1
|
Hongo T, Naito H, Nasu M, Yumoto T, Kosaki Y, Yorifuji T, Hifumi T, Inoue A, Sakamoto T, Kuroda Y, Nakao A. Prognostic performance of gray-white matter ratio in adult out-of-hospital cardiac arrest patients after receiving extracorporeal cardiopulmonary resuscitation. Resuscitation 2024:110351. [PMID: 39098375 DOI: 10.1016/j.resuscitation.2024.110351] [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: 05/24/2024] [Revised: 07/27/2024] [Accepted: 07/29/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Gray-to-white matter ratio (GWR), measured by computed tomography (CT), is commonly used to predict poor neurological outcomes after out-of-hospital cardiac arrest (OHCA). The prognostic performance of GWR in OHCA patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) is not known. METHODS This study is a secondary analysis of data from the SAVE-J II registry, a retrospective, multicenter study. Participants were divided into four groups according to average GWR (aGWR) values ranging from 1.00 to 1.39, separated by 0.1 intervals. The aGWR values were calculated for bilateral basal ganglia, centrum semiovale, and high convexity obtained by head CT within 24 h after ECPR. Primary outcome was poor neurological outcomes at 30-day. RESULTS In total, 1,146 OHCA patients treated with ECPR were included in our analysis. Overall, participants with lower aGWR more likely had poor neurological outcomes, aGWR 1.00-1.09 (94.6%), aGWR 1.10-1-19 (87.8%), aGWR 1.20-1.29 (78.5%), and aGWR 1.30-1.39 (70.3%). Multivariable logistic regression showed that lower aGWR was associated with poor neurological outcome at 30-day, aGWR 1.30-1.39: reference, aGWR 1.00-1.09: adjusted odds ratio (aOR) 10.01 (95% confidence interval (CI) [3.58-27.99]), aGWR 1.10-1.19: aOR 4.83 (95% CI [2.31-10.12]), aGWR 1.20-1.29: aOR 2.16 (95% CI [1.02-4.55]). Receiver operating characteristic curve analysis revealed that the prognostic performance of aGWR had an area under the curve of 0.628, 95% CI [0.59-0.66]). The aGWR threshold of 1.005 for predicting poor neurological outcome reached 100% specificity with 0.1% sensitivity. CONCLUSION Early neuro-prognostication depending on GWR may not be sufficient after ECPR and requires a multimodal approach.
Collapse
Affiliation(s)
- Takashi Hongo
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Hiromichi Naito
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan.
| | - Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, 1-56-1,Maeda, Urasoe, Okinawa Japan
| | - Tetsuya Yumoto
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Yoshinori Kosaki
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Takashi Yorifuji
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Epidemiology, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Toru Hifumi
- St. Luke's International Hospital, Department of Emergency and Critical Care Medicine, Akashi, Chuo, Tokyo, 104-8560, Japan
| | - Akihiko Inoue
- Hyogo Emergency Medical Center, Department of Emergency and Critical Care Medicine, 1-3-1 Wakihamakaigandori, Chuo, Kobe, Hyogo, 651-0073, Japan
| | - Tetsuya Sakamoto
- Teikyo University School of Medicine, Department of Emergency Medicine, 2-11-1 Kaga, Itabashi, Tokyo, 173-8606, Japan
| | - Yasuhiro Kuroda
- Kagawa University Hospital, Department of Emergency, Disaster, and Critical Care Medicine, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan
| | - Atsunori Nakao
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| |
Collapse
|
2
|
Johannes F, Frohofer-Vollenweider R, Teuschl Y. Neurological Complications of the Lower Extremities After Femoral Cannulated Extracorporeal Membrane Oxygenation: A Systematic Review. J Intensive Care Med 2024; 39:534-541. [PMID: 38018080 PMCID: PMC11092294 DOI: 10.1177/08850666231217679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/10/2023] [Accepted: 11/15/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Femoral cannulated extracorporeal membrane oxygenation (ECMO) has been associated with neurologic complications in the lower extremity ipsilateral to the cannulation. There is uncertainty about the prevalence of these complications and their mechanisms of development. OBJECTIVE Aim of this systematic review was to investigate the prevalence of neurological complications after ECMO and to describe possible underlying mechanisms. METHOD A systematic literature search was performed in Medline-Ovid, Embase, Cochrane Library, CINAHL, and PEDro until April 2021 for clinical trials in English or German language which quantified neurologic complications in the lower extremity ipsilateral to the ECMO cannulation of adults. The complications had to be delimitable to intensive care unit-acquired weakness. Methodological quality was assessed by 2 independent investigators using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the National Heart, Lung, and Blood Institute. RESULTS Eight observational studies were included in the synthesis. Study quality was good to fair in 88% of the papers. Overall, 47 of 202 patients (23.3%; ranging from 3% to 48% across studies) with femoral ECMO cannulation showed neurologic complications of the lower extremity ipsilateral to the cannulation. Peripheral ischemia and compression of nerves by the ECMO cannula are discussed as mechanisms of injury. CONCLUSION The occurrence of neurological complications after ECMO was common and can lead to long-term impairment. The mechanisms are largely unknown but currently there is no sufficient evidence for the involvement of ECMO. Standardized assessments are needed to systematically screen for neurological complications early after ECMO, to enable countermeasures and prevent further complications.
