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Hsu PS, Lin JY, Tsai YT, Lin CY, Chen JL, Chien WC, Tsai CS. Risk Factors of Mortality and Long-Term Survival in Burn Patients With/Without Extracorporeal Membrane Oxygenation: A 16 Year Real-World Study. ASAIO J 2024:00002480-990000000-00493. [PMID: 38809760 DOI: 10.1097/mat.0000000000002244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Burn patients face cardiopulmonary failure risks, with recent observational studies suggesting promising outcomes for extracorporeal membrane oxygenation (ECMO). However, the effectiveness and long-term survival remain unclear. Our study aims to assess mortality risk factors and long-term survival in burn patients with and without ECMO. This study used Taiwan's National Health Insurance Research Database and designed a case-control with onefold propensity score matching across variables including sex, age, total body surface area (TBSA) burned, and index date. We analyzed mortality and survival risk factors in each stratified group with/without ECMO. Finally, we analyze the mortality according to ECMO and TBSA burned, and the cause of death and long-term survival. From 2000 to 2015, 4,556 burn patients with ECMO compared to an equivalent number without ECMO. Primary mortality include male, age >65, TBSA ≥30%, escharotomy, hemodialysis, and bacteremia. The ECMO group showed lower survival across all stratified risk factors, with the primary cause of death being burn-related issues, followed by respiratory and heart failure. The overall mortality rate was 54.41% with ECMO and 40.94% without ECMO (p < 0.001). Additionally, long-term survival is lower in the group with ECMO. This research provides a valuable real-world gross report about ECMO efficacy and long-term survival among burn patients with/without ECMO.
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Affiliation(s)
- Po-Shun Hsu
- From the Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jiun-Yu Lin
- From the Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ting Tsai
- From the Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Yuan Lin
- From the Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jia-Lin Chen
- Department of Anesthesia, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Department of Medical Research, Tri-Service General Hospital, Taipei, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Sung Tsai
- From the Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Medical Affairs Bureau, Ministry of National Defense, Taiwan, R.O.C
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2
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Simons J, Mees B, MacLaren G, Fraser JF, Zaaqoq AM, Cho SM, Patel BM, Brodie D, Bělohlávek J, Belliato M, Jung JS, Salazar L, Meani P, Mariani S, Di Mauro M, Yannopoulos D, Broman LM, Chen YS, Riera J, van Mook WN, Lorusso R. Evolution of distal limb perfusion management in adult peripheral venoarterial extracorporeal membrane oxygenation with femoral artery cannulation. Perfusion 2024; 39:23S-38S. [PMID: 38651584 DOI: 10.1177/02676591241236650] [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: 04/25/2024]
Abstract
Limb ischaemia is a clinically relevant complication of venoarterial extracorporeal membrane oxygenation (VA ECMO) with femoral artery cannulation. No selective distal perfusion or other advanced techniques were used in the past to maintain adequate distal limb perfusion. A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.
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Affiliation(s)
- Jorik Simons
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Barend Mees
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Division of Neuroscience Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bhavesh M Patel
- Department of Critical Care, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jan Bělohlávek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic
| | - Mirko Belliato
- SC AR 2 Anestesia e Terapia Intensiva Cardiotoracica, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea
| | - Leonardo Salazar
- Department of Intensive Care, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Paolo Meani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- S. Gerardo Hospital is the hospital of the departmen, Monza, Italy
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Lars Mikael Broman
- Department of Pediatric Perioperative Medicine and Intensive Care, ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jordi Riera
- Department de Medicina Intensiva, Vall d'Hebron Institut de Recerca, SODIR, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Walther Nka van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
- Academy for Postgraduate Medical Training, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Baumgartner C, Wolf P, Hermann A, König S, Maleczek M, Laxar D, Poglitsch M, Domenig O, Krenn K, Schiefer J, Kautzky-Willer A, Krebs M, Hermann M. Profiling endogenous adrenal function during veno-venous ECMO support in COVID-19 ARDS: a descriptive analysis. Front Endocrinol (Lausanne) 2024; 14:1321511. [PMID: 38333725 PMCID: PMC10852060 DOI: 10.3389/fendo.2023.1321511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/18/2023] [Indexed: 02/10/2024] Open
Abstract
Background Prolonged critical illness is often accompanied by an impairment of adrenal function, which has been frequently related to conditions complicating patient management. The presumed connection between hypoxia and the pathogenesis of this critical- illness- related corticosteroid insufficiency (CIRCI) might play an important role in patients with severe acute respiratory distress syndrome (ARDS). Since extracorporeal membrane oxygenation (ECMO) is frequently used in ARDS, but data on CIRCI during this condition are scarce, this study reports the behaviour of adrenal function parameters during oxygenation support with veno-venous (vv)ECMO in coronavirus disease 2019 (COVID-19) ARDS. Methods A total of 11 patients undergoing vvECMO due to COVID-19 ARDS at the Medical University of Vienna, who received no concurrent corticosteroid therapy, were retrospectively included in this study. We analysed the concentrations of cortisol, aldosterone, and angiotensin (Ang) metabolites (Ang I-IV, Ang 1-7, and Ang 1-5) in serum via liquid chromatography/tandem mass spectrometry before, after 1 day, 1 week, and 2 weeks during vvECMO support and conducted correlation analyses between cortisol and parameters of disease severity. Results Cortisol concentrations appeared to be lowest after initiation of ECMO and progressively increased throughout the study period. Higher concentrations were related to disease severity and correlated markedly with interleukin-6, procalcitonin, pH, base excess, and albumin during the first day of ECMO. Fair correlations during the first day could be observed with calcium, duration of critical illness, and ECMO gas flow. Angiotensin metabolite concentrations were available in a subset of patients and indicated a more homogenous aldosterone response to plasma renin activity after 1 week of ECMO support. Conclusion Oxygenation support through vvECMO may lead to a partial recovery of adrenal function over time. In homogenous patient collectives, this novel approach might help to further determine the importance of adrenal stress response in ECMO and the influence of oxygenation support on CIRCI.
