Germany.The ECMO Dashboard ( https://www.ecmo-dash.de/ ), an innovative visual platform, presents the retrospective utilization patterns of ECMO support in Germany. It features interactive maps, comprehensive charts, and tables, providing insights at the hospital, district, and national levels. This tool also highlights the high prevalence of ECMO support in Germany and emphasizes districts with ECMO surplus - where patients from other regions are treated, or deficit - origins from which ECMO patients are transferred to other regions. The dashboard will evolve iteratively to provide stakeholders with vital information for informed and transparent resource allocation and decision-making.Accessible public routine data could support evidence-informed, forward-looking resource management policies, which are urgently needed to increase the quality and prepare the critical care infrastructure for future pandemics.

An intensivist-led ECMO accreditation pathway and safety data over the first 4 years

Objective

To describe the training and accreditation process behind an intensivist-led extracorporeal membrane oxygenation (ECMO) cannulation program, and identify the rate of complications associated with the ECMO cannulation procedure.

Design

A narrative review of the accreditation process, and a retrospective review of complications related to cannulation during the first four years of the intensivist program.

Setting

Royal Prince Alfred Hospital, a quaternary referral hospital in Sydney.

Participants

All patients initiated onto ECMO during the first four years of the intensivist cannulation program (August 2018 to August 2022).Main outcome measures: All cases were reviewed for identification of 14 pre-defined adverse events which were classified as low, medium or high clinical significance complications.

Results

A total of 402 cannulations were attempted by the intensivist group in 194 separate cannulation episodes involving 179 patients. This included 93 V-V initiations, 69 V-A initiations (36 of these ECMO-CPR), 3 V-AV (veno-arteriovenous) initiations, 25 ECMO reconfigurations and four patients cannulated for peripheral cardiopulmonary bypass in cardiothoracic theatre. One of the 402 cannulations was halted as resuscitation was ceased, and one was halted and the patient transferred to theatre for central arterial cannulation. 394 out of the remaining 400 cannulations were successful (98.5%). Of 402 total cannulations, 32 complication events occurred (7.96% event rate), of which 15 (3.7% event rate) were low significance complications, 10 medium significance (2.5% event rate), and seven high clinical significance (1.7% event rate).

Conclusions

Our experience of the first four years of an intensivist-led ECMO service demonstrates that our training process and cannulation technique result in the provision of a complex therapy with low levels of complications, on par with those in the published literature.

Defining Intensivists: A Retrospective Analysis of the Published Studies in the United States, 2010-2020

OBJECTIVES

The Society of Critical Care Medicine last published an intensivist definition in 1992. Subsequently, there have been many publications relating to intensivists. Our purpose is to assess how contemporary studies define intensivist physicians.

DESIGN

Systematic search of PubMed, Embase, and Web of Science (2010-2020) for publication titles with the terms intensivist, and critical care or intensive care physician, specialist, or consultant. We included studies focusing on adult U.S. intensivists and excluded non-data-driven reports, non-U.S. publications, and pediatric or neonatal ICU reports. We aggregated the study title intensivist nomenclatures and parsed Introduction and Method sections to discern the text used to define intensivists. Fourteen parameters were found and grouped into five definitional categories: A) No definition, B) Background training and certification, C) Works in ICU, D) Staffing, and E) Database related. Each study was re-evaluated against these parameters and grouped into three definitional classes (single, multiple, or no definition). The prevalence of each parameter is compared between groups using Fisher exact test.

SETTING

U.S. adult ICUs and databases.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 657 studies, 105 (16%) met inclusion criteria. Within the study titles, 17 phrases were used to describe an intensivist; these were categorized as intensivist in 61 titles (58%), specialty intensivist in 30 titles (29%), and ICU/critical care physician in 14 titles (13%). Thirty-one studies (30%) used a single parameter (B-E) as their definition, 63 studies (60%) used more than one parameter (B-E) as their definition, and 11 studies (10%) had no definition (A). The most common parameter "Works in ICU" (C) in 52 studies (50%) was more likely to be used in conjunction with other parameters rather than as a standalone parameter (multiple parameters vs single-parameter studies; 73% vs 17%; p < 0.0001).