Collapse
Affiliation(s)
- Frauke Johannes
- Department of Clinical Neurosciences and Preventive Medicine, University of Continuing Education Krems, Krems, Austria
| | - Rahel Frohofer-Vollenweider
- Nursing and Allied Health Profession Office, Physiotherapy Occupational Therapy, University Hospital Zurich, Zurich, Switzerland
| | - Yvonne Teuschl
- Department of Clinical Neurosciences and Preventive Medicine, University of Continuing Education Krems, Krems, Austria
| |
Collapse
|
3
|
Hanalioglu D, Temkit M'H, Hildebrandt K, MackDiaz E, Goldstein Z, Aggarwal S, Appavu B. Neurophysiologic Features Reflecting Brain Injury During Pediatric ECMO Support. Neurocrit Care 2024; 40:759-768. [PMID: 37697125 PMCID: PMC10959789 DOI: 10.1007/s12028-023-01836-9] [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: 05/01/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides lifesaving support to critically ill patients who experience refractory cardiopulmonary failure but carries a high risk for acute brain injury. We aimed to identify characteristics reflecting acute brain injury in children requiring ECMO support. METHODS This is a prospective observational study from 2019 to 2022 of pediatric ECMO patients undergoing neuromonitoring, including continuous electroencephalography, cerebral oximetry, and transcranial Doppler ultrasound (TCD). The primary outcome was acute brain injury. Clinical and neuromonitoring characteristics were collected. Multivariate logistic regression was implemented to model odds ratios (ORs) and identify the combined characteristics that best discriminate risk of acute brain injury using the area under the receiver operating characteristic curve. RESULTS Seventy-five pediatric patients requiring ECMO support were enrolled in this study, and 62 underwent neuroimaging or autopsy evaluations. Of these 62 patients, 19 experienced acute brain injury (30.6%), including seven (36.8%) with arterial ischemic stroke, four (21.1%) with hemorrhagic stroke, seven with hypoxic-ischemic brain injury (36.8%), and one (5.3%) with both arterial ischemic stroke and hypoxic-ischemic brain injury. A univariate analysis demonstrated acute brain injury to be associated with maximum hourly seizure burden (p = 0.021), electroencephalographic suppression percentage (p = 0.022), increased interhemispheric differences in electroencephalographic total power (p = 0.023) and amplitude (p = 0.017), and increased differences in TCD Thrombolysis in Brain Ischemia (TIBI) scores between bilateral middle cerebral arteries (p = 0.023). Best subset model selection identified increased seizure burden (OR = 2.07, partial R2 = 0.48, p = 0.013), increased quantitative electroencephalographic interhemispheric amplitude differences (OR = 2.41, partial R2 = 0.48, p = 0.013), and increased interhemispheric TCD TIBI score differences (OR = 4.66, partial R2 = 0.49, p = 0.006) to be independently associated with acute brain injury (area under the receiver operating characteristic curve = 0.92). CONCLUSIONS Increased seizure burden and increased interhemispheric differences in both quantitative electroencephalographic amplitude and TCD MCA TIBI scores are independently associated with acute brain injury in children undergoing ECMO support.
Collapse
Affiliation(s)
- Damla Hanalioglu
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - M 'Hamed Temkit
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Kara Hildebrandt
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Elizabeth MackDiaz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Zachary Goldstein
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Shefali Aggarwal
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Brian Appavu
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA.