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Affiliation(s)
- Clemens Baumgartner
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Wolf
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Hermann
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sebastian König
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Mathias Maleczek
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
| | - Daniel Laxar
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
| | | | | | - Katharina Krenn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Judith Schiefer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Michael Krebs
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Martina Hermann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Vienna, Austria
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Wiest C, Müller T, Lubnow M, Fisser C, Philipp A, Foltan M, Schneckenpointner R, Malfertheiner MV. Intracranial hemorrhage in a large cohort of patients supported with veno-venous ECMO. A retrospective single-center analysis. Perfusion 2023:2676591231213514. [PMID: 37948845 DOI: 10.1177/02676591231213514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND Intracranial bleeding (ICB) is a serious complication during veno-venous extracorporeal membrane oxygenation (V-V ECMO), with potentially fatal consequences. PURPOSE This study aimed to evaluate the incidence, time of detection of ICB among patients treated with V-V ECMO and potential risk factors for developing ICB during V-V ECMO. METHODS Five hundred fifty six patients were included in this retrospective single center analysis. RESULTS Median time on V-V ECMO was 9 (IQR 6-15) days. Intracranial bleeding during V-V ECMO was detected in 10.9% of all patients (61 patients with ICB). Only 17 patients with ICB presented obvious clinical symptoms. Intracranial bleeding was detected on cerebral imaging in median after 5 days (IQR 1-14) after starting V-V ECMO. Overall survival to hospital discharge was 63.7% (ICB: 29.5%). Risk factors of ICB before starting V-V ECMO in univariable analysis were platelets <100/nl (OR: 3.82), creatinine >1.5mg/dl (OR: 1.98), norepinephrine >2.5mg/h (OR: 2.5), ASAT >80U/L (OR: 1.86), blood-urea >100mg/dl (OR: 1.81) and LDH >550u/L (OR: 2.07). Factors associated with cannulation were rapid decrease in paCO2 >35mmHg (OR: 2.56) and rapid decrease in norepinephrine >1mg/h (OR: 2.53). Multivariable analysis revealed low platelets, high paCO2 before ECMO, and rapid drop in paCO2 after V-V ECMO initiation as significant risk factors for ICB. CONCLUSION The results emphasize that ICB is a frequent complication during V-V ECMO. Many bleedings were incidental findings, therefore screening for ICB is advisable. The univariate risk factors reflect the underlying disease severity, coagulation disorders and peri-cannulation factors, and may help to identify patients at risk.
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Affiliation(s)
- Clemens Wiest
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Clinic of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Clinic of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Roland Schneckenpointner
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maximilian V Malfertheiner
- Clinic and Policlinic of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
- Clinic of Pneumonology Donaustauf, Donaustauf, Germany
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5
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Hwang J, Kalra A, Shou BL, Whitman G, Wilcox C, Brodie D, Zaaqoq AM, Lorusso R, Uchino K, Cho SM. Epidemiology of ischemic stroke and hemorrhagic stroke in venoarterial extracorporeal membrane oxygenation. Crit Care 2023; 27:433. [PMID: 37946237 PMCID: PMC10633935 DOI: 10.1186/s13054-023-04707-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/23/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND While venoarterial extracorporeal membrane oxygenation (V-A ECMO) provides lifesaving support for cardiopulmonary failure, complications may increase mortality, with few studies focusing on ischemic/hemorrhagic stroke. We aimed to determine the trends and associations of stroke incidence and mortality, and their risk factors, including the effects of annual case volumes of ECMO centers. METHODS Retrospective analysis was performed on the Extracorporeal Life Support Organization (ELSO) registry, including adult V-A ECMO patients from 534 international centers between 2012 and 2021, excluding extracorporeal cardiopulmonary resuscitation. Temporal trend analyses were performed for stroke incidence and mortality. Univariate testing, multivariable regression, and survival analysis were used to evaluate the associations of stroke, 90-day mortality, and impact of annual center volume. RESULTS Of 33,041 patients, 20,297 had mortality data, and 12,327 were included in the logistic regression. Between 2012 and 2021, ischemic stroke incidence increased (p < 0.0001), hemorrhagic stroke incidence remained stable, and overall 90-day mortality declined (p < 0.0001). Higher 24-h PaO2 and greater decrease between pre-ECMO PaCO2 and post-cannulation 24-h PaCO2 were associated with greater ischemic stroke incidence, while annual case volume was not. Ischemic/hemorrhagic strokes were associated with increased 90-day mortality (both p < 0.0001), while higher annual case volume was associated with lower 90-day mortality (p = 0.001). Hazard of death was highest in the first several days of V-A ECMO. CONCLUSION In V-A ECMO patients between 2012 and 2021, 90-day mortality decreased, while ischemic stroke incidence increased. ELSO centers with higher annual case volumes had lower mortality, but were not associated with ischemic/hemorrhagic stroke incidence. Both ischemic/hemorrhagic strokes were associated with increased mortality.
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Affiliation(s)
- Jaeho Hwang
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christopher Wilcox
- Division of Critical Care, Department of Medicine, Mercy Hospital of Buffalo, Buffalo, NY, USA
| | - Daniel Brodie
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA.
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6
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Teixeira JP, Larson LM, Schmid KM, Azevedo K, Kraai E. Extracorporeal cardiopulmonary resuscitation. Int Anesthesiol Clin 2023; 61:22-34. [PMID: 37589133 DOI: 10.1097/aia.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- J Pedro Teixeira
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Lance M Larson
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Kristin M Schmid
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Keith Azevedo
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Erik Kraai
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Krasivskyi I, Großmann C, Dechow M, Djordjevic I, Ivanov B, Gerfer S, Bennour W, Kuhn E, Sabashnikov A, Rahmanian PB, Mader N, Eghbalzadeh K, Wahlers T. Acute Limb Ischaemia during ECMO Support: A 6-Year Experience. Life (Basel) 2023; 13:life13020485. [PMID: 36836842 PMCID: PMC9962883 DOI: 10.3390/life13020485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock is rising. Acute limb ischaemia remains one of the main complications after ECMO initiation. We analysed 104 patients from our databank from January 2015 to December 2021 who were supported with mobile ECMO therapy. We aimed to identify the impact of acute limb ischaemia on short-term outcomes in patients placed on ECMO in our institution. The main indication for ECMO therapy was left ventricular (LV) failure with cardiogenic shock (57.7%). Diameters of arterial cannulas (p = 0.365) showed no significant differences between both groups. Furthermore, concomitant intra-aortic balloon pump (IABP, p = 0.589) and Impella (p = 0.385) implantation did not differ significantly between both groups. Distal leg perfusion was established in approximately 70% of patients in two groups with no statistically significant difference (p = 0.960). Acute limb ischaemia occurred in 18.3% of cases (n = 19). In-hospital mortality was not significantly different (p = 0.799) in both groups. However, the bleeding rate was significantly higher (p = 0.005) in the limb ischaemia group compared to the no-limb ischaemia group. Therefore, early diagnosis and prevention of acute limb ischaemia might decrease haemorrhage complications in patients during ECMO therapy.
