Trends in Extracorporeal Membrane Oxygenation Growth in the United States, 2011-2014

A quality improvement initiative to increase adult ECMO decision-making abilities in a perfusion education program: The use of 3D ECMO simulation

INTRODUCTION

Adult and pediatric ECMO procedures have been increasingly established as conventional life-saving modalities in critical care services across the world. Since 2017, a multidisciplinary team of program advisors for our perfusion education program have aimed to increase cardiovascular perfusion (CVP) student ECMO exposure and improve clinical decision-making. In this QI intervention, the use of 3D computer-based simulation was assessed in establishing a standardized process to improve the diagnosis and treatment of adult ECMO complications among first year CVP students.

METHODS

The Califia 3D Patient Simulator was incorporated into the curriculum for first year CVP students (n = 26) along with traditional lecture for the adult ECMO complication laboratory session. Pre-class knowledge assessments using de-identified polling software were compared to post-class assessments following the first assigned learning activity. Assessments from students that received simulation before lecture (SIM, n = 15) were compared to students receiving lecture before simulation (LEC, n = 11). User experience questionnaires (UEQ) consisting of 26 questions for six scales of simulation instruction were administered to measure the comprehensive impression of the student experience.

RESULTS

Overall median [IQR] pre- and -post knowledge assessment scores were 74% [11] and 84% [11], respectively (p = 0.01). There were no significant differences in pre-class assessment scores between the SIM and LEC groups (74.0% and 74.0%, respectively, p = 0.959). The LEC group achieved higher median post-assessment scores than the SIM group (84% vs 79%, p = 0.032). Among the 26 UEQ survey scales, 23 were positively evaluated (>0.8), and three were a neutral evaluation (-0.8 to 0.8). Cronbach Alpha-Coefficients of >0.78 were measured for attractiveness, perspicuity, efficacy, and stimulation. The coefficient for dependability was 0.37. 25 (96.2%) students indicated that 3D simulation was beneficial to improving ECMO clinical decision-making.

CONCLUSIONS

In this QI intervention, the implementation of computer-based 3D simulation following lecture was perceived by learners to help improve the diagnosis and treatment of ECMO-related complications.

Neurological improvement following revision of vascular graft remnants in the upper extremity

Remnant vascular grafts may result in significant neurological deficits owing to compression of adjacent neural structures. We report this finding in two cases after extracorporeal membrane oxygenation decannulation and removal of an arteriovenous fistula in the upper extremity. In both cases, removal of the graft, patch arteriotomy, and external neurolysis resulted in significant recovery of neurological function. We review the preoperative workup, diagnostic studies, and technical approach to treatment in an effort to increase recognition among vascular and cardiovascular surgeons and to demonstrate a safe and effective management option through a multidisciplinary approach.

Regional access to a centralized extracorporeal membrane oxygenation (ECMO) service in Victoria, Australia

Introduction

Victoria, Australia provides a centralised state ECMO service, supported by ambulance retrieval. Equity of access to this service has not been previously described.

Objective

Describe the characteristics of ECMO recipients and quantify geographical and socioeconomic influence on access.

Design

Retrospective observational study with spatial mapping.

Participants and setting

Adult (≥18 years) ECMO recipients from July 2016-June 2022. Data from administrative Victorian Admissions Episodes Database analysed in conjunction with Australian Urban Research Infrastructure Network population data and choropleth mapping. Presumed ECMO modes were inferred from cardiopulmonary bypass and pre-hospital cardiac arrest codes. Spatial autoregressive models including Moran's test used for spatial lag testing.

Outcomes

Demographics and outcomes of ECMO recipients; ECMO incidence by patient residence (Statistical-Area Level 2, SA-2) and Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD); and ECMO utilisation adjusted for patient factors and linear distance from the central ECMO referral site.

Results

631 adults received ECMO over 6 years, after exclusion of paediatric (n = 242), duplicate (n = 135), and interstate or incomplete (n = 72) records. Mean age was 51.8 years, and 68.8 % were male. Overall ECMO incidence was 3.00 ± 3.95 per 105 population. 135 (21.4 %) were presumed VA-ECMO, 59 (9.3 %) presumed ECPR, and 437 (69.3 %) presumed VV-ECMO. Spatial lag was non-significant after adjusting for patient characteristics. Distance from the central referral site (dy/dx = 0.19, 95% CI -0.41-0.04, p = 0.105) and IRSAD score (dy/dx = 0.17, 95% CI -0.19-0.53, p = 0.359) did not predict ECMO utilisation.