CONCLUSIONS

There was no consistency of intensivist nomenclature or definitions in contemporary adult intensivist studies in the United States.

ECMO in trauma care: What you need to know

ABSTRACT

Over the past 10 years, extracorporeal membrane oxygenation (ECMO) use in trauma patients has increased significantly. This includes adult and pediatric trauma patients and even combat casualties. Most ECMO applications are in a venovenous (VV ECMO) configuration for acute hypoxemic respiratory failure or anatomic injuries that require pneumonectomy or extreme lung rest in a patient with insufficient respiratory reserve. In this narrative review, we summarize the most common indications for VV ECMO and other forms of ECMO support used in critically injured patients, underscore the importance of early ECMO consultation or regional referral, review the technical aspects of ECMO cannulation and management, and examine the expected outcomes for these patients. In addition, we evaluate the data where it exists to try to debunk some common myths surrounding ECMO management.

Extracorporeal membrane oxygenation and paediatric palliative care in an ICU

OBJECTIVES

Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU.

METHODS

Retrospective review of clinical characteristics and outcomes of children (aged 0-21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation.

MEASUREMENTS AND RESULTS

One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation.

CONCLUSIONS

Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.

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

Objectives

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

Objective

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

Materials and methods

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

Results

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

Conclusions

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

Top Ten Tips Palliative Care Clinicians Should Know About Working With Adults Receiving Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is an invasive intervention that is both resource- and labor-intensive. It can also be emotionally challenging for all involved. Palliative care (PC) clinicians can support adult patients, families, surrogate decision makers, and the interdisciplinary team (IDT) throughout ECMO, starting at the time of ECMO initiation through discontinuation and to bereavement in the event of a patient's death. In addition to knowing the basics of ECMO circuitry, indications to start ECMO, and the complex decision points throughout treatment, PC clinicians must understand the critical need for specialist and IDT coordination when discussing prognosis and resuscitation, clarifying goals of care, and identifying future treatment options. Not only are PC clinicians' skills needed to manage symptoms and psychosocial needs but also during end-of-life care, which can often be rapid and requires team consensus to ensure a smooth clinical process with continuous family support. While using their expert communication skills to conduct frequent family meetings, ideally starting within one week of ECMO initiation and weekly thereafter, PC clinicians offer a consistent presence and "big picture" perspective for patients and families, while other members of the IDT may rotate regularly. PC clinicians will also be called on to assist members of the IDT to debrief about the understandable moral and emotional distress they may experience while providing care for patients receiving ECMO and their families.

Percutaneous cannulation is associated with lower rate of severe neurological complication in femoro-femoral ECPR: results from the Extracorporeal Life Support Organization Registry

BACKGROUND

Percutaneous cannulation is now accepted as the first-line strategy for extracorporeal cardiopulmonary resuscitation (ECPR) in adults. However, previous studies comparing percutaneous cannulation to surgical cannulation have been limited by small sample size and single-center settings. This study aimed to compare in-hospital outcomes in cardiac arrest (CA) patients who received femoro-femoral ECPR with percutaneous vs surgical cannulation.

METHODS

Adults with refractory CA treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral ECPR between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was severe neurological complication. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes.

RESULTS

Among 3575 patients meeting study inclusion, 2749 (77%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 18% to 89% over the study period (p < 0.001 for trend). Severe neurological complication (13% vs 19%; p < 0.001) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rate of severe neurological complication (odds ratio [OR] 0.62; 95% CI 0.46-0.83; p = 0.002), similar rates of in-hospital mortality (OR 0.93; 95% CI 0.73-1.17; p = 0.522), limb ischemia (OR 0.84; 95% CI 0.58-1.20; p = 0.341) and cannulation site bleeding (OR 0.90; 95% CI 0.66-1.22; p = 0.471). The comparison of outcomes provided similar results across different levels of center percutaneous experience or center ECPR volume.