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Affiliation(s)
- Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-176-353-88719
| | - Clara Großmann
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Marit Dechow
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Borko Ivanov
- Department of Cardiothoracic Surgery, Heart Centre, Helios Hospital Siegburg, 53721 Siegburg, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Walid Bennour
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | | | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
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8
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Rajsic S, Treml B, Jadzic D, Breitkopf R, Oberleitner C, Popovic Krneta M, Bukumiric Z. Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications. Ann Intensive Care 2022; 12:93. [PMID: 36195759 PMCID: PMC9532225 DOI: 10.1186/s13613-022-01067-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock. METHODS We conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size. RESULTS Thirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality. CONCLUSIONS Extracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Benedikt Treml
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Dragana Jadzic
- Anesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, Cagliari, Italy
| | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | - Christoph Oberleitner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020, Innsbruck, Austria
| | | | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000, Belgrade, Serbia.
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9
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Rali AS, Ranka S, Butcher A, Shah Z, Tonna JE, Anders MM, Brinkley MD, Siddiqi H, Punnoose L, Wigger M, Sacks SB, Pedrotty D, Ooi H, Bacchetta MD, Hoffman J, McMaster W, Balsara K, Shah AS, Menachem JN, Schlendorf KH, Lindenfeld J, Zalawadiya SK. Early Blood Pressure Variables Associated With Improved Outcomes in VA-ECLS: The ELSO Registry Analysis. JACC. HEART FAILURE 2022; 10:397-403. [PMID: 35654524 PMCID: PMC9214574 DOI: 10.1016/j.jchf.2022.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/14/2022] [Accepted: 04/01/2022] [Indexed: 06/03/2023]
Abstract
BACKGROUND As utilization of veno-arterial extracorporeal life support (VA-ECLS) in treatment of cardiogenic shock (CS) continues to expand, clinical variables that guide clinicians in early recognition of myocardial recovery and therefore, improved survival, after VA-ECLS are critical. There remains a paucity of literature on early postinitiation blood pressure measurements that predict improved outcomes. OBJECTIVES The objective of this study is to help identify early blood pressure variables associated with improved outcomes in VA-ECLS. METHODS The authors queried the ELSO (Extracorporeal Life Support Organization) registry for cardiogenic shock patients treated with VA-ECLS or venovenous arterial ECLS between 2009 and 2020. Their inclusion criteria included treatment with VA-ECLS or venovenous arterial ECLS; absence of pre-existing durable right, left, or biventricular assist devices; no pre-ECLS cardiac arrest; and no surgical or percutaneously placed left ventricular venting devices during their ECLS runs. Their primary outcome of interest was the survival to discharge during index hospitalization. RESULTS A total of 2,400 CS patients met the authors' inclusion criteria and had complete documentation of blood pressures. Actual mortality during index hospitalization in their cohort was 49.5% and survivors were younger and more likely to be Caucasian, intubated for >30 hours pre-ECLS initiation, and had a favorable baseline SAVE (Survival After Veno-arterial ECMO) score (P < 0.05 for all). Multivariable regression analyses adjusting for SAVE score, age, ECLS flow at 4 hours, and race showed that every 10-mm Hg increase in baseline systolic blood pressure (HR: 0.92 [95% CI: 0.89-0.95]; P < 0.001), and baseline pulse pressure (HR: 0.88 [95% CI: 0.84-0.91]; P < 0.001) at 24 hours was associated with a statistically significant reduction in mortality. CONCLUSIONS Early (within 24 hours) improvements in pulse pressure and systolic blood pressure from baseline are associated with improved survival to discharge among CS patients treated with VA-ECLS.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sagar Ranka
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, Texas, USA
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Marc M Anders
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Marshal D Brinkley
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hasan Siddiqi
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn Punnoose
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Wigger
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne B Sacks
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dawn Pedrotty
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry Ooi
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jordan Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keki Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip K Zalawadiya
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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10
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Nair N, Yang S, Gongora E. Impact of mechanical circulatory support on post-transplant stroke risk. Int J Artif Organs 2021; 44:675-680. [PMID: 34407680 DOI: 10.1177/03913988211035143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The effect of type of mechanical circulatory support on stroke risk during the early post-transplant period remains undefined in patients bridged to transplant. This study assesses if the type of circulatory support device affects stroke risk in this population. The study cohort of 4257 adult patients bridged with mechanical support to cardiac transplant were derived from the UNOS transplant registry data. Risk factors assessed were age, gender, ischemic time, diabetes (recipient), durable mechanical support at listing and mechanical ventilation pre-transplant. Descriptive statistics were used to describe characteristics of the study cohort. Univariate logistic regression was used to test if there is a significant association between stroke event and all the potential risk factors. Multivariate logistic regression was used to test such associations while adjusting for all other risk factors. Odds ratios (ORs) and their 95% confidence intervals (CIs) in parenthesis, were calculated. p < 0.05 was considered significant. Patients on Extracorporeal membrane oxygenation (ECMO) had the highest risk of stroke immediately post-transplant prior to discharge (OR 3.03, {1.16, 7.95}) followed by Total Artificial Heart (TAH) (OR 2.03, {1.01, 4.07) as compared to those only on a Left Ventricular Assist Device (LVAD). Ischemic time (OR 1.3 {1.09, 1.45}) and diabetes (OR 1.8 {1.29, 2.51}) were significant risk factors. Patients on ECMO and TAH had a 203% and 103% increase respectively in the odds of having a stroke prior to discharge as compared to those only on LVADS.
