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Rilinger J, Book R, Kaier K, Giani M, Fumagalli B, Jäckel M, Bemtgen X, Zotzmann V, Biever PM, Foti G, Westermann D, Lepper PM, Supady A, Staudacher DL, Wengenmayer T. A Mortality Prediction Score for Patients With Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO): The PREDICT VV-ECMO Score. ASAIO J 2024; 70:293-298. [PMID: 37934747 PMCID: PMC10977052 DOI: 10.1097/mat.0000000000002088] [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] [Indexed: 11/09/2023] Open
Abstract
Mortality prediction for patients with the severe acute respiratory distress syndrome (ARDS) supported with veno-venous extracorporeal membrane oxygenation (VV-ECMO) is challenging. Clinical variables at baseline and on day 3 after initiation of ECMO support of all patients treated from October 2010 through April 2020 were analyzed. Multivariate logistic regression analysis was used to identify score variables. Internal and external (Monza, Italy) validation was used to evaluate the predictive value of the model. Overall, 272 patients could be included for data analysis and creation of the PREDICT VV-ECMO score. The score comprises five parameters (age, lung fibrosis, immunosuppression, cumulative fluid balance, and ECMO sweep gas flow on day 3). Higher score values are associated with a higher probability of hospital death. The score showed favorable results in derivation and external validation cohorts (area under the receiver operating curve, AUC derivation cohort 0.76 [95% confidence interval, CI, 0.71-0.82] and AUC validation cohort 0.74 [95% CI, 0.67-0.82]). Four risk classes were defined: I ≤ 30, II 31-60, III 61-90, and IV ≥ 91 with a predicted mortality of 28.2%, 56.2%, 84.8%, and 96.1%, respectively. The PREDICT VV-ECMO score suggests favorable performance in predicting hospital mortality under ongoing ECMO support providing a sound basis for further evaluation in larger cohorts.
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Affiliation(s)
- Jonathan Rilinger
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rebecca Book
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Giani
- Department School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Benedetta Fumagalli
- Department School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Markus Jäckel
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Xavier Bemtgen
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Paul M. Biever
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Giuseppe Foti
- Department School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive care, Azienda Socio Sanitaria Territoriale Monza, Monza, Italy
| | - Dirk Westermann
- Department of Cardiology and Angiology, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp M. Lepper
- Department of Internal Medicine V – Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Alexander Supady
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Dawid L. Staudacher
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- From the Department of Interdisciplinary Medical Intensive Care, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Pladet LCA, Barten JMM, Vernooij LM, Kraemer CVE, Bunge JJH, Scholten E, Montenij LJ, Kuijpers M, Donker DW, Cremer OL, Meuwese CL. Prognostic models for mortality risk in patients requiring ECMO. Intensive Care Med 2023; 49:131-141. [PMID: 36600027 PMCID: PMC9944134 DOI: 10.1007/s00134-022-06947-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To provide an overview and evaluate the performance of mortality prediction models for patients requiring extracorporeal membrane oxygenation (ECMO) support for refractory cardiocirculatory or respiratory failure. METHODS A systematic literature search was undertaken to identify studies developing and/or validating multivariable prediction models for all-cause mortality in adults requiring or receiving veno-arterial (V-A) or veno-venous (V-V) ECMO. Estimates of model performance (observed versus expected (O:E) ratio and c-statistic) were summarized using random effects models and sources of heterogeneity were explored by means of meta-regression. Risk of bias was assessed using the Prediction model Risk Of BiAS Tool (PROBAST). RESULTS Among 4905 articles screened, 96 studies described a total of 58 models and 225 external validations. Out of all 58 models which were specifically developed for ECMO patients, 14 (24%) were ever externally validated. Discriminatory ability of frequently validated models developed for ECMO patients (i.e., SAVE and RESP score) was moderate on average (pooled c-statistics between 0.66 and 0.70), and comparable to general intensive care population-based models (pooled c-statistics varying between 0.66 and 0.69 for the Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score). Nearly all models tended to underestimate mortality with a pooled O:E > 1. There was a wide variability in reported performance measures of external validations, reflecting a large between-study heterogeneity. Only 1 of the 58 models met the generally accepted Prediction model Risk Of BiAS Tool criteria of good quality. Importantly, all predicted outcomes were conditional on the fact that ECMO support had already been initiated, thereby reducing their applicability for patient selection in clinical practice. CONCLUSIONS A large number of mortality prediction models have been developed for ECMO patients, yet only a minority has been externally validated. Furthermore, we observed only moderate predictive performance, large heterogeneity between-study populations and model performance, and poor methodological quality overall. Most importantly, current models are unsuitable to provide decision support for selecting individuals in whom initiation of ECMO would be most beneficial, as all models were developed in ECMO patients only and the decision to start ECMO had, therefore, already been made.