CONCLUSIONS

Among adults receiving ECPR, percutaneous cannulation was associated with probable lower rate of severe neurological complication, and similar rates of in-hospital mortality, limb ischemia and cannulation site bleeding.

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

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

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

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

Extracorporeal Membrane Oxygenation Then and Now; Broadening Indications and Availability

Extracorporeal membrane oxygenation (ECMO) is a life support technology provided to children to support respiratory failure, cardiac failure, or cardiopulmonary resuscitation after failure of conventional management. Over the decades, ECMO has expanded in use, advanced in technology, shifted from experimental to a standard of care, and evidence supporting its use has increased. The expanded ECMO indications and medical complexity of children have also necessitated focused studies in the ethical domain such as decisional authority, resource allocation, and equitable access.

Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement

Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.

Extracorporeal Membrane Oxygenation in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To systematically review and assimilate literature on children receiving extracorporeal membrane oxygenation (ECMO) support in pediatric acute respiratory distress syndrome (PARDS) with the goal of developing an update to the Pediatric Acute Lung Injury Consensus Conference recommendations and statements about clinical practice and research.

DATA SOURCES

Electronic searches of MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost).

STUDY SELECTION

The search used a medical subject heading terms and text words to capture studies of ECMO in PARDS or acute respiratory failure. Studies using animal models and case reports were excluded from our review.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. There were 18 studies identified for full-text extraction. When pediatric data was lacking, adult and neonatal data from randomized clinical trials and observational studies were considered. Six clinical recommendations were generated related to ECMO indications, initiation, and management in PARDS. There were three good practice statements generated related to ECMO indications, initiation, and follow-up in PARDS. Two policy statements were generated involving the impact of ECMO team organization and training in PARDS. Last, there was one research statement.

CONCLUSIONS

Based on a systematic literature review, we propose clinical management, good practice and policy statements within the domains of ECMO indications, initiation, team organization, team training, management, and follow-up as they relate to PARDS.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Concern for Patient Safety Culture of ECMO Team in Emergency Department: A Cross-Sectional Survey

To evaluate the patient safety culture status of the ECMO team in the emergency department of a tertiary care hospital. A cross-sectional survey was conducted in the emergency department of Xiangya Hospital from September 1st to 30th, 2021. The Chinese version of HSOPSC electronic questionnaire was administered to all staff involved in ECMO management and initiation. A total of 152 ECMO team members completed the survey. Among the 12 dimensions of patient safety culture, 4 dimensions recorded relatively high positive response rates (&gt;50%): organizational learning-continuous improvement (87.1%), teamwork within units (86.8%), feedback and communication about errors (58.5%), and supervisor/manager expectations and actions promoting patient safety (55.6%). 8 dimensions recorded relatively low positive response rates (&lt;50%): nonpunitive responses to errors (24.1%), hospital handoffs and transitions (27.1%), staffing (28.6%), the frequency of event reporting (32.4%), teamwork across units (33.2%), communication openness (39.7%), management support for patient safety (48.7%), and overall perceptions of patient safety (49.3%). The overall level of patient safety culture was measured at 47.6%. The ECMO team should immediately address issues of nonpunitive responses to errors, hospital handoffs and transitions, and staffing to improve the safety of ECMO. Going forward, the head of the ECMO team should regard patient safety culture as a top priority, improve staff satisfaction, standardize the transfer and handover process, and create a blame-free environment to facilitate event reporting.

Impact of trained intensivist coverage on survival outcomes after in-hospital cardiopulmonary resuscitation: A nationwide cohort study in South Korea

AIM

We aimed to investigate whether trained intensivist coverage affects survival outcomes following in-hospital cardiopulmonary resuscitation (ICPR) for in-hospital cardiac arrest (IHCA).