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Affiliation(s)
- Nandini Nair
- Department of Medicine, TTUHSC, Lubbock, TX, USA
| | | | - Enrique Gongora
- Department of Cardiothoracic Surgery, University of Alabama School of Medicine, Birmingham, AL, USA
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11
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Welker C, Huang J, Ramakrishna H. Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support. J Cardiothorac Vasc Anesth 2021; 36:2207-2219. [PMID: 34332842 DOI: 10.1053/j.jvca.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.
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Affiliation(s)
- Carson Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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12
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Makhoul M, Heuts S, Mansouri A, Taccone FS, Obeid A, Mirko B, Broman LM, Malfertheiner MV, Meani P, Raffa GM, Delnoij T, Maessen J, Bolotin G, Lorusso R. Understanding the "extracorporeal membrane oxygenation gap" in veno-arterial configuration for adult patients: Timing and causes of death. Artif Organs 2021; 45:1155-1167. [PMID: 34101843 PMCID: PMC8518076 DOI: 10.1111/aor.14006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/08/2021] [Accepted: 06/01/2021] [Indexed: 11/28/2022]
Abstract
Timing and causes of hospital mortality in adult patients undergoing veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) have been poorly described. Aim of the current review was to investigate the timing and causes of death of adult patients supported with V‐A ECMO and subsequently define the “V‐A ECMO gap,” which represents the patients who are successfully weaned of ECMO but eventually die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V‐A ECMO patients from January 1993 to December 2020 were screened. The studies included in this review were studies that reported more than 10 adult, human patients, and no mechanical circulatory support other than V‐A ECMO. Information extracted from each study included mainly mortality and causes of death on ECMO and after weaning. Complications and discharge rates were also extracted. Sixty studies with 9181 patients were included for analysis in this systematic review. Overall mortality was 38.0% (95% confidence intervals [CIs] 34.2%‐41.9%) during V‐A ECMO support (reported by 60 studies) and 15.3% (95% CI 11.1%‐19.5%, reported by 57 studies) after weaning. Finally, 44.0% of patients (95% CI 39.8‐52.2) were discharged from hospital (reported by 60 studies). Most common causes of death on ECMO were multiple organ failure, followed by cardiac failure and neurological causes. More than one‐third of V‐A ECMO patients die during ECMO support. Additionally, many of successfully weaned patients still decease during hospital stay, defining the “V‐A ECMO gap.” Underreporting and lack of uniformity in reporting of important parameters remains problematic in ECMO research. Future studies should uniformly define timing and causes of death in V‐A ECMO patients to better understand the effectiveness and complications of this support.
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Affiliation(s)
- Maged Makhoul
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Abdulrahman Mansouri
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Clinique Universitaire de Bruxelles (CUB) Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Amir Obeid
- Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Belliato Mirko
- U.O.C. Anestesia e Rianimazione II Cardiopolmonare, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Paolo Meani
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Thijs Delnoij
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy.,Intensive Care Department, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jos Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Gil Bolotin
- Cardiac Surgery Unit, Rambam Medical Centre, Haifa, Israel
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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13
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Malfertheiner MV, Koch A, Fisser C, Millar JE, Maier LS, Zeman F, Poschenrieder F, Lubnow M, Philipp A, Müller T. Incidence of early intra-cranial bleeding and ischaemia in adult veno-arterial extracorporeal membrane oxygenation and extracorporeal cardiopulmonary resuscitation patients: a retrospective analysis of risk factors. Perfusion 2021; 35:8-17. [PMID: 32397881 DOI: 10.1177/0267659120907438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral complications in veno-arterial extracorporeal membrane oxygenation are known to have a strong impact on mortality and morbidity. Aim of this study is to investigate the early incidence, risk factors and in-hospital mortality of intra-cranial ischaemia and haemorrhage in adults undergoing veno-arterial extracorporeal membrane oxygenation treatment. METHODS This study is a single-centre retrospective analysis on adult patients undergoing veno-arterial extracorporeal membrane oxygenation for different indications. The inclusion criterion included patients with early routine cerebral computed tomography imaging during extracorporeal membrane oxygenation, with no clinical evidence of cerebral pathology prior to cannulation. Cerebral complications were grouped by aetiology and the territories of the brain's supplying arteries. RESULTS One hundred eighty-seven adult patients with a total of 190 veno-arterial extracorporeal membrane oxygenation treatments were included. A total of 16.3% (n = 31) had evidence of either cerebral ischaemia (11.1%) or haemorrhage (5.8%); one patient suffered from both. Cerebral computed tomography scans were performed early in median on the first day after extracorporeal membrane oxygenation cannulation; in-hospital mortality of intra-cranial ischaemia and haemorrhage was 71.4% and 45.5%, respectively. Associated with an increased risk for ischaemic lesions were cannulation of the ascending aorta, higher age, presence of an autoimmune disease and cardiac surgery prior to veno-arterial extracorporeal membrane oxygenation. An association with haemorrhagic lesions was found for a lower blood PaCO2 at 2 hours, lower blood flow through the extracorporeal membrane oxygenation device at 2 hours, higher international normalized ratio and constantly higher activated partial thromboplastin time values as well as higher mean arterial pressures until haemorrhagic lesions were evident. CONCLUSION Cerebral complications are frequent in patients on veno-arterial extracorporeal membrane oxygenation and may be clinically silent events. Careful monitoring with routine neuroimaging seems to be the most appropriate diagnostic approach at present. Intra-cranial ischaemia occurs more frequent than haemorrhage and is associated with cannulation of the aorta ascendens.