Conclusion

Victorian ECMO incidence rates were low. We did not find evidence of inequity of access to ECMO irrespective of regional area or socioeconomic status.

Nursing in deathworlds: Necropolitics of the life, dying and death of an unhoused person in the United States healthcare industrial complex

This paper begins with the lived accounts of emergency and critical care medical interventions in which an unhoused person is brought to the emergency department in cardiac arrest. The case is a dramatised representation of the extent to which biopolitical forces via reduction to bare life through biopolitical and necropolitical operations are prominent influences in nursing and medical care. This paper draws on the scholarship of Michel Foucault, Giorgio Agamben, and Achille Mbembe to offer a theoretical analysis of the power dynamics that influence the health care and death care of patients who are caught in the auspices of a neoliberal capitalist healthcare apparatus. This paper offers analysis of the overt displays of biopower over those individuals cast aside as generally unworthy of access to healthcare in a postcolonial capitalist system, in addition to the ways in which humans are reduced to 'bare life' in their dying days. We analyse this case study through Agamben's description of thanatopolitics, a 'regime of death', and the technologies that accompany the dying process, particularly in that of the homo sacer. Additionally, this paper illustrates the ways in which necropolitics and biopower are integral to understanding how the most advanced and expensive medical interventions make visible the political values of the healthcare system and how nurses and healthcare functions in these deathworlds. The purpose of this paper is to develop a greater understanding of biopolitical and necropolitical operations in acute and critical care environments, and to offer guidance to nurses in these spaces as they work to uphold ethical duties in a system that increasingly dehumanises.

Disparities in Adult Patient Selection for Extracorporeal Membrane Oxygenation in the United States: A Population-Level Study

Rationale: Disparities in patient selection for advanced therapeutics in health care have been identified in multiple studies, but it is unclear if disparities exist in patient selection for extracorporeal membrane oxygenation (ECMO), a rapidly expanding critical care resource. Objectives: To determine if disparities exist in patient selection for ECMO based on sex, primary insurance, and median income of the patient's neighborhood. Methods: In a retrospective cohort study using the Nationwide Readmissions Database 2016-2019, we identified patients treated with mechanical ventilation (MV) and/or ECMO with billing codes. Patient sex, insurance, and income level for patients receiving ECMO were compared with the patients treated with MV only, and hierarchical logistic regression with the hospital as a random intercept was used to determine odds of receiving ECMO based on patient demographics. Results: We identified 2,170,752 MV hospitalizations with 18,725 cases of ECMO. Among patients treated with ECMO, 36.1% were female compared with 44.5% of patients treated with> MV only (adjusted odds ratio [aOR] for ECMO, 0.73; 95% confidence interval [CI], 0.70-0.75). Of patients treated with ECMO, 38.1% had private insurance compared with 17.4% of patients treated with MV only. Patients with Medicaid were less likely to receive ECMO than patients with private insurance (aOR, 0.55; 95% CI, 0.52-0.57). Patients treated with ECMO were more likely to live in the highest-income neighborhoods compared with patients treated with MV only (25.1% vs. 17.3%). Patients living in the lowest-income neighborhoods were less likely to receive ECMO than those living in the highest-income neighborhoods (aOR, 0.63; 95% CI, 0.60-0.67). Conclusions: Significant disparities exist in patient selection for ECMO. Female patients, patients with Medicaid, and patients living in the lowest-income neighborhoods are less likely to be treated with ECMO. Despite possible unmeasured confounding, these findings were robust to multiple sensitivity analyses. On the basis of previous work describing disparities in other areas of health care, we speculate that limited access in some neighborhoods, restrictive/biased interhospital transfer practices, differences in patient preferences, and implicit provider bias may contribute to the observed differences. Future studies with more granular data are needed to identify and modify drivers of observed disparities.

Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature

OBJECTIVES

To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes.

DATA SOURCES

PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population).

STUDY SELECTION

Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support.

DATA EXTRACTION

Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool.

DATA SYNTHESIS

Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors.

CONCLUSIONS

Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.

Racial disparities in outcomes for extracorporeal membrane oxygenation in the United States

BACKGROUND

Racial disparities in extracorporeal membrane oxygenation (ECMO) outcomes in patients with a broad set of indications are not well documented.

