Examining Noncardiac Surgical Procedures in Patients on Extracorporeal Membrane Oxygenation

Total Thyroidectomy while on Extracorporeal Membrane Oxygenation for Thyroid Storm

Thyroid storm is an acute life-threatening condition of hyperthyroidism that can present with cardiac failure, requiring extracorporeal membrane oxygenation (ECMO). We present the first case reported of total thyroidectomy successfully performed while on ECMO for thyroid storm in a 32-year-old male. This case highlights the challenges of managing refractory thyroid storm with multi-organ failure. We demonstrate that total thyroidectomy may still be safely performed while on ECMO for thyroid storm, if steps are taken to optimise the patient perioperatively, with careful surgical and anaesthesia planning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04430-9.

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

Shifting surgical archetypes of ICG fluorescent-angiography for bowel perfusion assessment in cardiogenic shock under ECMO support

Extracorporeal membrane oxygenation (ECMO) has been adopted to support patients with acute severe cardiac or pulmonary failure that is potentially reversible and unresponsive to conventional management. Mesenteric ischemia (MI) can present as a life-threatening complication in patients receiving veno-arterial echocardiogram (ECHO) support. Due to the nature and acuity of these conditions, determining adequate perfusion upon surgical intervention is challenging for the operating surgeon, especially in cardiogenic shock (CS) patients on ECMO support persenting low arterial pulsatility. Indocyanine green fluorescent angiography (ICG-FA) has proven to be useful for real-time assessment of vascular perfusion, which may help determine the extent of bowel ischemia in patients receiving ECMO support. The case report here-in presented, breaks the paradigm of performing non-cardiac surgical procedures on ECMO support via a pioneering visual aid technique. LEARNING OBJECTIVE: ICG-FA is a promising visual intraoperatory technique providing real-time feedback for the adequate identification and assessment of target tissue/organs. The high morbidity and mortality rates associated to MI and CS-particularly when concomitantly present-hinders salvage surgical therapy. The use of ECMO provides hemodynamic stability This case report highlights the importance of adequate surgical intervention under extracorporeal life support in the presence of both CS and MI. To the authors' knowledge, this is the first report of application of ICG-FA to evaluate mesenteric perfusion in a patient receiving ECMO support.

A 21-Year-Old Man With a Cough

CASE PRESENTATION

A 21-year-old male African American college student from Southern California, with no significant medical history, was visiting family in southwestern Texas when he presented to the hospital with 1 week history of cough, shortness of breath, lower back pain, and a 10-pound weight loss.

Surgery in Neonatal and Pediatric ECMO Patients Other Than Congenital Diaphragmatic Hernia Repair: A 10-Year Experience

Aim of Study: The use of extracorporeal membrane oxygenation (ECMO) has increased as a result of technological developments and the expansion of indications. Relatedly, the number of patients undergoing surgery during ECMO is also rising, at least in the adult population. Little is known on surgery in children during ECMO-therapy. We therefore aimed to assess the frequencies and types of surgical interventions in neonatal and pediatric patients on ECMO and to analyze surgery-related morbidity and mortality. Methods: We retrospectively collected information of all patients on ECMO over a 10-year period in a single tertiary and designated ECMO-center, excluding patients undergoing cardiac surgery, and correction of congenital diaphragmatic hernia. Chi-squared test and Mann-Whitney U test were used to analyze data. Main Results: Thirty-two of 221 patients (14%) required surgery when on ECMO. Common interventions were thoracotomy (32%), laparotomy (23%), fasciotomy (17%), and surgical revision of ECMO (15%). Complications occurred in 28 cases (88%), resulting in a 50% in-hospital mortality rate. Surgical patients had a longer ICU stay and longer total hospital stay compared to those not receiving surgery during ECMO. No significant difference in mortality was found when comparing surgical to non-surgical patients (50 vs. 41%). Conclusions: Approximately one in seven neonatal or pediatric patients required surgical intervention during ECMO, of whom almost 90% developed a complication, resulting in a 50% mortality rate. These results should be taken into account in counseling.