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Affiliation(s)
| | - Andrea Koch
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jonathan Edward Millar
- Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Lars Sigfried Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | | | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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14
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Bickel TJ, Gunasekaran P, Parashara DK, Alpert MA. Mechanical Circulatory Support Prior to Heart Transplantation Predicts Early Post-Operative Stroke. Am J Med Sci 2021; 362:34-38. [PMID: 33785302 DOI: 10.1016/j.amjms.2021.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/04/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices are often deployed to treat patients with refractory cardiogenic shock, rapid deterioration of heart failure, and inotrope-dependent patients. Stroke is a common complication of MCS therapy. This study assesses the risk of stroke during the early post-heart transplantation (HT) period (days from successful HT to discharge or death) in patients who received MCS therapy leading to HT. METHODS Data were derived from the United Organ Sharing (UNOS) database. MCS modalities studied include left ventricular assist devices (LVAD), right ventricular assist devices (RVAD), biventricular ventricular assist devices (BiVAD), and extra-corporeal membrane oxygenation (ECMO). A multiple logistic regression model was used to determine the risk of stroke during the early post-HT period associated in patients treated with MCS leading to HT. RESULTS Between 1988 and 2014, 10,258 patients received MCS therapy leading to HT. Of these, 160 patients (1.96%) developed stroke during the early post-HT period. Multiple regression analysis showed that MCS modalities and associated odds ratios for early post-HT stroke and associated 95% confidence intervals were as follows: LVAD (1.44, 0.70-2.94), RVAD (2.89, 1.03-8.05, BiVAD (3.24, 1.15-9.10), ECMO (2.27 (1.17-4.40), and any MCS (1.60 (1.20-2.12). CONCLUSIONS With the exception of left ventricular assist devices, use of MCS modalities leading to HT is significantly and independently associated with stroke during the early post-HT period.
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Affiliation(s)
| | | | - Deepak K Parashara
- Kansas City Veterans Administration Medical Center, Kansas City, KS, USA
| | - Martin A Alpert
- Columbia School of Medicine, University of Missouri, Columbia, MO, USA.
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15
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Guo JG, Cao J, Zhang WM, Meng FG, Zhang Z, Xu BJ, Qian XM. Application of extracorporeal cardiopulmonary resuscitation in adult patients with refractory cardiac arrest. J Thorac Dis 2021; 13:831-836. [PMID: 33717556 PMCID: PMC7947475 DOI: 10.21037/jtd-20-1573] [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] [Indexed: 11/06/2022]
Abstract
Background The aim of this study was to summarize the clinical experience of extracorporeal cardiopulmonary resuscitation (ECPR) in the treatment of adult patients with refractory cardiac arrest. Methods The clinical data of 12 cases of adult patients with cardiac arrest hospitalized between June 2015 and September 2019 who were unable to achieve return of spontaneous circulation effectively with conventional cardiopulmonary resuscitation (CCPR) and were treated with ECPR technology were retrospectively analyzed. The group included six males and six females aged between 18 and 69 years. All the patients underwent veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support with the adoption of femoral artery and vein catheterization. Results The duration of cardiopulmonary resuscitation (CPR) for the 12 patients was 32-125 min, and the ECMO duration was 2-190 h. Four patients were successfully weaned from ECMO and survived until hospital discharge. The other eight patients died in hospital; hemodynamic collapse (four patients) in the early stage of ECMO and severe neurological complications (three patients) were the main causes of death. Conclusions Single-center data showed that ECPR provided a new rescue alternative for some patients with reversible refractory cardiac arrest. We have demonstrated that the success rate of treatment could be improved by selecting suitable patients and reducing the CPR duration as much as possible.
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Affiliation(s)
- Ji-Ge Guo
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jie Cao
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Wei-Min Zhang
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Fan-Gang Meng
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zheng Zhang
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Bi-Jun Xu
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xi-Ming Qian
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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16
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Loungani RS, Fudim M, Ranney D, Kochar A, Samsky MD, Bonadonna D, Itoh A, Takayama H, Takeda K, Wojdyla D, DeVore AD, Daneshmand M. Contemporary Use of Venoarterial Extracorporeal Membrane Oxygenation: Insights from the Multicenter RESCUE Registry. J Card Fail 2021; 27:327-337. [PMID: 33347997 DOI: 10.1016/j.cardfail.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge. METHODS AND RESULTS We created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at 3 high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were postcardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% of patients (n = 290) survived to discharge, with a minority receiving durable cardiac support (left ventricular assist device [n = 48] or heart transplantation [n = 7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12-1.42) and female sex (OR, 1.44; 95% CI, 1.02-2.02) and risk factors for mortality after decannulation as higher body mass index (OR 1.17; 95% CI, 1.01-1.35) and major bleeding while on ECMO support (OR, 1.92; 95% CI, 1.23-2.99). CONCLUSIONS Despite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. The optimization of outcomes will require refinements in patient selection and improvement of care delivery.
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Affiliation(s)
- Rahul S Loungani
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Marat Fudim
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Dave Ranney
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Ajar Kochar
- Division of Cardiology, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Marc D Samsky
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Desiree Bonadonna
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Akinobu Itoh
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Hiroo Takayama
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Daniel Wojdyla
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Adam D DeVore
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Mani Daneshmand
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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17
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Kwon SS, Park BW, Lee MH, Bang DW, Hyon MS, Chang WH, Oh HC, Park YW. Role and Prognosis of Extracorporeal Life Support in Patients Who Develop Cardiac Arrest during or after Office-Based Cosmetic Surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:277-284. [PMID: 32919449 PMCID: PMC7553826 DOI: 10.5090/kjtcs.19.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 04/25/2020] [Accepted: 05/04/2020] [Indexed: 11/17/2022]
Abstract
Background Cardiac arrest during or after office-based cosmetic surgery is rare, and little is known about its prognosis. We assessed the clinical outcomes of patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics. Methods Between May 2009 and May 2016, 32 patients who developed cardiac arrest during or after treatment at cosmetic surgery clinics were consecutively enrolled. We compared clinical outcomes, including complications, between survivors (n=19) and non-survivors (n=13) and attempted to determine the prognostic factors of mortality. Results All 32 of the patients were female, with a mean age of 30.40±11.87 years. Of the 32 patients, 13 (41%) died. Extracorporeal life support (ECLS) was applied in a greater percentage of non-survivors than survivors (92.3% vs. 47.4%, respectively; p=0.009). The mean duration of in-hospital cardiopulmonary resuscitation (CPR) was longer for the non-survivors than the survivors (31.55±33 minutes vs. 7.59±9.07 minutes, respectively; p=0.01). The mean Acute Physiology and Chronic Health Evaluation score was also higher among non-survivors than survivors (23.85±6.68 vs. 16.79±7.44, respectively; p=0.01). No predictor of death was identified in the patients for whom ECLS was applied. Of the 19 survivors, 10 (52.6%) had hypoxic brain damage, and 1 (5.3%) had permanent lower leg ischemia. Logistic regression analyses revealed that the estimated glomerular filtration rate was a predictor of mortality. Conclusion Patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics experienced poor prognoses, even though ECLS was applied in most cases. The survivors suffered serious complications. Careful monitoring of subjects and active CPR (when necessary) in cosmetic surgery clinics may be essential.