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Affiliation(s)
- Lara C A Pladet
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jaimie M M Barten
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J H Bunge
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care Medicine, Sint Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Leon J Montenij
- Department of Intensive Care Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Marijn Kuijpers
- Department of Intensive Care Medicine, Isala Hospital Zwolle, Zwolle, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Time-Course of Physiologic Variables During Extracorporeal Membrane Oxygenation and Outcome of Severe Acute Respiratory Distress Syndrome. ASAIO J 2021; 66:663-670. [PMID: 31335371 DOI: 10.1097/mat.0000000000001048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In patients undergoing extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS), it is unknown which clinical physiologic variables should be monitored to follow the evolution of lung injury and extrapulmonary organ dysfunction and to differentiate patients according to their course. We analyzed the time-course of prospectively collected clinical physiologic variables in 83 consecutive ARDS patients undergoing ECMO at a single referral center. Selected variables-including ventilator settings, respiratory system compliance, intrapulmonary shunt, arterial blood gases, central hemodynamics, and sequential organ failure assessment (SOFA) score-were compared according to outcome at time-points corresponding to 0%, 25%, 50%, 75%, and 100% of the entire ECMO duration and daily during the first 7 days. A logistic regression analysis was performed to identify changes between ECMO start and end that independently predicted hospital mortality. Tidal volume, intrapulmonary shunt, arterial lactate, and SOFA score differentiated survivors and nonsurvivors early during the first 7 days and over the entire ECMO duration. Respiratory system compliance, PaO2/FiO2 ratio, arterial pH, and mean pulmonary arterial pressure showed distinct temporal course according to outcome over the entire ECMO duration. Lack of improvement of SOFA score independently predicted hospital mortality. In ARDS patients on ECMO, temporal trends of specific physiologic parameters differentiate survivors from non-survivors and could be used to monitor the evolution of lung injury. Progressive worsening of extrapulmonary organ dysfunction is associated with worse outcome.
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Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Chiostri M, Fulceri G, Peris A. Right Ventricular Hypertrophy in Refractory Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation Support. J Cardiothorac Vasc Anesth 2019; 34:1441-1445. [PMID: 31540754 DOI: 10.1053/j.jvca.2019.08.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/15/2019] [Accepted: 08/18/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In severe acute respiratory distress syndrome (ARDS) treated with extracorporeal membrane oxygenation (ECMO), right ventricular (RV failure) and dilation have been investigated with the use of echocardiography, whereas RV hypertrophy has not been addressed in the literature. The present study assessed the incidence of RV hypertrophy using echocardiography before ECMO treatment and at intensive care unit (ICU) discharge in severe ARDS patients. DESIGN Observational, retrospective, single-center study. SETTING A single ECMO center. PARTICIPANTS The study comprised 46 consecutive patients with severe ARDS. INTERVENTION Echocardiographic evaluation and ECMO support. MEASUREMENTS AND MAIN RESULTS A dual-lumen cannula was implanted in most patients (38/46 [82.6%]). Before the start of ECMO, RV hypertrophy was present in 28 patients (60.8%) with no significant differences in baseline characteristics between the 2 subgroups. The ICU mortality rate was 30.4% (14/46), with no difference between patients with RV hypertrophy and those without. At ICU discharge, all patients showed RV hypertrophy. CONCLUSIONS In severe ARDS treated with ECMO support, RV hypertrophy is a common finding and patients with normal RV wall thickness developed RV hypertrophy after ECMO support. The latter finding may suggest that during ECMO support, the right ventricle still may be subjected to increased afterload. However, additional research should be performed to elucidate the spectrum of mechanism(s) involved in the genesis of RV hypertrophy.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Cianchi
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Batacchi
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Chiostri
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giorgio Fulceri