- Department of Child Health, The University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
| |
Collapse
|
4
|
Kalra A, Kang JK, Khanduja S, Menta AK, Ahmad SA, Liu O, Rodriguez E, Spann M, Hernandez AV, Brodie D, Whitman GJR, Cho SM. Long-Term Neuropsychiatric, Neurocognitive, and Functional Outcomes of Patients Receiving ECMO: A Systematic Review and Meta-Analysis. Neurology 2024; 102:e208081. [PMID: 38181313 PMCID: PMC11023037 DOI: 10.1212/wnl.0000000000208081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/26/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the common occurrence of neurologic complications during extracorporeal membrane oxygenation (ECMO) support, data on long-term neuropsychiatric, neurocognitive, and functional outcomes are sparse. We aimed to determine the prevalence of long-term neuropsychiatric symptoms, neurocognitive and functional impairment, and favorable neurologic outcomes in adult patients who receive ECMO. METHODS PubMed, Embase, Cochrane, Web of Science, and Scopus were searched for text related to ECMO and neuropsychiatric, neurocognitive, and functional outcomes from inception to May 3, 2023. Our primary outcome was the prevalence of neuropsychiatric symptoms (pain/discomfort, anxiety, depression, posttraumatic stress disorder [PTSD], and sleep disturbance) at long-term (≥6 months) follow-up. Our secondary outcomes were the prevalence of neurocognitive impairment (memory, attention, and reasoning), functional impairment (daily activities, physical activity/mobility, and personal/self-care), and favorable neurologic outcomes (Cerebral Performance Category ≤2, modified Rankin scale ≤3, or Glasgow Outcome Scale ≥4). This study was registered in PROSPERO (CRD42023420565). RESULTS We included 59 studies with 3,280 patients (median age 54 years, 69% male). The cohort consisted of 86% venoarterial (VA)-ECMO (n = 2,819) and 14% venovenous (VV)-ECMO (n = 461) patients. More than 10 tools were used to assess neuropsychiatric and neurocognitive outcomes, indicating a lack of standardization in assessment methodologies. The overall prevalence of neuropsychiatric symptoms was 41% (95% CI 33%-49%): pain/discomfort (52%, 95% CI 42%-63%), sleep disturbance (37%, 95% CI 0%-98%), anxiety (36%, 95% CI 27%-46%), depression (31%, 95% CI 22%-40%), and PTSD (18%, 95% CI 9%-29%). The prevalence of neurocognitive impairment was 38% (95% CI 13%-65%). The prevalence of functional impairment was 52% (95% CI 40%-64%): daily activities (54%, 95% CI 41%-66%), mobility (41%, 95% CI 28%-54%), and self-care (21%, 95% CI 13%-31%). The prevalence of neuropsychiatric symptoms in VV-ECMO patients was higher than that in VA-ECMO patients (55% [95% CI 34%-75%] vs 32% [95% CI 23%-41%], p = 0.01), though the prevalence of neurocognitive and functional impairment was not different between the groups. The prevalence of favorable neurologic outcomes was not different at various follow-ups: 3 months (23%, 95% CI 12%-36%), 6 months (25%, 95% CI 16%-35%), and ≥1 year (28%, 95% CI 21%-36%, p = 0.68). DISCUSSION A substantial proportion of ECMO patients seemed to experience neuropsychiatric symptoms and neurocognitive and functional impairments at long-term follow-up. Considerable heterogeneity in methodology for gauging these outcomes exists, warranting the need for standardization. Multicenter prospective observational studies are indicated to further investigate risk factors for these outcomes in ECMO-supported patients.
Collapse
Affiliation(s)
- Andrew Kalra
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin Kook Kang
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shivalika Khanduja
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arjun K Menta
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Syed A Ahmad
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Olivia Liu
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily Rodriguez
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Spann
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adrian V Hernandez
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Brodie
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
5
|
Fernando SM, MacLaren G, McIsaac DI, Brodie D. Testing the Age Limits of Extracorporeal Cardiopulmonary Resuscitation: How Old Is Too Old? Crit Care Med 2024; 52:142-145. [PMID: 38095520 DOI: 10.1097/ccm.0000000000006060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Shannon M Fernando
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
6
|
Salvas JP, Leyba KA, Schepers LE, Paiyabhroma N, Goergen CJ, Sicard P. Neurovascular Hypoxia Trajectories Assessed by Photoacoustic Imaging in a Murine Model of Cardiac Arrest and Resuscitation. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2023; 70:1661-1670. [PMID: 37043326 DOI: 10.1109/tuffc.2023.3265800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Cardiac arrest is a common cause of death annually mainly due to postcardiac arrest syndrome that leads to multiple organ global hypoxia and dysfunction after resuscitation. The ability to quantify vasculature changes and tissue oxygenation is crucial to adapt patient treatment in order to minimize major outcomes after resuscitation. For the first time, we applied high-resolution ultrasound associated with photoacoustic imaging (PAI) to track neurovascular oxygenation and cardiac function trajectories in a murine model of cardiac arrest and resuscitation. We report the preservation of brain oxygenation is greater compared to that in peripheral tissues during the arrest. Furthermore, distinct patterns of cerebral oxygen decay may relate to the support of vital brain functions. In addition, we followed trajectories of cerebral perfusion and cardiac function longitudinally after induced cardiac arrest and resuscitation. Volumetric cerebral oxygen saturation (sO2) decreased 24 h postarrest, but these levels rebounded at one week. However, systolic and diastolic cardiac dysfunction persisted throughout and correlated with cerebral hypoxia. Pathophysiologic biomarker trends, identified via cerebral PAI in preclinical models, could provide new insights into understanding the pathophysiology of cardiac arrest and resuscitation.
