Peri-operative massive pulmonary embolism management: is veno-arterial ECMO a therapeutic option?

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy.

CONCLUSIONS

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

INTRODUCTION

Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines.

MATERIAL AND METHODS

The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches.

RESULTS

This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy.

CONCLUSION

Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Extracorporeal Membrane Oxygenation—First Strategy for Acute Life-Threatening Pulmonary Embolism

Background

Both venoarterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous mechanical thrombectomy (PMT) are increasingly used to treat acute life-threatening pulmonary embolism (PE). However, there are little data regarding their effectiveness. This study aimed to present the short-term outcomes after managing nine patients with acute life-threatening massive or submassive PE by VA-ECMO with or without complemented PMT and propose a preliminary treatment algorithm.

Methods

This study was a single-center retrospective review of a prospectively maintained registry. It included nine consecutive patients with massive or submassive pulmonary embolism who underwent VA-ECMO for initial hemodynamic stabilization, with or without PMT, from August 2018 to November 2021.

Results

Mean patient age was 54.7 years. Four of nine patients (44.4%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All cannulations (100%) were successfully performed percutaneously. Overall survival was 88.9% (8 of 9 patients). One patient died from a hemorrhagic stroke. Of the survivors, the median ECMO duration was 8 days in patients treated with ECMO alone and 4 days in those treated with EMCO and PMT. Five of nine patients (55.6%) required concomitant PMT to address persistent right heart dysfunction, with the remaining survivors (44.4%) receiving VA-ECMO and anticoagulation alone. For survivors receiving VA-ECMO plus PMT, median hospital lengths of stay were 7 and 13 days, respectively.

Conclusions

An ECMO-first strategy complemented with PMT can be performed effectively and safely for acute life-threatening massive or submassive PE. VA-ECMO is feasible for initial stabilization, serving as a bridge to therapy primarily in inoperable patients with massive PE. Further evaluation in a larger cohort of patients is warranted to assess whether VA-ECMO plus PMT may offer an alternative or complementary therapy to thrombolysis or surgical thrombectomy.

Type of Research

Single-center retrospective review of a prospectively maintained registry.

Can VA-ECMO Be Used as an Adequate Treatment in Massive Pulmonary Embolism?

Introduction: Massive acute pulmonary embolism (MAPE) with obstructive cardiogenic shock is associated with a mortality rate of more than 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used in refractory cardiogenic shock with very good results. In MAPE, although it is currently recommended as part of initial resuscitation, it is not yet considered a stand-alone therapy. Material and Methods: All patients with MAPE requiring the establishment of VA-ECMO and admitted to our tertiary intensive care unit were analysed over a period of 10 years. The characteristics of these patients, before, during and after ECMO were extracted and analysed. Results: A total of 36 patients were included in the present retrospective study. Overall survival was 64%. In the majority of cases, the haemodynamic and respiratory status of the patient improved significantly within the first 24 h on ECMO. The 30-day survival significantly increased when ECMO was used as stand-alone therapy (odds ratio (OR) 15.58, 95% confidence interval (CI) 2.65–91.57, p = 0.002). Nevertheless, when ECMO was implanted following the failure of thrombolysis, the bleeding complications were major (17 (100%) vs. 1 (5.3%) patients, p < 0.001) and the 30-day mortality increased significantly (OR 0.11, 95% CI 0.022–0.520, p = 0.006). Conclusions: The present retrospective study is certainly one of the most important in terms of the number of patients with MAPE and shock treated with VA-ECMO. This short-term mechanical circulatory support, used as a stand-alone therapy in MAPE, allows for the optimal stabilisation of patients.

Utilization of ECMO in vascular surgery: A presentation of two cases

Introduction

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a form of temporary mechanical circulatory support commonly used during cardiothoracic interventions. Malperfusion during complex vascular procedures remains a significant risk that may potentially lead to multiple complications. Here, we report two cases highlighting the efficacy of VA-ECMO in both planned and emergent vascular interventions.

Presentation of case

In our first case, VA-ECMO was used to support an 82-year-old male during a high-risk thoracoabdominal aortic aneurysm repair. Our second case details an emergent pulmonary embolectomy in which VA-ECMO was used as a bridge to cardiopulmonary bypass. In both cases, the procedures were well-tolerated, and the patients were discharged 17 days postoperatively.

Discussion

VA-ECMO has been increasingly used as a form of post-operative circulatory support following cardiothoracic and vascular interventions. However, only few instances of perioperative VA-ECMO use have been reported in the field of vascular surgery.