METHODS

Adults requiring ECMO were identified in the 2016-2019 National Inpatient Sample. Patient and hospital characteristics, including mortality, clinical outcomes, and resource utilization were analyzed using multivariable regressions.

RESULTS

Of 43,190 adult ECMO patients, 67.8% were classified as White, 18.1% Black, and 10.4% Hispanic. Although mortality for Whites declined from 47.5 to 41.0% (P = 0.002), it remained steady for others. Compared to White, Asian/Pacific Islander (PI) race was linked to increased odds of mortalty (AOR = 1.4, 95% CI = 1.1-2.0). Black race was associated with increased odds of acute kidney injury (AOR = 1.4, 95%-CI: 1.2-1.7), while Hispanic race was linked to neurologic complications (AOR 21.6; 95% CI 1.2-2.3). Black and Hispanic race were also associated with increased incremental costs.

CONCLUSIONS

Race-based disparities in ECMO outcomes persist in the United States. Further work should aim to understand and mitigate the underlying reasons for such findings.

Outcomes With Direct and Indirect Thrombin Inhibition During Extracorporeal Membrane Oxygenation for COVID-19

Anticoagulation during extracorporeal membrane oxygenation (ECMO) for Coronovirus Disease 2019 (COVID-19) can be performed by direct or indirect thrombin inhibitors but differences in outcomes with these agents are uncertain. A retrospective, multicenter study was conducted. All consecutive adult patients with COVID-19 placed on ECMO between March 1, 2020 and April 30, 2021 in participating centers, were included. Patients were divided in groups receiving either a direct thrombin inhibitor (DTI) or an indirect thrombin inhibitor such as unfractionated heparin (UFH). Overall, 455 patients with COVID-19 from 17 centers were placed on ECMO during the study period. Forty-four patients did not receive anticoagulation. Of the remaining 411 patients, DTI was used in 160 (39%) whereas 251 (61%) received UFH. At 90-days, in-hospital mortality was 50% (DTI) and 61% (UFH), adjusted hazard ratio: 0.81, 95% confidence interval (CI): 0.49-1.32. Deep vein thrombosis [adjusted odds ratio (aOR): 2.60, 95% CI: 0.90-6.65], ischemic (aOR: 1.58, 95% CI: 0.18-14.0), and hemorrhagic (aOR:1.22, 95% CI: 0.39-3.87) stroke were similar with DTI in comparison to UFH. Bleeding requiring transfusion was lower in patients receiving DTI (aOR: 0.40, 95% CI: 0.18-0.87). Anticoagulants that directly inhibit thrombin are associated with similar in-hospital mortality, stroke, and venous thrombosis and do not confer a higher risk of clinical bleeding in comparison to conventional heparin during ECMO for COVID-19.

Rise in Percutaneous Vascular Procedures and Extracorporeal Membrane Oxygenation Is Associated With Increase in Emergent Vascular Operations

Background: The workload of vascular surgeons is widely affected by the procedural activity of other departments within the same medical center. The purpose of this study was to evaluate the trend in emergent vascular surgery procedures over a 5 year period in a tertiary referral hospital and categorize these procedures based on the nature of the operative procedure required. Methods: A single center, retrospective review of all emergent surgical operations performed at our tertiary referral hospital between the years 2017-2021. Data collected included types of emergent vascular surgery performed, in addition to procedures performed by the departments of interventional cardiology (IC), interventional radiology (IR), neurointerventional radiology (NIR) and extracorporeal membrane oxygenation (ECMO) at our institution. Results: During the study period were performed a total of 1783 operative procedures (mean 356 ± 26/year). Of those, 485 (27%) were emergent cases. We observed a gradual increase in emergent operative procedures performed from 2017 to 2021 (22% to 34% of all cases, increase of 56%, P<.01). A striking increase was seen with vascular repairs performed for iatrogenic vascular injuries secondary to arterial access complications (47% to 65% of all iatrogenic vascular injuries, increase of 38%). The increase correlated with an increase in activity seen in the departments of IC, IR/NIR and ECMO (15%, 31% and 300%, respectively). Conclusions: An increasing number of emergent surgical procedures performed by our vascular surgery department correlates with the increasing number of endovascular procedures performed by non- vascular services. As these procedures are expected to increase, together with the number of stroke units and ECMO units being created, medical centers must be aware that these may result in a significant increase in the workload of the vascular surgery department in order to deal with complications associated with these procedures.