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Affiliation(s)
- Seong Soon Kwon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Byoung-Won Park
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Min-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Duk Won Bang
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Min-Su Hyon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Won-Ho Chang
- Department of Chest Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Hong Chul Oh
- Department of Chest Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Young Woo Park
- Department of Chest Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
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18
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Prognostic Factors for Survival After Extracorporeal Membrane Oxygenation for Cardiogenic Shock. ASAIO J 2020; 66:141-145. [PMID: 30864968 DOI: 10.1097/mat.0000000000000984] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study is to examine factors that can predict mortality in patients that have veno-arterial extracorporeal membrane oxygenation (VA-ECMO) instituted for cardiogenic shock. A single-center, retrospective study of 127 patients who underwent VA-ECMO for cardiogenic shock between January 2003 and December 2017 was conducted. Eighty-three (65%) patients survived to weaning or bridging therapy. Complications on VA-ECMO include: hemorrhage (40%), stroke (14%), requirement for dialysis (42%), and limb ischemia (24%). Univariate analysis revealed shorter ECMO duration, higher body mass index, preimplantation creatinine > 100 mmol/l, lower preimplantation serum albumin, and the development of stroke or limb ischemia on ECMO to be significantly associated with mortality while on ECMO. Multivariate analysis by logistic regression found shorter ECMO duration and lower preimplantation serum albumin to be significantly associated with mortality. VA-ECMO is an effective strategy in treating patients with cardiogenic shock and provides a reasonable chance of survival to weaning or bridging to other therapy. Preimplantation hypoalbuminemia, preimplantation serum creatinine > 100 mmol/l, and the development of stroke and limb ischemia while on VA-ECMO are strongly associated with mortality.
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The Effect of Acute Limb Ischemia on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation. Ann Vasc Surg 2020; 62:318-325. [DOI: 10.1016/j.avsg.2019.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 11/20/2022]
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Rali AS, Chandler J, Sauer A, Solomon MA, Shah Z. Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU. J Intensive Care Med 2019; 36:290-303. [PMID: 31830842 DOI: 10.1177/0885066619894541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.
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Affiliation(s)
- Aniket S Rali
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Jonathan Chandler
- Department of Internal Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Andrew Sauer
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Michael A Solomon
- Critical Care Medicine, 2511National Institutes of Health Clinical Center, Bethesda, MD, USA.,Cardiology Branch, National Heart, Lung, and Blood Institute, 2511National Institutes of Health, Bethesda, MD, USA
| | - Zubair Shah
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
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Agarwal S, Morris N, Der-Nigoghossian C, May T, Brodie D. The Influence of Therapeutics on Prognostication After Cardiac Arrest. Curr Treat Options Neurol 2019; 21:60. [PMID: 31768661 DOI: 10.1007/s11940-019-0602-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to highlight the influence of therapeutic maneuvers on neuro-prognostication measures administered to comatose survivors of cardiac arrest. We focus on the effect of sedation regimens in the setting of targeted temperature management (TTM), one of the principle interventions known to improve neurological recovery after cardiac arrest. Further, we discuss the critical need for novel markers, as well as refinement of existing markers, among patients receiving extracorporeal membrane oxygenation (ECMO) in the setting of failed conventional resuscitation, known as extracorporeal cardiopulmonary resuscitation (ECPR). RECENT FINDINGS Automated pupillometry may have some advantage over standard pupillary examination for prognostication following TTM, sedation, or the use of ECMO after cardiac arrest. New serum biomarkers such as Neurofilament light chain have shown good predictive abilities and need further validation in these populations. There is a high-level uncertainty in brain death declaration protocols particularly related to apnea testing and appropriate ancillary tests in patients receiving ECMO. Both sedation and TTM alone and in combination have been shown to affect prognostic markers to varying degrees. The optimal approach to analog-sedation is unknown, and requires further study. Moreover, validation of known prognostic markers, as well as brain death declaration processes in patients receiving ECMO is warranted. Data on the effects of TTM, sedation, and ECMO on biomarkers (e.g., neuron-specific enolase) and electrophysiology measures (e.g., somatosensory-evoked potentials) is sparse. The best approach may be one customized to the individual patient, a precision-medicine approach.
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Affiliation(s)
- Sachin Agarwal
- Division of Neurocritical Care and Hospitalist Neurology, Department of Neurology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.
| | - Nicholas Morris
- Department of Neurology, Program in Trauma, University of Maryland Medical Center, Baltimore, MD, USA
| | - Caroline Der-Nigoghossian
- Clinical Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Teresa May
- Division of Pulmonary and Critical Care Medicine, Maine Medical Center, Portland, ME, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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Lorusso R, Raffa GM, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Kowalewski M, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, D'Alessandro DA, Boeken U, Whitman GJR. Structured review of post-cardiotomy extracorporeal membrane oxygenation: part 1-Adult patients. J Heart Lung Transplant 2019; 38:1125-1143. [PMID: 31522913 PMCID: PMC8152367 DOI: 10.1016/j.healun.2019.08.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 07/21/2019] [Accepted: 08/05/2019] [Indexed: 01/25/2023] Open
Abstract
Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands.