Conclusion

The presented cases highlight that the perioperative use of VA-ECMO may be a viable modality for required perfusion during complex planned or emergent vascular procedures.

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Perioperative use of VA-ECMO in vascular surgery has not been sufficiently explored.

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VA-ECMO can be used to maintain perfusion during high-risk vascular interventions.

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VA-ECMO can serve as a bridge to cardiopulmonary bypass in emergent scenarios.

Relationship between 30 Days Mortality and Incidence of Intraoperative Cardiac Arrest According to the Timing of ECMO

Background: Recently, the use of extracorporeal membrane oxygenation (ECMO) in noncardiac surgery, such as thoracic surgery, has increased. However, there have been no studies on the mortality and incidence of intraoperative cardiac arrest with or without ECMO during thoracic surgery. Methods: Between January 2011 and October 2018, 63 patients received ECMO support during thoracic surgery. All patients who applied ECMO from starting at any time before surgery to the day of surgery were included. Patients were divided into the emergency ECMO group and the non-emergency ECMO group according to the timing of ECMO. We compared the factors related to 30 day mortality using Cox regression analysis. Results: The emergency ECMO and non-emergency ECMO groups comprised 27 and 36 patients, respectively. On the operation day, cardiopulmonary resuscitation (CPR) was a very important result, and only occurred in the emergency ECMO group (n = 20, 74.1% vs. 0%, p < 0.001). The most common cause of ECMO indication was the CPR in the emergency ECMO group and respiratory failure in the non-emergency ECMO group. There were significant differences in 30 day mortality between the emergency ECMO group and the non-emergency ECMO group (n = 12, 44.4% vs. n = 3, 8.3%, p = 0.001). The Kaplan–Meier analysis curve for 30 day mortality showed that the emergency ECMO group had a significantly higher rate of 30 day mortality than the non-emergency ECMO group (X² = 14.7, p < 0.001). Conclusions: A lower incidence of intraoperative cardiac arrest occurred in the non-emergency ECMO group than in the emergency ECMO group. Moreover, 30 day mortality was associated with emergency ECMO.

Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review

OBJECTIVE

Management of patients experiencing massive pulmonary embolism-related cardiac arrest is controversial. Venoarterial extracorporeal membranous oxygenation has emerged as a potential therapeutic option for these patients. We performed a systematic review assessing survival and predictors of mortality in patients with massive PE-related cardiac arrest with venoarterial extracorporeal membranous oxygenation use.

DATA SOURCES

A literature search was started on February 16, 2020, and completed on March 16, 2020, using PubMed, Embase, Cochrane Central, Cinahl, and Web of Science.

STUDY SELECTION

We included all available literature that reported survival to discharge in patients managed with venoarterial extracorporeal membranous oxygenation for massive PE-related cardiac arrest.

DATA EXTRACTION

We extracted patient characteristics, treatment details, and outcomes.

DATA SYNTHESIS

About 301 patients were included in our systemic review from 77 selected articles (total screened, n = 1,115). About 183 out of 301 patients (61%) survived to discharge. Patients (n = 51) who received systemic thrombolysis prior to cannulation had similar survival compared with patients who did not (67% vs 61%, respectively; p = 0.48). There was no significant difference in risk of death if PE was the primary reason for admission or not (odds ratio, 1.62; p = 0.35) and if extracorporeal membranous oxygenation cannulation occurred in the emergency department versus other hospital locations (odds ratio, 2.52; p = 0.16). About 53 of 60 patients (88%) were neurologically intact at discharge or follow-up. Multivariate analysis demonstrated three-fold increase in the risk of death for patients greater than 65 years old (adjusted odds ratio, 3.08; p = 0.03) and six-fold increase if cannulation occurred during cardiopulmonary resuscitation (adjusted odds ratio, 5.67; p = 0.03).

CONCLUSIONS

Venoarterial extracorporeal membranous oxygenation has an emerging role in the management of massive PE-related cardiac arrest with 61% survival. Systemic thrombolysis preceding venoarterial extracorporeal membranous oxygenation did not confer a statistically significant increase in risk of death, yet age greater than 65 and cannulation during cardiopulmonary resuscitation were associated with a three- and six-fold risks of death, respectively.

ECMO in Cardiac Arrest: A Narrative Review of the Literature

Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.

Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review

Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has increased significantly. In some centers, ECMO has been deployed to manage perioperative emergencies and plays a role in facilitating high-risk thoracic, airway, and trauma surgery, which may not be feasible without ECMO support. General anesthesiologists who usually manage these cases may not be familiar with the initiation and management of patients on ECMO. This review discusses the use of ECMO in the operating room for thoracic, airway, and trauma surgery, as well as obstetric and perioperative emergencies.