Fatal adenovirus pneumonia in a 15-day-old infant despite extracorporeal life support treatment: A case report

Infections are one of the most common causes of severe neonatal diseases and the leading cause of neonatal death. Although respiratory viral infections are widespread, they are still not recognized as the predominant causes of neonatal deaths. Adenovirus infection is uncommon during the neonatal period, and it frequently has a fatal outcome. Furthermore, it is difficult to distinguish from other common bacterial and respiratory viral infections. The present study reports the case of a 15-day-old newborn who presented with coagulation disorders and hypoxemia in September, 2020. Human adenovirus of species D-53 (HAdV-D53) was detected in the blood and sputum. Severe pneumonia rapidly progressed to multiple organ failure syndrome and the patient succumbed to the disease, despite receiving extracorporeal membrane oxygenation.

Complications of Peripheral Cannulation Site in Obese Patients on Adult Extracorporeal Membrane Oxygenation

Placement of extracorporeal membrane oxygenation (ECMO) in obese patients has been challenging; however, cannulation risk in obese patients has not been clearly investigated. We therefore explored ECMO cannulation complications in this obese population. Data were reviewed from adult ECMO database from 2010 to 2019. Patients were stratified by body mass index (BMI) (normal weight [NW] [BMI 18.5-24.9], overweight [BMI 25-29.9], class I [BMI 30-34.9], class II [BMI 35-39.9], class III [BMI >40]). Patients with central cannulation were excluded from this study. Combined ECMO cannulation complications and survival data were retrospectively analyzed. There were 233 patients, 156 venoarterial (VA) ECMO patients (45 [28%] NW, 51 [33%] overweight, 37 [24%] class I, 12 [8%] class II, and 11 [7.0%] class III) and 77 venovenous (VV) ECMO patients (14 [18%] NW, 13 [17%] overweight, 17 [22%] class I, 11 [14%] class II, and 22 [29%] class III). There were significantly more cannulation site bleeds in VA class III (55%) patients compared with VA NW patients (22%), p = 0.006. There was no significant difference in cannulation site bleeding between BMI groups for VV ECMO. There was no difference in 30 day mortality, ECMO survival for all BMI groups in both VA and VV ECMO. There is significant increased risk of bleeding with peripheral VA cannulation of obese patients with BMI > 35. Cannulating surgeon should be aware of this bleeding risk in morbidly obese patient who undergo VA ECMO.

Proposal for a trial of early left ventricular venting during venoarterial extracorporeal membrane oxygenation for cardiogenic shock

Objective

Patients with profound cardiogenic shock may require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for circulatory support most commonly via the femoral vessels. The rate of cardiac recovery in this population remains low, possibly because peripheral VA-ECMO increases ventricular afterload. Whether direct ventricular unloading in peripheral VA-ECMO enhances cardiac recovery is unknown, but is being more frequently utilized. A randomized trial is warranted to evaluate the clinical effectiveness of percutaneous left ventricle venting to enhance cardiac recovery in the setting of VA-ECMO.

Methods

We describe the rationale, design, and initial testing of a randomized controlled trial of VA-ECMO with and without percutaneous left ventricle venting using a percutaneous micro-axial ventricular assist device.

Results

This is an ongoing prospective randomized controlled trial in adult patients with primary cardiac failure presenting in cardiogenic shock requiring peripheral VA-ECMO, designed to test the safety and effectiveness of percutaneous left ventricle venting in improving the rate of cardiac recovery.

Conclusions

The results of this nonindustry-sponsored trial will provide critical information on whether left ventricle unloading in peripheral VA-ECMO is safe and effective.

Clinical Characteristics, Complications and Outcomes of Patients with Severe Acute Respiratory Distress Syndrome Related to COVID-19 or Influenza Requiring Extracorporeal Membrane Oxygenation-A Retrospective Cohort Study