Outcomes of noncardiotomy patients requiring postoperative extracorporeal membrane oxygenation

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) in the postoperative period has expanded to include a variety of noncardiotomy procedures. It is important to investigate outcomes for this uniquely ill subset of patients as currently published data on this subject is limited.

METHODS

All ECMO events at our institution from 2006 to 2017 were retrospectively considered. Patients were grouped into a postoperative noncardiotomy (PNC) cohort (n = 20) and a larger control cohort (n = 220). For additional analysis, the PNC cohort was further split into a liver transplant group (n = 4) and thoracic surgery group (n = 10). Basic demographics, medical history, type of operation performed, indication for support, and survival data were collected on all patients. Appropriate statistical analyses were performed and a P < .05 was considered statistically significant.

RESULTS

Twenty PNC-ECMO patients were identified. The indications for support were respiratory failure, cardiac arrest, and cardiogenic shock. PNC patient survival was similar to our control cohort, as well as extracorporeal life support organization (ELSO) published data with 55% weaning off ECMO and 50% surviving to discharge. Twelve-month predicted survival was 40%. Post thoracic surgical patients were reviewed, and their survival rates were similar to the larger control cohort as well. There were no survivors in the liver transplant group.

CONCLUSIONS

Despite recent noncardiotomy surgery, patients who required ECMO for salvage in the postoperative period showed similar outcomes compared to our larger cohort and to published ELSO data, and reasonable long-term survival outcomes. This suggests that ECMO may be applied to a variety of postoperative settings with outcomes on par with nationally published results.

Emergency Abdominal Surgery Outcomes of Critically Ill Patients on Extracorporeal Membrane Oxygenation: A Case-Matched Study with a Propensity Score Analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) induces coagulation disorders increasing the risk of bleeding during invasive procedures. We aimed to describe the outcomes of critically ill ECMO patients undergoing emergency abdominal surgery compared to non-ECMO patients.

STUDY DESIGN

This is a retrospective case-matched single-center study with propensity score analysis in a tertiary ICU. All patients who underwent abdominal surgery were included.

RESULTS

From 2006 to 2014, 77 patients admitted in our ICU underwent emergency abdominal surgery, 35 were on ECMO. Surgery indications were comparable for ECMO and non-ECMO patients: mostly intestinal ischemia (42%) and cholecystectomy (25%). Postoperative bleeding was significantly more frequent in ECMO group versus non-ECMO: 77% versus 40% transfused, with medians of 13 (6-22) versus 3 (0-5) packed red blood cell; 9 (3-17) versus 0 (0-4) fresh frozen plasma and 12 (3-22) versus 0 (0-8) platelet units (p < 0.001 for all items). Reintervention for hemorrhage was required in 20% versus 2%, respectively, p = 0.02. At multivariable analysis, ECMO was strongly associated with bleeding (OR, 5.6 [95% CI, 2.0-15.4]; p = 0.001). ICU mortality was higher for ECMO-treated patients (69% vs. 33%; p = 0.003), but perioperative mortality remained comparable between groups (11% vs. 12%, NS). Propensity score-matched analysis confirmed more frequent and severe bleeding in ECMO patients.

CONCLUSIONS

Abdominal surgery procedures on ECMO-treated patients are associated with a higher risk of hemorrhage compared to non-ECMO ICU patients. Further studies are needed to optimize ECMO patient management during such interventions.

Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study

PURPOSE

There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre.

MATERIALS AND METHODS

A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017.

RESULTS

The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required.

CONCLUSION

Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.

Incidence of general surgical procedures in adult patients on extracorporeal membrane oxygenation

Purpose

Extracorporeal membrane oxygenation use may predispose patients to developing conditions that require either consultation with a general surgeon or a general surgical procedure. We aimed to evaluate the incidence and outcomes of adult extracorporeal membrane oxygenation patients who underwent general surgical procedure.

Methods

This was a single institution retrospective study of adult extracorporeal membrane oxygenation patients from 2012 to 2015. Outcomes were compared between patients who underwent general surgical procedure with those that did not.