Update on Perioperative Pulmonary Embolism Management: A Decision Support Tool to Aid in Diagnosis and Treatment

Pulmonary embolism (PE) affects up to 1 in every 1000 people per year, one-third of whom do not survive. Moreover, perioperative presentation of PE is 5 times more likely than at other times and poses a unique set of challenges for both diagnosis and treatment. This article discusses several important aspects regarding the prevention, diagnosis, and management of perioperative PE, incorporating information from the most recent practice guidelines, emerging literature on medical therapy, and interventional therapies. It proposes a clinical decision support tool that organizes the salient aspects of perioperative PE management to serve as an aid in practice.

Extracorporeal membrane oxygenation improved survival in patients with massive pulmonary embolism

BACKGROUND

Current guidelines for massive pulmonary embolism (PE) treatment recommend primary reperfusion therapy and the option of extracorporeal membrane oxygenation (ECMO). However, these recommendations might not be optimal for patients with poor prognoses who are in cardiogenic shock (CS) or require cardiopulmonary resuscitation (CPR).

OBJECTIVE

Evaluate the impact of ECMO support on the clinical outcome of patients with massive PE complicated by CPR or CS.

DESIGN

Retrospective review of medical records.

SETTING

A university hospital, South Korea.

PATIENTS AND METHODS

We collected data on patients from 2004 through 2009 (stage 1) and from 2010 through June 2017 (stage 2). Patients with confirmed massive PE received medical therapy (stage 1) or medical therapy that included extracorporeal membrane oxygen.ation (ECMO) support (stage 2).

MAIN OUTCOME MEASURES

All-cause mortality at 90 days after therapy.

SAMPLE SIZE

9 patients with confirmed massive PE that received medical therapy (stage 1); 14 patients with confirmed massive PE that received medical therapy with ECMO support (stage 2).

RESULTS

In stage 1, 5 of 9 patients received systemic thrombolysis and 4 patients received anticoagulation. Thirteen of the 14 stage 2 patients received anticoagulation with ECMO support and one patient received systemic thrombolysis with ECMO support. Tricuspid annular plane systolic excursion in stage 1 was lower than in stage 2. Proximal PE in chest CT was more common in stage 2. Survival was significantly improved at 90 days for patients in stage 2 (log-rank, P=.048). There were no differences in baseline characteristics, ECMO complications and transfusion between survivors and nonsurvivors in stage 2.

CONCLUSIONS

Anticoagulation with ECMO support is associated with good survival rate outcomes compared with medical therapy alone.

LIMITATIONS

Relatively small number of patients and retrospective design.

CONFLICT OF INTEREST

None.

Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation

Background

Despite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation.

Methods

ECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006–2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted.

Results

Seventeen high-risk PE patients [median age 51 (range 18–70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45–95)] were placed on VA-ECMO for 4 (1–12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0–106) mmHg, 6.99 (6.54–7.37) and 13 (4–19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4–69) months post-ICU discharge.

Conclusions

VA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1655-8) contains supplementary material, which is available to authorized users.

Achieving Multidisciplinary Collaboration for the Creation of a Pulmonary Embolism Response Team: Creating a "Team of Rivals"

Pulmonary embolism response teams (PERTs) have recently been developed to streamline care for patients with life-threatening pulmonary embolism (PE). PERTs are unique among rapid response teams, in that they bring together a multidisciplinary team of specialists to care for a single disease for which there are novel treatments but few comparative data to guide treatment. The PERT model describes a process that includes activation of the team; real-time, multidisciplinary consultation; communication of treatment recommendations; mobilization of resources; and collection of research data. Interventional radiologists, along with cardiologists, emergency physicians, hematologists, pulmonary/critical care physicians, and surgeons, are core members of most PERTs. Bringing together such a wide array of experts leverages the expertise and strengths of each specialty. However, it can also lead to challenges that threaten team cohesion and cooperation. The purpose of this article is to discuss ways to integrate multiple specialists, with diverse perspectives and skills, into a cohesive PERT. The authors will discuss the purpose of forming a PERT, strengths of different PERT specialties, strategies to leverage these strengths to optimize participation and cooperation across team members, as well as unresolved challenges.

The Expanding Role of Extracorporeal Membrane Oxygenation Retrieval Services in Australia

Herein we detail the cases of three patients transferred on veno-arterial extracorporeal membrane oxygenation (VA ECMO) from a tertiary referral hospital to an ECMO centre. We highlight the benefits of such a transfer and offer this as a model of care for unwell patients likely to require a prolonged period of ECMO support.

Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has known a widespread application over the last decade and is now an effective and valuable therapeutic option in refractory cardiogenic shock of various etiologies. In this subgroup of critically ill and unstable patients in cardiogenic shock, VA-ECMO allows, on the one hand, temporary hemodynamic stabilization with improvement of end-organ function and, on the other hand, gives the time to perform complementary diagnostic exams and to decide the therapeutic strategy in these high-risk candidates for immediate long-term mechanical circulatory support (MCS) implantation. VA-ECMO could also be suggested as a rescue therapeutic option for refractory cardiac arrest. It showed promising results in the specific setting of in-hospital cardiac arrest and survival rates with good neurological outcome are reported between 20% and 40%. Conversely, there are contrasting data in the literature about survival after VA-ECMO for out-of-hospital cardiac arrest, as results are highly dependent on low-flow time. The aim of the present report is to offer an overview of different cannulation techniques of VA-ECMO.

Safe ECMO femoral decannulation by placement of inferior vena cava filter via internal jugular vein

Veno-arterial extracorporeal membrane oxygenation (ECMO) is a lifesaving treatment in patients with cardiogenic shock or cardiac arrest caused by massive pulmonary embolism. In these patients, positioning an inferior vena cava filter is often advisable, especially if deep venous thrombosis is not resolved at the time of the ECMO suspension. Moreover, in ECMO patients, a high incidence of deep venous thrombosis at the site of venous cannulation has been reported, and massive pulmonary embolism following ECMO decannulation has been described. Nonetheless, an inferior vena cava filter cannot be positioned as long as an ECMO cannula is inside the inferior vena cava. Thus, we developed a strategy to allow placement of an inferior vena cava filter through the internal jugular concurrently with the removal of the femoral venous ECMO cannula. In two women supported by veno-arterial ECMO for cardiac arrest secondary to pulmonary embolism, this novel approach allowed for safe ECMO decannulation.

Extracorporeal membrane oxygenation for failed tPA therapy of pulmonary embolism

Background:

Pulmonary embolism may cause cardiac arrest secondary to obstruction of blood flow. Traditional treatment strategies include anticoagulation, thrombolysis, and mechanical extraction. Some advocate for support with extra corporeal membrane oxygenation; however, surgical therapies are contraindicated following thrombolytics.

Methods:

We describe the emergent use of peripheral extra corporeal membrane oxygenation following thrombolytic therapy for a saddle pulmonary embolism associated with multiple episodes of cardiac arrest.

Results:

The patient was stabilized with peripheral extra corporeal membrane oxygenation, anticoagulated and subsequently weaned from extra corporeal membrane oxygenation without any major bleeding complications.

Conclusion:

The administration of thrombolytics should not be a contraindication for extra corporeal membrane oxygenation in patients with massive pulmonary embolism associated with hemodynamic instability.

Complex Perioperative Decision-Making: Liver Resection in a Patient with Extensive Superior Vena Cava/Right Atrial Thrombus and Superior Vena Cava Syndrome

The perioperative management of patients suffering from extensive superior vena cava (SVC) thrombus complicated by SVC syndrome presents unique challenges. The anesthesiologist needs to be prepared for possible thrombus dislodgement resulting in pulmonary embolism and also has to assess the need for fluid resuscitation given the dangers of massive intravenous fluid application via the upper extremities. We present our perioperative approach in management of a patient scheduled for right hepatectomy who was previously diagnosed with extensive SVC and right atrial (RA) thrombus complicated by SVC syndrome.

Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review

Massive pulmonary embolism (PE) can present with extreme physiological dysfunction, characterised by acute right ventricular failure, hypoxaemia unresponsive to conventional therapy and cardiac arrest. Consensus regarding the management of patients with persistent shock following thrombolysis is lacking. Our primary objective was to describe the application of extracorporeal membrane oxygenation (ECMO) in the treatment of acute massive PE. We were unable to identify any randomised controlled trials (RCTs) comparing ECMO with other support systems in the setting of massive PE. We reviewed case reports and case series published in the past 20 years to evaluate the mortality rate and any poor prognostic factors. Overall survival was 70.1% and none of the definitive treatment modalities was associated with a higher mortality (thrombolysis - OR - 0.99, P - 0.9, catheter embolectomy - OR - 1.01, P - 0.99, surgical embolectomy - OR - 0.44, P - 0.20). Patients who had ECMO instituted whilst in cardiorespiratory arrest had a higher risk of death. (OR - 16.71, P - 0.0004). When compared with other causes of cardiac arrest, patients who survived a massive PE presented a good neurological outcome (cerebral performance category 1 or 2).