Extracorporeal membrane oxygenation (ECMO) represents a viable therapy option for patients with refractory acute respiratory distress syndrome (ARDS). Currently, veno-venous (vv) ECMO is frequently used in patients suffering from coronavirus disease 2019 (COVID-19). VV-ECMO was also frequently utilised during the influenza pandemic and experience with this complex and invasive treatment has increased worldwide since. However, data on comparison of clinical characteristics and outcome of patients with COVID-19 and influenza-related severe ARDS treated with vv-ECMO are scarce. This is a retrospective analysis of all consecutive patients treated with vv/(veno-arterial)va-ECMO between January 2009 and January 2021 at the University Medical Centre Hamburg-Eppendorf in Germany. All patients with confirmed COVID-19 or influenza were included. Patient characteristics, parameters related to ICU and vv/va-ECMO as well as clinical outcomes were compared. Mortality was assessed up to 90 days after vv/va-ECMO initiation. Overall, 113 patients were included, 52 (46%) with COVID-19 and 61 (54%) with influenza-related ARDS. Median age of patients with COVID-19 and influenza was 58 (IQR 53-64) and 52 (39-58) years (p < 0.001), 35% and 31% (p = 0.695) were female, respectively. Charlson Comorbidity Index was 3 (1-5) and 2 (0-5) points in the two groups (p = 0.309). Median SAPS II score pre-ECMO was 27 (24-36) vs. 32 (28-41) points (p = 0.009), and SOFA score was 13 (11-14) vs. 12 (8-15) points (p = 0.853), respectively. Median P/F ratio pre-ECMO was 64 (46-78) and 73 (56-104) (p = 0.089); pH was 7.20 (7.16-7.29) and 7.26 (7.18-7.33) (p = 0.166). Median days on vv/va-ECMO were 17 (7-27) and 11 (7-20) (p = 0.295), respectively. Seventy-one percent and sixty-nine percent had renal replacement therapy (p = 0.790). Ninety-four percent of patients with COVID-19 and seventy-seven percent with influenza experienced vv/va-ECMO-associated bleeding events (p = 0.004). Thirty-four percent and fifty-five percent were successfully weaned from ECMO (p = 0.025). Ninety-day mortality was 65% and 57% in patients with COVID-19 and influenza, respectively (p = 0.156). Median length of ICU stay was 24 (13-44) and 28 (16-14) days (p = 0.470), respectively. Despite similar disease severity, the use of vv/va-ECMO in ARDS related to COVID-19 and influenza resulted in similar outcomes at 90 days. A significant higher rate of bleeding complications and thrombosis was observed in patients with COVID-19.

Clinical Characteristics, Complications and Outcomes of Patients with Severe Acute Respiratory Distress Syndrome Related to COVID-19 or Influenza Requiring Extracorporeal Membrane Oxygenation-A Retrospective Cohort Study

Extracorporeal membrane oxygenation (ECMO) represents a viable therapy option for patients with refractory acute respiratory distress syndrome (ARDS). Currently, veno-venous (vv) ECMO is frequently used in patients suffering from coronavirus disease 2019 (COVID-19). VV-ECMO was also frequently utilised during the influenza pandemic and experience with this complex and invasive treatment has increased worldwide since. However, data on comparison of clinical characteristics and outcome of patients with COVID-19 and influenza-related severe ARDS treated with vv-ECMO are scarce. This is a retrospective analysis of all consecutive patients treated with vv/(veno-arterial)va-ECMO between January 2009 and January 2021 at the University Medical Centre Hamburg-Eppendorf in Germany. All patients with confirmed COVID-19 or influenza were included. Patient characteristics, parameters related to ICU and vv/va-ECMO as well as clinical outcomes were compared. Mortality was assessed up to 90 days after vv/va-ECMO initiation. Overall, 113 patients were included, 52 (46%) with COVID-19 and 61 (54%) with influenza-related ARDS. Median age of patients with COVID-19 and influenza was 58 (IQR 53–64) and 52 (39–58) years (p < 0.001), 35% and 31% (p = 0.695) were female, respectively. Charlson Comorbidity Index was 3 (1–5) and 2 (0–5) points in the two groups (p = 0.309). Median SAPS II score pre-ECMO was 27 (24–36) vs. 32 (28–41) points (p = 0.009), and SOFA score was 13 (11–14) vs. 12 (8–15) points (p = 0.853), respectively. Median P/F ratio pre-ECMO was 64 (46–78) and 73 (56–104) (p = 0.089); pH was 7.20 (7.16–7.29) and 7.26 (7.18–7.33) (p = 0.166). Median days on vv/va-ECMO were 17 (7–27) and 11 (7–20) (p = 0.295), respectively. Seventy-one percent and sixty-nine percent had renal replacement therapy (p = 0.790). Ninety-four percent of patients with COVID-19 and seventy-seven percent with influenza experienced vv/va-ECMO-associated bleeding events (p = 0.004). Thirty-four percent and fifty-five percent were successfully weaned from ECMO (p = 0.025). Ninety-day mortality was 65% and 57% in patients with COVID-19 and influenza, respectively (p = 0.156). Median length of ICU stay was 24 (13–44) and 28 (16–14) days (p = 0.470), respectively. Despite similar disease severity, the use of vv/va-ECMO in ARDS related to COVID-19 and influenza resulted in similar outcomes at 90 days. A significant higher rate of bleeding complications and thrombosis was observed in patients with COVID-19.