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Khalid Alenizy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Niels Sluijpers
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Maged Makhoul
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Daniel Brodie
- Center for Acute Respiratory Care, Columbia University college of Physicians & Surgeon/New Yor Presbyterian Hospital, New York, New York
| | - Mike McMullan
- Cardiac Surgery Unit, Seattle Children Hospital, Seattle, Washington
| | - I-Wen Wang
- Cardiac Transplantation and Mechanical Circulatory Support Unit, Indiana University School of Medicine, Health Methodist Hospital, Indianapolis, Indiana
| | - Paolo Meani
- Heart & Vascular Centre, Cardiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University, Singapore, Singapore
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Heidi Dalton
- I.N.O.V.A. Fairfax Medical Centre, Adult and Pediatric ECMO Service, Falls Church, Virginia
| | - Ryan Barbaro
- Division of Pediatric Critical Care and Child Health Evaluation and Research Unit, Ann Arbor, Michigan
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nicholas Cavarocchi
- Surgical Cardiac Care Unit, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Pediatric Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ravi Thiagarajan
- Department of Cardiology, Boston Children's Hospital; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Peta Alexander
- Department of Cardiology, Boston Children's Hospital; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - David A D'Alessandro
- Cardio-Thoracic Surgery Department, Massachusetts Medical Centre, Boston, Massachusetts
| | - Udo Boeken
- Cardiovascular Surgery Unit, University of Düsseldorf, Düsseldorf, Germany
| | - Glenn J R Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, Maryland
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Pozzebon S, Blandino Ortiz A, Franchi F, Cristallini S, Belliato M, Lheureux O, Brasseur A, Vincent JL, Scolletta S, Creteur J, Taccone FS. Cerebral Near-Infrared Spectroscopy in Adult Patients Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation. Neurocrit Care 2019; 29:94-104. [PMID: 29560599 DOI: 10.1007/s12028-018-0512-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Acute cerebral complications (ACC) of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are associated with poor long-term neurologic outcome. We described the role of rSO2 monitoring in detecting ACC and desaturations and their relationship with poor outcome when employing VA-ECMO. METHODS Retrospective analysis of patients monitored by cerebral frontal near-infrared spectroscopy (NIRS) (CAS Medical Systems Inc., Branford, CT, USA) during VA-ECMO (November 2008-December 2015). ACC was defined as the presence of stroke and/or brain death, while cerebral desaturation as cortical oxygen tissue saturation (rSO2) < 60%. RESULTS Fifty-six of 159 VA-ECMO patients (age 55 [36-60] years) were included; 18 (32%) developed ACC and 36 died (64%). Cerebral desaturation occurred in 43 (74%) patients, who had a higher mortality than those without cerebral desaturation (74 vs. 31%). A high sequential organ failure assessment (SOFA) score on the first day of ECMO (OR 1.40 [95% CIs 1.06-1.84]) and the minimum ECMO blood flow during the first 4 days of therapy (OR 3.05 [1.01-9.17]) were independently associated with the occurrence of cerebral desaturation. Cerebral desaturation occurred more frequently in patients with ACC than others (94 vs. 68%); patients with ACC also had a lower minimal rSO2 over time (49 vs. 54%) and more frequently had high right-left rSO2 differences (33 vs. 8%), which were both independent predictors of ACC. The occurrence of cerebral desaturation (OR 7.93 [1.62-38.74]) and high lactate concentrations during the first 4 days of ECMO support (OR 1.22 [1.03-1.46]) was independently associated with hospital mortality. CONCLUSIONS Monitoring of rSO2 could be considered as an interesting tool to monitor the brain of patients on VA-ECMO.
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Affiliation(s)
- Selene Pozzebon
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Aaron Blandino Ortiz
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Federico Franchi
- Department of Anesthesia and Intensive Care, Università di Siena - Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Stefano Cristallini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Olivier Lheureux
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Alexandre Brasseur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sabino Scolletta
- Department of Anesthesia and Intensive Care, Università di Siena - Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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Acute Neurologic Complications During Extracorporeal Membrane Oxygenation: A Systematic Review. Crit Care Med 2019; 46:1506-1513. [PMID: 29782356 DOI: 10.1097/ccm.0000000000003223] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We determine the frequency, risk factors, and mortality of neurologic complications in adults on extracorporeal membrane oxygenation and propose an algorithm for preventive strategies. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY SELECTION Screening was performed using predefined search terms to identify cohort studies reporting neurologic complications in adults during extracorporeal membrane oxygenation from 1990 to 2017. DATA EXTRACTION The final reference list was generated on the basis of relevance to the discussed topics. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation classification of evidence scheme. DATA SYNTHESIS In 44 studies, the median frequency of acute neurologic complications is 13% (1-78%; 5% intracranial hemorrhages, 5% ischemic strokes, 2% seizures). Neurologic complications are reported more frequently with venoarterial extracorporeal membrane oxygenation compared with venovenous extracorporeal membrane oxygenation (14 vs eight studies) with a median proportion of complications of 15% (6-33%; 95% CI, 8-19) for venoarterial extracorporeal membrane oxygenation. Median in-hospital mortality is higher with neurologic complications (83%; interquartile range, 54-100% vs 42%; interquartile range, 24-55% without neurologic complications; p < 0.001). Median mortality is 96% for hemorrhages, 84% for ischemic strokes 84%, and 40% for seizures. Risk factors are age, preextracorporeal membrane oxygenation cardiac arrest, hypoglycemia, and administration of inotropes. Hemorrhages are associated with female gender, duration of ventilation and extracorporeal membrane oxygenation, decreased serum fibrinogen, heparin, serum creatinine greater than 2.6 mg/dL, hemodialysis, and thrombocytopenia. Increased odds for ischemic stroke is seen with a preextracorporeal membrane oxygenation serum lactate greater than 10 mmol/L. No studies report daily coagulation monitoring and neurologic assessments, and quality of evidence was low to very low. CONCLUSIONS Neurologic complications are reported frequently and with high occurrence rate, especially with venoarterial extracorporeal membrane oxygenation, and associated with high mortality calling for daily weaning from sedation and neuromuscular blockers for neurologic assessment and coagulation monitoring. The low quality of evidence indicates the need for higher quality studies in this context.