Results

Of the 115 patients, 54 (46.9%) required a general surgeon while 42 (36.5%) required a general surgical procedure. No significant differences were observed in mortality (35.7% vs. 46.6%; p = 0.256) and extracorporeal membrane oxygenation-related complications (45.7% vs. 32.5%; p = 0.175). Patients with general surgical procedure had longer extracorporeal membrane oxygenation duration (13 vs. 5 days; p < 0.0001), longer length of stay (36 vs. 15 days; p = 0.0005), more wound infections (19.05% vs. 5.5%; p = 0.029), more urinary tract infections (38.1% vs. 10.96%; p = 0.0006), and more pulmonary emboli (19.05% vs. 5.48%; p = 0.029). In general surgical procedure patients, no difference in bleeding complications was observed regardless of anti-coagulation status (29.4% vs. 16%; p = 0.44).

Conclusion

Common general surgical procedures are safe and feasible in adult extracorporeal membrane oxygenation patients. Duration of extracorporeal membrane oxygenation was longer for patients requiring general surgical procedure. Despite the common use of anticoagulants, there was no increase in bleeding events in general surgical procedure patients.

Thoracic Bleeding Complications in Patients With Venovenous Extracorporeal Membrane Oxygenation

BACKGROUND

Patients with respiratory failure are treated more frequently with venovenous extracorporeal membrane oxygenation (vv-ECMO). These patients are at risk for bleeding due to complex multifactorial coagulation disorders resulting from the extracorporeal circulation.

METHODS

A retrospective analysis was conducted of prospectively collected data on all patients requiring vv-ECMO between December 2010 and December 2016. End points were the incidence, consequence, and in-hospital mortality of patients with thoracic bleeding complications.

RESULTS

The study included 418 patients (aged 50 ± 16.5 years) requiring vv-ECMO. In 23.2% (n = 97) of patients, relevant hemorrhage was documented. Thoracic bleeding developed in 40 patients (41.2%), followed by diffuse (21.6%), cerebral (14.4%), gastrointestinal (6.2%), cannulation site (6.2%), and other bleeding locations. Thoracic bleeding complications occurred spontaneously (40%), postoperatively (37.5%), after interventions (20%), and after trauma (2.5%). A thoracic operation was performed in 60% (n = 24) of these patients, and a repeated operation due to bleeding was necessary in 45.8%. Mean ECMO duration (18.6 ± 16.8 days; p = 0.035) and hospital length of stay (58 ± 50 days; p = 0.002) were significantly longer than that in patients without bleeding. In-hospital mortality was significantly higher in patients with thoracic bleeding complications (52.5%) than in patients without bleeding complications (32.7%; p = 0.013).

CONCLUSIONS

Thoracic bleeding complications were observed in 9.6% of patients and represented the most frequent bleeding complication during vv-ECMO treatment. Almost 60% of patients required surgical revision, and nearly half of these patients underwent a repeated operation. Because mortality is high in these patients, vv-ECMO should be performed in only centers experienced with thoracic surgery.

Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery

The use of venovenous extracorporeal membrane oxygenation is increasing worldwide. These patients often require noncardiac surgery. In the perioperative period, preoperative assessment, patient transport, choice of anesthetic type, drug dosing, patient monitoring, and intraoperative and postoperative management of common patient problems will be impacted. Furthermore, common monitoring techniques will have unique limitations. Importantly, patients on venovenous extracorporeal membrane oxygenation remain subject to hypoxemia, hypercarbia, and acidemia in the perioperative setting despite extracorporeal support. Treatments of these conditions often require both manipulation of extracorporeal membrane oxygenation settings and physiologic interventions. Perioperative management of anticoagulation, as well as thresholds to transfuse blood products, remain highly controversial and must take into account the specific procedure, extracorporeal membrane oxygenation circuit function, and patient comorbidities. We will review the physiologic management of the patient requiring surgery while on venovenous extracorporeal membrane oxygenation.