Checklists Improve Team Performance During Simulated Extracorporeal Membrane Oxygenation Emergencies: A Randomized Trial

Supplemental Digital Content is available in the text.

Objectives:

Extracorporeal membrane oxygenation–related complications are potentially catastrophic if not addressed quickly. Because complications are rare, high-fidelity simulation is recommended as part of the training regimen for extracorporeal membrane oxygenation specialists. We hypothesized that the use of standardized checklists would improve team performance during simulated extracorporeal membrane oxygenation emergencies.

Design:

Randomized simulation-based trial.

Setting:

A quaternary-care academic hospital with a regional extracorporeal membrane oxygenation referral program.

Subjects:

Extracorporeal membrane oxygenation specialists and other healthcare providers.

Interventions:

We designed six read-do checklists for use during extracorporeal membrane oxygenation emergencies using a modified Delphi process. Teams of two to three providers were randomized to receive the checklists or not. All teams then completed four simulated extracorporeal membrane oxygenation emergencies.

Measurements and Main Results:

Simulation sessions were video-recorded, and the number of critical tasks performed and time-to-completion were compared between groups. A survey instrument was administered before and after simulations to assess participants’ attitudes toward the simulations and checklists. We recruited 36 subjects from a single institution, randomly assigned to 15 groups. The groups with checklists completed more critical tasks than participants in the control groups (90% vs 75%; p < 0.001). The groups with checklists performed a higher proportion of both nontechnical tasks (71% vs 44%; p < 0.001) and extracorporeal membrane oxygenation–specific technical tasks (94% vs 86%; p < 0.001). Both groups reported an increase in reported self-efficacy after the simulations (p = 0.003). After adjusting for multiple comparisons, none of the time-to-completion measures achieved statistical significance.

Conclusions:

The use of checklists resulted in better team performance during simulated extracorporeal membrane oxygenation emergencies. As extracorporeal membrane oxygenation use continues to expand, checklists may be an attractive low-cost intervention for centers looking to reduce errors and improve response to crisis situations.

Association of Hospital Safety Net Status With Outcomes and Resource Use for Extracorporeal Membrane Oxygenation in the United States

PURPOSE

Safety net hospitals (SNH) have been associated with inferior surgical outcomes and increased resource use. Utilization and outcomes for extracorporeal membrane oxygenation (ECMO), a rescue modality for patients with respiratory or cardiac failure, may vary by safety net status. We hypothesized SNH to be associated with inferior outcomes and costs of ECMO in a national cohort.

MATERIALS AND METHODS

The 2008-2017 National Inpatient Sample was queried for ECMO hospitalizations and safety net hospitals were identified. Multivariable regression was used to perform risk-adjusted comparisons of mortality, complications and resource utilization at safety net and non-safety net hospitals.

RESULTS

Of 36,491 ECMO hospitalizations, 28.2% were at SNH. On adjusted comparison SNH was associated with increased odds of mortality (AOR: 1.23), tracheostomy use (AOR: 1.51), intracranial hemorrhage (AOR: 1.39), as well as infectious complications (AOR: 1.21, all P < .05), with NSNH as reference. SNH was also associated with increased hospitalization duration (β=+4.5 days) and hospitalization costs (β=+$32,880, all P < .01).

CONCLUSIONS

We have found SNH to be associated with inferior survival, increased complications, and higher costs compared to NSNH. These disparate outcomes warrant further studies examining systemic and hospital-level factors that may impact outcomes and resource use of ECMO at SNH.

ECMO as a Bridge to Left Ventricular Assist Device or Heart Transplantation

OBJECTIVES

The purpose of this study was to compare outcomes between patients on extracorporeal membrane oxygenation (ECMO) bridged to left ventricular assist device (LVAD) versus heart transplantation (HT) using registry data.