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Cianchi G, Lazzeri C, Bonizzoli M, Batacchi S, Di Lascio G, Ciapetti M, Franci A, Chiostri M, Peris A. Activities of an ECMO Center for Severe Respiratory Failure: ECMO Retrieval and Beyond, A 4-Year Experience. J Cardiothorac Vasc Anesth 2019; 33:3056-3062. [PMID: 31072711 DOI: 10.1053/j.jvca.2019.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Beyond retrieval and management of patients with severe acute respiratory distress syndrome, an extracorporeal membrane oxygenation (ECMO) center also encompasses several other actions, such as on-call consultations, advice, and counseling, to the physicians at the peripheral centers, but few data are available on this topic. Therefore, the authors describe the composite activities of retrieval and counseling of an ECMO center since 2014. DESIGN The referral calls addressed to the authors' ECMO center for patients with respiratory failure were prospectively recorded in a dedicated database. Referral call frequency, patient data, and results of the calls were analyzed. SETTING The 12-bed intensive care unit of Careggi Hospital in Florence, the ECMO referral center for Tuscany, and the center of Italy, with a mobile ECMO team. PARTICIPANTS Patients from intensive care units of peripheral hospitals for whom a referral call was addressed to the authors' ECMO center. INTERVENTIONS Many possible responses were given after a referral call, varying from ECMO team deployment to advice or to refusal. MEASUREMENTS AND MAIN RESULTS From January 1, 2014, to December 31, 2017, 231 calls were received at the authors' ECMO center, of which 220 calls were for acute respiratory failure cases. Throughout the study period the overall number of calls did not vary, but the percentage of ECMO retrievals decreased, whereas the percentage of ARF patients from peripheral hospital admitted to our ECMO center on conventional ventilation increased. Fifty-five patients were treated by the mobile ECMO team and were transferred on ECMO; 59 were admitted on ventilatory support. In flu periods the overall calls were more frequent than in the no-flu periods (171 v 82 calls), and more ECMO retrieval missions were deployed. CONCLUSIONS During the study period, a decreased number of patients retrieved on ECMO was observed, whereas patients transferred on ventilation increased, with an overall unchanged number of referred patients.
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Affiliation(s)
- Giovanni Cianchi
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Batacchi
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gabriella Di Lascio
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Ciapetti
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Andrea Franci
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Chiostri
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Peris A, Lazzeri C, Cianchi G, Bonizzoli M, Batacchi S, Franci A, Rugna M, De Vito L, Ticali PF, Li Marzi V, Migliaccio ML. Implementing a donation after circulatory death program in a setting of donation after brain death activity. Minerva Anestesiol 2018; 84:1387-1392. [DOI: 10.23736/s0375-9393.18.12635-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bautista-Rodriguez C, Sanchez-de-Toledo J, Da Cruz EM. The Role of Echocardiography in Neonates and Pediatric Patients on Extracorporeal Membrane Oxygenation. Front Pediatr 2018; 6:297. [PMID: 30416991 PMCID: PMC6212474 DOI: 10.3389/fped.2018.00297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledge that the utility of echocardiography in ECMO patients is not limited to the evaluation of cardiac function, and that clinical decisions should not be made exclusively upon echocardiographic findings. Though echocardiography has specific indications and applications, it also has limitations, characterized as: prior to and during cannulation, throughout the ECMO run, upon separation and after separation from the circuit. The use of specific and consistent echocardiographic protocols for patients on ECMO is recommended.
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Affiliation(s)
- Carles Bautista-Rodriguez
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Paediatric Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Joan Sanchez-de-Toledo
- Pediatric Cardiology Department, Hospital Sant Joan de Deu Barcelona, Universitat de Barcelona, Barcelona, Spain
- Division of Cardiac Intensive Care, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eduardo M. Da Cruz
- Department of Pediatrics, Heart Institute, Children's Hospital Colorado, School of Medicine, University of Colorado Denver, Aurora, CO, United States
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Lazzeri C, Peris A. Risk stratification for severe acute respiratory distress syndrome requiring veno venous extracorporeal membrane oxygenation: a clinical need. J Thorac Dis 2018; 10:E669-E671. [PMID: 30233913 PMCID: PMC6129888 DOI: 10.21037/jtd.2018.07.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/11/2018] [Indexed: 08/30/2023]
Affiliation(s)
- Chiara Lazzeri
- Emergency Department, Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Emergency Department, Intensive Care Unit and Regional ECMO Referral centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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