Collapse
|
7
|
Tonna JE. How confidently can we prognosticate survival when starting ECPR? Resuscitation 2023; 192:109972. [PMID: 37734701 PMCID: PMC10642582 DOI: 10.1016/j.resuscitation.2023.109972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA.
| |
Collapse
|
8
|
Kapoor S, Kolchinski A, Gusdon AM, Premraj L, Cho SM. Plasma biomarkers for brain injury in extracorporeal membrane oxygenation. Acute Crit Care 2023; 38:389-398. [PMID: 38052506 PMCID: PMC10718502 DOI: 10.4266/acc.2023.01368] [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: 10/27/2023] [Revised: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiorespiratory failure. Despite its benefits, ECMO carries a significant risk of neurological complications, including acute brain injury (ABI). Although standardized neuromonitoring and neurological care have been shown to improve early detection of ABI, the inability to perform neuroimaging in a timely manner is a major limitation in the accurate diagnosis of neurological complications. Therefore, blood-based biomarkers capable of detecting ongoing brain injury at the bedside are of great clinical significance. This review aims to provide a concise review of the current literature on plasma biomarkers for ABI in patients on ECMO support.
Collapse
Affiliation(s)
- Shrey Kapoor
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anna Kolchinski
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M. Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Lavienraj Premraj
- Griffith University School of Medicine, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
| | - Sung-Min Cho
- Division of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
9
|
Jeung KW, Jung YH, Gumucio JA, Salcido DD, Menegazzi JJ. Benefits, key protocol components, and considerations for successful implementation of extracorporeal cardiopulmonary resuscitation: a review of the recent literature. Clin Exp Emerg Med 2023; 10:265-279. [PMID: 37439142 PMCID: PMC10579726 DOI: 10.15441/ceem.23.063] [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: 05/24/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 07/14/2023] Open
Abstract
The application of venoarterial extracorporeal membrane oxygenation (ECMO) in patients unresponsive to conventional cardiopulmonary resuscitation (CPR) has significantly increased in recent years. To date, three published randomized trials have investigated the use of extracorporeal CPR (ECPR) in adults with refractory out-of-hospital cardiac arrest. Although these trials reported inconsistent results, they suggest that ECPR may have a significant survival benefit over conventional CPR in selected patients only when performed with strict protocol adherence in experienced emergency medical services-hospital systems. Several studies suggest that identifying suitable ECPR candidates and reducing the time from cardiac arrest to ECMO initiation are key to successful outcomes. Prehospital ECPR or the rendezvous approach may allow more patients to receive ECPR within acceptable timeframes than ECPR initiation on arrival at a capable hospital. ECPR is only one part of the system of care for resuscitation of cardiac arrest victims. Optimizing the chain of survival is critical to improving outcomes of patients receiving ECPR. Further studies are needed to find the optimal strategy for the use of ECPR.
Collapse
Affiliation(s)
- Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jorge Antonio Gumucio
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David D. Salcido
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James J. Menegazzi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
10
|
Wang L, Li C, Hao X, Rycus P, Tonna JE, Alexander P, Fan E, Wang H, Yang F, Hou X. Percutaneous cannulation is associated with lower rate of severe neurological complication in femoro-femoral ECPR: results from the Extracorporeal Life Support Organization Registry. Ann Intensive Care 2023; 13:77. [PMID: 37646841 PMCID: PMC10469150 DOI: 10.1186/s13613-023-01174-1] [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: 05/31/2023] [Accepted: 08/19/2023] [Indexed: 09/01/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xin Hao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Peter Rycus
- Extracorporeal Life Support Organization (ELSO), University of Michigan, Ann Arbor, MI, USA
| | - Joseph E Tonna
- Division of Emergency Medicine, Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Peta Alexander
- Department of Cardiology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China.