BACKGROUND

Patients with heart failure supported with ECMO represent the highest priority in the new HT allocation system. For patients on ECMO, bridging to LVAD may be non-inferior compared with bridging to HT.

METHODS

Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 2006 to 2017 and United Network for Organ Sharing (UNOS) database from 2006 to June 2019 requiring ECMO were included. Cause-specific hazard models were created and cumulative incidence functions were calculated with mortality, transplantation, and re-transplantation as competing events.

RESULTS

A total of 906 patients received ECMO as bridge to VAD (n = 587, 64.8%) or as bridge to HT (n = 319, 35.2%). Patients bridged directly to HT were younger (age 46.3 ± 15.4 years vs. 52.1 ± 13.2 years; p < 0.001) and more likely to be female (93 [29.2%] vs. 139 [23.7%]; p = 0.022). Patients bridged directly to HT were more likely to have a nonischemic cardiomyopathy, restrictive physiologies, and allograft failure; (p < 0.05 for all). ECMO use increased over time in both UNOS and INTERMACS. There was no significant difference in mortality between groups (Gray's p = 0.581). This remained true even when the analysis was restricted to transplant-listed or eligible patients as well as patients with dilated phenotypes (excluding patients with congenital heart disease, restrictive phenotypes, and allograft failure).

CONCLUSIONS

There was no difference in mortality on pump support compared with posttransplant mortality among those bridged from ECMO to LVAD or HT.

Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.

Dual RVAD-ECMO Circuits to Treat Cardiogenic Shock and Hypoxemia Due to Necrotizing Lung Infection: A Case Report

Utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is expanding, but dual VA-ECMO circuits to treat cardiogenic shock with refractory hypoxemia is unreported. We describe the case of combined cardiogenic and distributive shock due to necrotizing pulmonary blastomycosis. After initial central VA-ECMO cannulation, acute respiratory distress syndrome (ARDS) with increasing shunt resulted in significant central hypoxemia due to progressive ventilation-perfusion mismatch. An additional circuit provided complete oxygenation of the high circulating volume. After 4 months on support, he underwent successful heart-lung-kidney transplantation. Dual ECMO circuits are technically feasible and may be advantageous in specific circumstances of high pulmonary shunting resulting in excessive hypoxemia unbalanced with appropriate oxygen delivery.

The Ethics of Extracorporeal Membrane Oxygenation: Revisiting the Principles of Clinical Bioethics

BACKGROUND

Extracorporeal life support has become accepted as a rescue therapy for cardiopulmonary shock, and there have been over 100,000 extracorporeal membrane oxygenation (ECMO) cases since 1987. Rapid growth has presented ethical challenges and concerns. Here, we discuss core principles of bioethics in an attempt to more thoroughly appreciate the ethical concerns and considerations raised by use of this technology.

METHODS

An extensive literature review was performed on current papers on ECMO and ethics. In this paper, we utilized 3 case studies to highlight 4 major tenets of bioethics as they relate to use of ECMO: autonomy, beneficence, nonmaleficence, and justice.

RESULTS

Case studies presented involved unique perspectives on utilization of ECMO and a careful balance of benefits and harms as they relate to autonomy, beneficence, nonmaleficence and justice. We present nuanced interpretations of autonomy (eg, physician autonomy) and justice (eg, various providers interpret and offer ECMO differently). An additional challenge includes contending with potentially prolonged clinical courses and/or complications that either result directly from cannulation for ECMO or indirectly from being subject to ensuing extreme conditions and prolongation of life that medical science has yet to fully understand.

CONCLUSIONS

ECMO programs continue to grow in number and capacity. A deep appreciation of the bioethical dimensions of this technology and its application must be pursued, understood and applied to individual patient scenarios.

Predicting Survival After Extracorporeal Membrane Oxygenation by Using Machine Learning

BACKGROUND

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) undoubtedly saves many lives, but it is associated with a high degree of patient morbidity, mortality, and resource use. This study aimed to develop a machine learning algorithm to augment clinical decision making related to VA-ECMO.

METHODS

Patients supported by VA-ECMO at a single institution from May 2011 to October 2018 were retrospectively reviewed. Laboratory values from only the initial 48 hours of VA-ECMO support were used. Data were split into 70% for training, 15% for validation, and 15% withheld for testing. Feature importance was estimated, and dimensionality reduction techniques were used. A deep neural network was trained to predict survival to discharge, and the final model was assessed using the independent testing cohort. Model performance was compared with that of the SAVE (Survival After Veno-arterial ECMO) score by using a receiver operator characteristic curve.