METHODS

All adult patients who received ICPR for IHCA between January 1, 2016 and December 31, 2019 in South Korea were included. Patients who received ICPR in hospitals with trained intensivist coverage for ICU staffing were defined as the intensivist group, whereas other patients were considered the non-intensivist group.

RESULTS

In total 68,286 adult patients (36,025 [52.8%] in the intensivist group and 32,261 [47.2%] in the non-intensivist group) were included in the analysis. After propensity score (PS) matching 40,988 patients (20,494 in each group) were included. In logistic regression after PS matching, the intensivist group showed a 17% (odds ratio: 1.17; 95% confidence interval [CI]: 1.12-1.22; P < 0.001) higher live discharge rate after ICPR than the non-intensivist group. In Cox regression after PS matching, the 6-month and the 1-year mortality rates in the intensivist group after ICPR were 11% (hazard ratio [HR]: 0.89; 95% CI: 0.87-0.91; P < 0.001) and 10% (HR: 0.90; 95% CI: 0.88-0.92; P < 0.001) lower than those in the non-intensivist group, respectively. In Kaplan-Meir estimation the median survival time after ICPR in the intensivist group was 12.0 days (95% CI: 11.6-12.4) while that in the non-intensivist group was 8.0 days (95% CI: 7.7-8.3).

CONCLUSIONS

Trained intensivist coverage in the ICU was associated with improvements in both short and long-term survival outcomes after ICPR for IHCA.

Establishing a New ECMO Referral Center Using an ICU-Based Approach: A Feasibility and Safety Study

Background: A high-volume center with a multidisciplinary team is regarded as the optimal place for providing extracorporeal membrane oxygenation (ECMO). We hypothesize that an ECMO center can also be successfully created and subsequently developed entirely by intensivists in a mid-size mixed intensive care unit (ICU). Methods: A model was created for setting up a new ECMO referral center within the structure of an existing mixed ICU in a tertiary hospital. A retrospective analysis was carried out of the first 33 patients treated in the initial period of the center’s activity, from mid 2018 to the end of 2020. Results: An ECMO center was established and developed entirely based on the resources of an existing mixed ICU. Thirty-three patients were treated. They had an overall survival rate at 90 days of 60.6%. In veno-venous (VV) mode ECMO duration, ICU length of stay, and SOFA score were significantly higher than in veno-arterial mode. No significant differences in clinical characteristics were observed between survivors and non-survivors on VV-ECMO. Conclusions: A regional ECMO center can be set up as an integral part of a mixed ICU in a tertiary hospital. Extracorporeal therapy, such as continuous renal replacement therapy and mechanical ventilation can be managed entirely by intensivists. Further studies are needed to show that the ICU-based approach to setting up a new ECMO center is no less effective than the multidisciplinary approach.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda

Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Extracorporeal Life Support (ECLS): A Review and Focus on Considerations for COVID-19

ABSTRACT

Extracorporeal life support (ECLS) is a support modality for patients with severe acute respiratory distress syndrome (ARDS) who have failed conventional treatments including low tidal volume ventilation, prone positioning, and neuromuscular blockade. In addition, ECLS can be used for hemodynamic support for patients with cardiogenic shock or following cardiac arrest. Injured patients may also require ECLS support for ARDS and other indications. We review the use of ECLS for ARDS patients, trauma patients, cardiogenic shock patients, and post-cardiac arrest patients. We then describe how these principles are applied in the management of the novel coronavirus disease 2019 pandemic. Indications, predictors, procedural considerations, and post-cannulation management strategies are discussed.

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

Objectives:

Venovenous extracorporeal membrane oxygenation is increasingly being established as a treatment option for severe acute respiratory failure. We sought to evaluate the impact of a dedicated specialist team-based approach on patient outcomes.

Design:

Retrospective cohort study.

Setting:

Single-center medical ICU in an academic tertiary hospital.