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China.
| |
Collapse
|
11
|
Cai J, Abudou H, Chen Y, Wang H, Wang Y, Li W, Li D, Niu Y, Chen X, Liu Y, Li Y, Liu Z, Meng X, Fan H. The effects of ECMO on neurological function recovery of critical patients: A double-edged sword. Front Med (Lausanne) 2023; 10:1117214. [PMID: 37064022 PMCID: PMC10098123 DOI: 10.3389/fmed.2023.1117214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/16/2023] [Indexed: 04/01/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) played an important role in the treatment of patients with critical care such as cardiac arrest (CA) and acute respiratory distress syndrome. ECMO is gradually showing its advantages in terms of speed and effectiveness of circulatory support, as it provides adequate cerebral blood flow (CBF) to the patient and ensures the perfusion of organs. ECMO enhances patient survival and improves their neurological prognosis. However, ECMO-related brain complications are also important because of the high risk of death and the associated poor outcomes. We summarized the reported complications related to ECMO for patients with CA, such as north–south syndrome, hypoxic–ischemic brain injury, cerebral ischemia–reperfusion injury, impaired intracranial vascular autoregulation, embolic stroke, intracranial hemorrhage, and brain death. The exact mechanism of ECMO on the role of brain function is unclear. Here we review the pathophysiological mechanisms associated with ECMO in the protection of neurologic function in recent years, as well as the ECMO-related complications in brain and the means to improve it, to provide ideas for the treatment of brain function protection in CA patients.
Collapse
Affiliation(s)
- Jinxia Cai
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Halidan Abudou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yuansen Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Haiwang Wang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yiping Wang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Wenli Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Duo Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanxiang Niu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Xin Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Yongmao Li
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- *Correspondence: Ziquan Liu,
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- Xiangyan Meng,
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, China
- Haojun Fan,
| |
Collapse
|
12
|
Kannapadi NV, Jami M, Premraj L, Etchill EW, Giuliano K, Bush EL, Kim BS, Seal S, Whitman G, Cho SM. Neurological Complications in COVID-19 Patients With ECMO Support: A Systematic Review and Meta-Analysis. Heart Lung Circ 2022; 31:292-298. [PMID: 34756659 PMCID: PMC8553269 DOI: 10.1016/j.hlc.2021.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/11/2021] [Accepted: 10/07/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with Coronavirus disease 2019 (COVID-19)-related acute respiratory disease (ARDS) increasingly receive extracorporeal membrane oxygenation (ECMO) support. While ECMO has been shown to increase risk of stroke, few studies have examined this association in COVID-19 patients. OBJECTIVE We conducted a systematic review to characterise neurological events during ECMO support in COVID-19 patients. DESIGN Systematic review of cohort and large case series of COVID-19 patients who received ECMO support. DATA SOURCES Studies retrieved from PubMed, EMBASE, Cochrane, Cochrane COVID-19 Study Register, Web of Science, Scopus, Clinicaltrials.gov, and medRχiv from inception to November 11, 2020. ELIGIBILITY CRITERIA Inclusion criteria were a) Adult population (>18 year old); b) Positive PCR test for SARS-CoV-2 with active COVID-19 disease; c) ECMO therapy due to COVID-19 ARDS; and d) Neurological events and outcome described while on ECMO support. We excluded articles when no details of neurologic events were available. RESULTS 1,322 patients from 12 case series and retrospective cohort studies were included in our study. The median age was 49.2, and 75% (n=985) of the patients were male. Diabetes mellitus and dyslipidaemia were the most common comorbidities (24% and 20%, respectively). Most (95%, n=1,241) patients were on venovenous ECMO with a median P:F ratio at the time of ECMO cannulation of 69.1. The prevalence of intracranial haemorrhage (ICH), ischaemic stroke, and hypoxic ischaemic brain injury (HIBI) was 5.9% (n=78), 1.1% (n=15), and 0.3% (n=4), respectively. The overall mortality of the 1,296 ECMO patients in the 10 studies that reported death was 36% (n=477), and the mortality of the subset of patients who had a neurological event was 92%. CONCLUSIONS Neurological injury is a concern for COVID-19 patients who receive ECMO. Further research is required to explore how neuromonitoring protocols can inform tailored anticoagulation management and improve survival in COVID-19 patients with ECMO support.
Collapse
Affiliation(s)
- Nivedha V Kannapadi
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghana Jami
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katherine Giuliano
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Errol L Bush
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, MD, USA
| | - Stella Seal
- Department of Hospital, Health and Community Services, Johns Hopkins University School of Medicine, MD, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
13
|
Lim JH, Chakaramakkil MJ, Tan BKK. Extracorporeal life support in adult patients with out-of-hospital cardiac arrest. Singapore Med J 2022; 62:433-437. [PMID: 35001109 DOI: 10.11622/smedj.2021113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The use of extracorporeal life support in cardiopulmonary resuscitation (CPR) of adult patients experiencing out-of-hospital cardiac arrest by the application of veno-arterial extracorporeal membrane oxygenation (ECMO) during cardiac arrest has been increasing over the past decade. This can be attributed to the encouraging results of extracorporeal CPR (ECPR) in multiple observational studies. To date, only one randomised controlled trial has compared ECPR to conventional advanced life support measures. Patient selection is crucial for the success of ECPR programmes. A rapid and organised approach is required for resuscitation, i.e. cannula insertion with ECMO pump initiation in combination with other aspects of post-cardiac arrest care such as targeted temperature management and early coronary reperfusion. The provision of an ECPR service can be costly, resource intensive and technically challenging, as limited studies have reported on its cost-effectiveness.