RESULTS

Of the 282 eligible adult patients who were undergoing VA-ECMO, 117 (41%) survived to discharge. A total of 1.96 million laboratory values were extracted from the electronic medical record, from which 270 different summary variables were derived for each patient. The most important variables in predicting the primary outcome included lactate, age, total bilirubin, and creatinine. For the testing cohort, the final model achieved 82% overall accuracy and a greater area under the curve than the SAVE score (0.92 vs 0.65; P = .01) in predicting survival to discharge.

CONCLUSIONS

This proof of concept study demonstrates the potential for machine learning models to augment clinical decision making for patients undergoing VA-ECMO. Further development with multi-institutional data is warranted.

Extracorporeal Membrane Oxygenation in Cardiogenic Shock due to Acute Myocardial Infarction: A Systematic Review

Background

Cardiogenic shock is associated with high mortality, despite new strategies for reperfusion therapy. Short-term circulatory support devices may provide adequate support for appropriate myocardial and organ perfusion.

Objectives

This review is aimed at evaluating the impact on survival when using venoarterial extracorporeal membrane oxygenation (V-A ECMO) in patients with cardiogenic shock due to acute myocardial infarction (AMI).

Methods

We performed a systematic review that included studies using V-A ECMO in patients with cardiogenic shock. Time on ECMO, side effects, and the number of deceased patients, transplanted or upgraded to durable assist devices were analysed. Literature search was done using PubMed/MEDLINE (inception (1969) to January 10, 2019), ProQuest (inception (January 14, 1988) to January 10, 2019), and clinicaltrials.gov (inception (September 12, 2005) to January 10, 2019), by 2 authors. This protocol is registered with PROSPERO (no. CRD42019123982).

Results

We included 9 studies with a total of 1,998 adult patients receiving V-A ECMO for AMI-induced cardiogenic shock. Survival rate varied from 30.0% to 79.2% at discharge and from 23.2% to 36.1% at 12 months. Time on ECMO varied between 1.96 and 6.0 days. Reported serious adverse events were gastrointestinal bleeding (3.6%) and peripheral complications (8.5%).

Conclusion

The use of V-A ECMO among patients with AMI-induced cardiogenic shock may provide survival benefits. However, V-A ECMO treatment effects are inconclusive because of limitations in cohort design and reporting.

Mesenchymal stem cells may ameliorate inflammation in an ex vivo model of extracorporeal membrane oxygenation

INTRODUCTION

Mesenchymal stem cells exhibit immunomodulatory properties which are currently being investigated as a novel treatment option for Acute Respiratory Distress Syndrome. However, the feasibility and efficacy of mesenchymal stem cell therapy in the setting of extracorporeal membrane oxygenation is poorly understood. This study aimed to characterise markers of innate immune activation in response to mesenchymal stem cells during an ex vivo simulation of extracorporeal membrane oxygenation.

METHODS

Ex vivo extracorporeal membrane oxygenation simulations (n = 10) were conducted using a commercial extracorporeal circuit with a CO₂-enhanced fresh gas supply and donor human whole blood. Heparinised circuits (n = 4) were injected with 40 × 10⁶-induced pluripotent stem cell-derived human mesenchymal stem cells, while the remainder (n = 6) acted as controls. Simulations were maintained, under physiological conditions, for 240 minutes. Circuits were sampled at 15, 30, 60, 120 and 240 minutes and assessed for levels of interleukin-1β, interleukin-6, interleukin-8, interleukin-10, tumour necrosis factor-α, transforming growth factor-β1, myeloperoxidase and α-Defensin-1. In addition, haemoglobin, platelet and leukocyte counts were performed.

RESULTS

There was a trend towards reduced levels of pro-inflammatory cytokines in mesenchymal stem cell-treated circuits and a significant increase in transforming growth factor-β1. Blood cells and markers of neutrophil activation were reduced in mesenchymal stem cell circuits during the length of the simulation. As previously reported, the addition of mesenchymal stem cells resulted in a reduction of flow and increased trans-oxygenator pressures in comparison to controls.

CONCLUSIONS

The addition of mesenchymal stem cells during extracorporeal membrane oxygenation may cause an increase in transforming growth factor-β1. This is despite their ability to adhere to the membrane oxygenator. Further studies are required to confirm these findings.