Patients:

Adult patients initiated on venovenous extracorporeal membrane oxygenation for severe acute respiratory failure.

Interventions:

Initiation of an extracorporeal membrane oxygenation intensivist-led multidisciplinary team; critical decisions on extracorporeal membrane oxygenation management were jointly made by a dedicated team of extracorporeal membrane oxygenation intensivists, together with the multidisciplinary team.

Measurements and Main Results:

Eighty-one patients (75%) and 27 patients (35%) were initiated on venovenous extracorporeal membrane oxygenation in the preextracorporeal membrane oxygenation intensivist-led multidisciplinary team (before January 2018) and postextracorporeal membrane oxygenation intensivist-led multidisciplinary team period (after January 2018), respectively. Inhospital (14.8% vs 44.4%, p = 0.006) and ICU mortality (11.1% vs 40.7%, p = 0.005) were significantly lower in the postextracorporeal membrane oxygenation intensivist-led multidisciplinary team period. On multivariate analysis correcting for possible confounding factors (ICU severity and extracorporeal membrane oxygenation-specific mortality prediction scores, body mass index, preextracorporeal membrane oxygenation vasopressor support, preextracorporeal membrane oxygenation cardiac arrest, and days on mechanical ventilation before extracorporeal membrane oxygenation initiation), management by an extracorporeal membrane oxygenation intensivist-led multidisciplinary team remained associated with improved hospital survival (odds ratio, 5.06; 95% CI, 1.20–21.28). Patients in the postextracorporeal membrane oxygenation intensivist-led multidisciplinary team period had less nosocomial infections (18.5% vs 46.9%, p = 0.009), a shorter ICU stay (12 days [interquartile range, 6–16 d] vs 15 days [interquartile range, 10–24 d]; p = 0.049), and none suffered an intracranial hemorrhage or nonhemorrhagic stroke.

Conclusions:

An extracorporeal membrane oxygenation intensivist-led multidisciplinary team approach is associated with improved outcomes in patients initiated on venovenous extracorporeal membrane oxygenation for severe acute respiratory failure.

Rescue therapy with inhaled nitric oxide and almitrine in COVID-19 patients with severe acute respiratory distress syndrome

BACKGROUND

In COVID-19 patients with severe acute respiratory distress syndrome (ARDS), the relatively preserved respiratory system compliance despite severe hypoxemia, with specific pulmonary vascular dysfunction, suggests a possible hemodynamic mechanism for VA/Q mismatch, as hypoxic vasoconstriction alteration. This study aimed to evaluate the capacity of inhaled nitric oxide (iNO)-almitrine combination to restore oxygenation in severe COVID-19 ARDS (C-ARDS) patients.

METHODS

We conducted a monocentric preliminary pilot study in intubated patients with severe C-ARDS. Respiratory mechanics was assessed after a prone session. Then, patients received iNO (10 ppm) alone and in association with almitrine (10 μg/kg/min) during 30 min in each step. Echocardiographic and blood gases measurements were performed at baseline, during iNO alone, and iNO-almitrine combination. The primary endpoint was the variation of oxygenation (PaO₂/FiO₂ ratio).

RESULTS

Ten severe C-ARDS patients were assessed (7 males and 3 females), with a median age of 60 [52-72] years. Combination of iNO and almitrine outperformed iNO alone for oxygenation improvement. The median of PaO₂/FiO₂ ratio varied from 102 [89-134] mmHg at baseline, to 124 [108-146] mmHg after iNO (p = 0.13) and 180 [132-206] mmHg after iNO and almitrine (p < 0.01). We found no correlation between the increase in oxygenation caused by iNO-almitrine combination and that caused by proning.

CONCLUSION

In this pilot study of severe C-ARDS patients, iNO-almitrine combination was associated with rapid and significant improvement of oxygenation. These findings highlight the role of pulmonary vascular function in COVID-19 pathophysiology.

Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers

The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.

Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers

Disclaimer: The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.