Collapse
Affiliation(s)
- Jia Hao Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | | | | |
Collapse
|
14
|
Yin T, Becker LB, Choudhary RC, Takegawa R, Shoaib M, Shinozaki K, Endo Y, Homma K, Rolston DM, Eguchi S, Ariyoshi T, Matsumoto A, Oka K, Takahashi M, Aoki T, Miyara SJ, Nishikimi M, Sasaki J, Kim J, Molmenti EP, Hayashida K. Hydrogen gas with extracorporeal cardiopulmonary resuscitation improves survival after prolonged cardiac arrest in rats. J Transl Med 2021; 19:462. [PMID: 34781966 PMCID: PMC8594155 DOI: 10.1186/s12967-021-03129-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/23/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Despite the benefits of extracorporeal cardiopulmonary resuscitation (ECPR) in cohorts of selected patients with cardiac arrest (CA), extracorporeal membrane oxygenation (ECMO) includes an artificial oxygenation membrane and circuits that contact the circulating blood and induce excessive oxidative stress and inflammatory responses, resulting in coagulopathy and endothelial cell damage. There is currently no pharmacological treatment that has been proven to improve outcomes after CA/ECPR. We aimed to test the hypothesis that administration of hydrogen gas (H2) combined with ECPR could improve outcomes after CA/ECPR in rats. METHODS Rats were subjected to 20 min of asphyxial CA and were resuscitated by ECPR. Mechanical ventilation (MV) was initiated at the beginning of ECPR. Animals were randomly assigned to the placebo or H2 gas treatment groups. The supplement gas was administered with O2 through the ECMO membrane and MV. Survival time, electroencephalography (EEG), brain functional status, and brain tissue oxygenation were measured. Changes in the plasma levels of syndecan-1 (a marker of endothelial damage), multiple cytokines, chemokines, and metabolites were also evaluated. RESULTS The survival rate at 4 h was 77.8% (7 out of 9) in the H2 group and 22.2% (2 out of 9) in the placebo group. The Kaplan-Meier analysis showed that H2 significantly improved the 4 h-survival endpoint (log-rank P = 0.025 vs. placebo). All animals treated with H2 regained EEG activity, whereas no recovery was observed in animals treated with placebo. H2 therapy markedly improved intra-resuscitation brain tissue oxygenation and prevented an increase in central venous pressure after ECPR. H2 attenuated an increase in syndecan-1 levels and enhanced an increase in interleukin-10, vascular endothelial growth factor, and leptin levels after ECPR. Metabolomics analysis identified significant changes at 2 h after CA/ECPR between the two groups, particularly in D-glutamine and D-glutamate metabolism. CONCLUSIONS H2 therapy improved mortality in highly lethal CA rats rescued by ECPR and helped recover brain electrical activity. The underlying mechanism might be linked to protective effects against endothelial damage. Further studies are warranted to elucidate the mechanisms responsible for the beneficial effects of H2 on ischemia-reperfusion injury in critically ill patients who require ECMO support.
Collapse
Affiliation(s)
- Tai Yin
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Lance B Becker
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Rishabh C Choudhary
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Ryosuke Takegawa
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Muhammad Shoaib
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Koichiro Shinozaki
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Yusuke Endo
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Daniel M Rolston
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Shuhei Eguchi
- R&D Division, Miyarisan Pharmaceutical Co., Ltd., Saitama, Japan
| | - Tadashi Ariyoshi
- R&D Division, Miyarisan Pharmaceutical Co., Ltd., Saitama, Japan
| | - Asami Matsumoto
- R&D Division, Miyarisan Pharmaceutical Co., Ltd., Saitama, Japan
| | - Kentaro Oka
- R&D Division, Miyarisan Pharmaceutical Co., Ltd., Saitama, Japan
| | | | - Tomoaki Aoki
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Santiago J Miyara
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Mitsuaki Nishikimi
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Junhwan Kim
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | | | - Kei Hayashida
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA. .,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA. .,Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan.
| |
Collapse
|
15
|
Zhang H, Xu J, Yang X, Zou X, Shu H, Liu Z, Shang Y. Narrative Review of Neurologic Complications in Adults on ECMO: Prevalence, Risks, Outcomes, and Prevention Strategies. Front Med (Lausanne) 2021; 8:713333. [PMID: 34660625 PMCID: PMC8513760 DOI: 10.3389/fmed.2021.713333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/02/2021] [Indexed: 01/18/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.
Collapse
Affiliation(s)
- Hongling Zhang
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
16
|
Luo Y, Gu Q, Wen X, Li Y, Peng W, Zhu Y, Hu W, Xi S. Neurological Complications of Veno-Arterial Extracorporeal Membrane Oxygenation: A Retrospective Case-Control Study. Front Med (Lausanne) 2021; 8:698242. [PMID: 34277671 PMCID: PMC8280317 DOI: 10.3389/fmed.2021.698242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background: To explore the epidemiology, clinical features, risk indicators, and long-term outcomes of neurological complications caused by veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Methods: We retrospectively analyzed 60 adult patients who underwent V-A ECMO support in our unit from February 2012 to August 2020. These patients were separated into the neurological complications group (NC group) and the non-neurological complications group (nNC group). The differences in basic data and ECMO data between the two groups were compared. The data of long-term neurological prognosis were collected by telephone follow-up. Results: Thirty-nine patients (65.0%) had neurological complications. There were significant differences between the two groups in terms of median age, hypertension, median blood urea nitrogen, median troponin I (TNI), median lactic acid, pre-ECMO percutaneous coronary intervention, continuous renal replacement therapy (CRRT), median Sequential Organ Failure Assessment score, median Acute Physiology and Chronic Health Evaluation II score, median peak inspiratory pressure, median positive end expiratory pressure, and median fresh frozen plasma (P < 0.05). The median Intensive Care Unit length of stay (ICU LOS), 28-day mortality, median post-ECMO vasoactive inotropic score, non-pulsate perfusion (NP), and median ECMO duration of the NC group were significantly higher than those of the nNC group (P < 0.05). Furthermore, multiple logistic regression analysis revealed that TNI (P = 0.043), CRRT (P = 0.047), and continuous NP > 12 h (P = 0.043) were independent risk indicators for neurological complications in patients undergoing ECMO. Forty-four patients (73.3%) survived after discharge, and 38 patients (63.3%) had Cerebral Performance Category score of 1–2. And there were significant differences between the two groups in long-term neurological outcomes after discharge for 6 months (P < 0.05). Conclusion: The incidence of neurological complications was higher in patients undergoing V-A ECMO and was closely related to adverse outcomes (including ICU LOS and 28-day mortality). TNI, CRRT, and continuous NP > 12 h were independent risk indicators for predicting neurological complications in ECMO supporting patients. And the neurological complications of patients during ECMO support had significant adverse effect on long-term surviving and neurological outcomes of patients after discharge for 6 months.
Collapse
Affiliation(s)
- Yinan Luo
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiao Gu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Wen
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiwei Li
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weihua Peng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Zhu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
17
|
Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review. Curr Treat Options Neurol 2021; 23:15. [PMID: 33814895 PMCID: PMC8009934 DOI: 10.1007/s11940-021-00671-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 01/21/2023]
Abstract
Purpose Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists. Recent findings The most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death. These result from events prior to initiation of ECMO, failure of ECMO to provide adequate oxygen delivery, and/or complications that occur during ECMO. ECMO survivors also experience neurological and psychological sequelae similar to other survivors of critical illness. Summary Since many of the risk factors for neurologic injury cannot be easily mitigated, early diagnosis and intervention are crucial to limit morbidity and mortality from neurologic injury during ECMO.
Collapse
|
18
|
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.
Collapse
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.
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Abstract
Supplemental Digital Content is available in the text. Objectives: We aimed to determine if elevations in serum neuron-specific enolase are associated with brain injury and outcomes in adults who require venoarterial extracorporeal membrane oxygenation. Design: Prospective observational study. Setting: Two ICUs of a university hospital, Paris, France. Patients: Consecutive adult patients treated with venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock or in-hospital refractory cardiac arrest. Interventions: None. Measurements and Main Results: Serum sampled 1, 3, and 7 days after venoarterial extracorporeal membrane oxygenation cannulation was stored at –80°C and neuron-specific enolase concentrations were measured in batches at the end of the study. The association between neuron-specific enolase concentrations and outcomes (28-d mortality and poor outcome, defined by a score of 4–6 on the modified Rankin scale at 90 d) were explored by multivariable logistic regression, with neuron-specific enolase concentrations dichotomized according to median values. One-hundred three patients were included, of whom 26 (25%) received preextracorporeal membrane oxygenation cardiopulmonary resuscitation. Median (interquartile range) day-1, day-3, and day-7 neuron-specific enolase serum concentrations were 37 μg/L (26–51 μg/L), 25 μg/L (19–37) μg/L, and 22 μg/L (17–31 μg/L). After adjustment for Simplified Acute Physiology Score II, preextracorporeal membrane oxygenation cardiopulmonary resuscitation, and Sepsis Organ Failure Assessment score at time of cannulation, a day-3 neuron-specific enolase greater than 25 μg/L remained independently associated with 28-day mortality (adjusted odds ratio, 4.98; 95% CI, 1.86–13.32) and poor outcome at 90 days (adjusted odds ratio, 4.63; 95% CI, 1.81–11.84). A day-3 neuron-specific enolase threshold greater than 80 μg/L had a 100% specificity for prediction of both mortality (95% CI, 92–100%) and poor functional outcome (95% CI, 89–100%). In a subset of patients who underwent brain CT, neuron-specific enolase concentrations were significantly higher in patients diagnosed with stroke, as compared with those without stroke. Conclusions: In adult patients under venoarterial extracorporeal membrane oxygenation, day-3 serum neuron-specific enolase concentrations are independently associated with short-term mortality and poor functional outcomes. These findings deserve validation in a multicenter setting.
Collapse
|
21
|
Magalhaes E, Reuter J, Wanono R, Bouadma L, Jaquet P, Tanaka S, Sinnah F, Ruckly S, Dupuis C, de Montmollin E, Para M, Braham W, Pisani A, d'Ortho MP, Rouvel-Tallec A, Timsit JF, Sonneville R. Early EEG for Prognostication Under Venoarterial Extracorporeal Membrane Oxygenation. Neurocrit Care 2020; 33:688-694. [PMID: 32789602 DOI: 10.1007/s12028-020-01066-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND/OBJECTIVES Tools for prognostication of neurologic outcome of adult patients under venoarterial ECMO (VA-ECMO) have not been thoroughly investigated. We aimed to determine whether early standard electroencephalography (stdEEG) can be used for prognostication in adults under VA-ECMO. METHODS Prospective single-center observational study conducted in two intensive care units of a university hospital, Paris, France. Early stdEEG was performed on consecutive adult patients treated with VA-ECMO for refractory cardiogenic shock or refractory cardiac arrest. The association between stdEEG findings and unfavorable outcome was investigated. The primary endpoint was 28-day mortality. The secondary endpoint was severe disability or death at 90 days, defined by a score of 4-6 on the modified Rankin scale. RESULTS A total of 122 patients were included, of whom 35 (29%) received cardiopulmonary resuscitation before VA-ECMO cannulation. Main stdEEG findings included low background frequency ≤ 4 Hz (n = 27, 22%) and background abnormalities, i.e., a discontinuous (n = 20, 17%) and/or an unreactive background (n = 12, 10%). Background abnormalities displayed better performances for prediction of unfavorable outcomes, as compared to clinical parameters at time of recording. An unreactive stdEEG background in combination with a background frequency ≤ 4 Hz had a false positive rate of 0% for prediction of unfavorable outcome at 28 days and 90 days, with sensitivities of 8% and 6%, respectively. After adjustment for confounders, a lower background frequency was independently associated with unfavorable outcome at 28 days (adjusted odds ratio per 1-Hz increment, 95% CI 0.71, 0.52-0.97), whereas no such independent association was observed at 90 days. CONCLUSION Standard EEG abnormalities recorded at time of VA-ECMO initiation are predictive of unfavorable outcomes. However, the low sensitivity of these parameters highlights the need for a multimodal evaluation for improving management of care and prognostication.
Collapse
Affiliation(s)
- Eric Magalhaes
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France
| | - Jean Reuter
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France.,INSERM UMR1148, Team 6, Université de Paris, 75018, Paris, France
| | - Ruben Wanono
- Department of Physiology, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Lila Bouadma
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France.,UMR 1137, IAME, Université de Paris, Paris, France
| | - Pierre Jaquet
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France
| | - Sébastien Tanaka
- Department of Anesthesiology and Intensive Care, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France.,INSERM 1188, DéTROI, Reunion Island University, Saint-Denis de la Réunion, France
| | - Fabrice Sinnah
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France
| | | | - Claire Dupuis
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France.,UMR 1137, IAME, Université de Paris, Paris, France
| | - Etienne de Montmollin
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France.,UMR 1137, IAME, Université de Paris, Paris, France
| | - Marylou Para
- Department of Cardiac Surgery, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Wael Braham
- Department of Cardiac Surgery, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Angelo Pisani
- Department of Cardiac Surgery, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Marie-Pia d'Ortho
- Department of Physiology, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Anny Rouvel-Tallec
- Department of Physiology, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Jean-François Timsit
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France.,UMR 1137, IAME, Université de Paris, Paris, France
| | - Romain Sonneville
- Department of Intensive Care Medicine, AP-HP, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris Cedex, France. .,INSERM UMR1148, Team 6, Université de Paris, 75018, Paris, France.
| | | |
Collapse
|