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Early Electroencephalography Findings in Cardiogenic Shock Patients Treated by Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Med 2019; 46:e389-e394. [PMID: 29389771 DOI: 10.1097/ccm.0000000000003010] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We aimed to assess early electroencephalography findings in patients treated by venoarterial extracorporeal membrane oxygenation and their association with neurologic outcome. DESIGN Single-center observational study. SETTING Medical ICU of a university hospital. PATIENTS An early standardized electroencephalography assessment, that is, standard electroencephalography followed by continuous electroencephalography, was performed in consecutive cardiogenic shock patients requiring venoarterial extracorporeal membrane oxygenation. Associations between electroencephalography findings and outcome, defined as a composite of acute brain injury or death at 14 days, were investigated. MEASUREMENTS AND MAIN RESULTS Twenty-two patients with a median Full Outline of Unresponsiveness score of 4 (interquartile range, 3-6) were studied. Pupillary light reflex, corneal reflex, and cough reflex were preserved in 20 (90%), 17 (77%), and 17 (77%) patients, respectively. Overall, standard electroencephalography findings consisted of diffuse slowing in 21 patients (95%) and severe background abnormalities in 13 patients (59%) (i.e., a discontinuous [n = 5; 23%] and/or an unreactive background [n = 9; 41%]). Severe background abnormalities on standard electroencephalography (poor outcome rate: 69% vs 22%; p = 0.03) and absence of sleep transients on continuous electroencephalography (poor outcome rate: 67% vs 14%; p = 0.02) were associated with a poor outcome, whereas neurologic findings and doses of sedation were not. Patients without sleep transients on continuous electroencephalography tended to have lower Full Outline of Unresponsiveness scores than patients with preserved sleep transients-appearing patterns. CONCLUSIONS In patients treated by venoarterial extracorporeal membrane oxygenation, early severe background abnormalities on standard electroencephalography provide important information on neurologic outcome. The lack of sleep transients on continuous electroencephalography reflects the severity of brain dysfunction and might represent an additional prognostic marker.
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Thongprayoon C, Cheungpasitporn W, Lertjitbanjong P, Aeddula NR, Bathini T, Watthanasuntorn K, Srivali N, Mao MA, Kashani K. Incidence and Impact of Acute Kidney Injury in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis. J Clin Med 2019; 8:jcm8070981. [PMID: 31284451 PMCID: PMC6678289 DOI: 10.3390/jcm8070981] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/23/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Although acute kidney injury (AKI) is a frequent complication in patients receiving extracorporeal membrane oxygenation (ECMO), the incidence and impact of AKI on mortality among patients on ECMO remain unclear. We conducted this systematic review to summarize the incidence and impact of AKI on mortality risk among adult patients on ECMO. METHODS A literature search was performed using EMBASE, Ovid MEDLINE, and Cochrane Databases from inception until March 2019 to identify studies assessing the incidence of AKI (using a standard AKI definition), severe AKI requiring renal replacement therapy (RRT), and the impact of AKI among adult patients on ECMO. Effect estimates from the individual studies were obtained and combined utilizing random-effects, generic inverse variance method of DerSimonian-Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018103527). RESULTS 41 cohort studies with a total of 10,282 adult patients receiving ECMO were enrolled. Overall, the pooled estimated incidence of AKI and severe AKI requiring RRT were 62.8% (95%CI: 52.1%-72.4%) and 44.9% (95%CI: 40.8%-49.0%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of AKI (p = 0.67) or AKI requiring RRT (p = 0.83). The pooled odds ratio (OR) of hospital mortality among patients receiving ECMO with AKI on RRT was 3.73 (95% CI, 2.87-4.85). When the analysis was limited to studies with confounder-adjusted analysis, increased hospital mortality remained significant among patients receiving ECMO with AKI requiring RRT with pooled OR of 3.32 (95% CI, 2.21-4.99). There was no publication bias as evaluated by the funnel plot and Egger's regression asymmetry test with p = 0.62 and p = 0.17 for the incidence of AKI and severe AKI requiring RRT, respectively. CONCLUSION Among patients receiving ECMO, the incidence rates of AKI and severe AKI requiring RRT are high, which has not changed over time. Patients who develop AKI requiring RRT while on ECMO carry 3.7-fold higher hospital mortality.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | | | - Narothama Reddy Aeddula
- Division of Nephrology, Department of Medicine, Deaconess Health System, Evansville, IN 47747, USA
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA
| | | | - Narat Srivali
- Division of Pulmonary and Critical Care Medicine, St. Agnes Hospital, Baltimore, MD 21229, USA
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Abouelwafa M, Radwan W, Abdelfattah A, Abdelbary A, Khaled M, Samy W, Yousry M, Saeed A, Saad M. The usefulness of Veno-Arterial Extracorporeal Membranous Oxygenation in Patients with Cardiogenic Shock. Open Access Maced J Med Sci 2019; 7:1768-1773. [PMID: 31316656 PMCID: PMC6614275 DOI: 10.3889/oamjms.2019.547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/09/2019] [Accepted: 06/10/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: Venoarterial extracorporeal membranous oxygenation is a form of temporary mechanical circulatory support that gets as a salvage technique in patients with cardiogenic shock, we intended to evaluate the effect of (VA ECMO) support on hemodynamics and lactate levels in patients with cardiogenic shock. AIM: The aim of our study is to detect the ability to introduce veno-arterial extracorporeal membranous oxygenation (VA ECMO) as a temporary extracorporeal life support system (ECLS) in our unit, demonstrate the role of ECMO in cardiogenic shock patients regarding improving hemodynamics and microcirculation, and demonstrate the complications and drawbacks in our first center experience regarding VA ECMO. MATERIAL AND METHODS: This was a single-centre observational study that included 10 patients admitted with cardiogenic shock for which VA ECMO was used as mechanical circulatory support. RESULTS: The MAP increased after initiation of the support. It was 41.8 ± 9.3 mmHg and 59.5 ± 6.8 mmHg (P = 0.005). The use of VA ECMO support was associated with a statistically significant decrease in the base deficit (-10.6 ± 4.2 and -6.3 ± 7.4, P = 0.038). The serum lactate declined from 5.9 ± 3.5 mmoL/L to 0.6 ± 4.4 mmoL/L by the use of VA ECMO; a statistically significant change (P = 0.005). CONCLUSIONS: We concluded that VA ECMO as mechanical support for patients with cardiogenic shock might improve mean arterial blood pressure, base deficit and lactate clearance.
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Affiliation(s)
| | - Waheed Radwan
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Alia Abdelfattah
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Akram Abdelbary
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Mohamed Khaled
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Wael Samy
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Mohamed Yousry
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Ahmed Saeed
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
| | - Mahmood Saad
- Critical Care Department, Cairo University Hospitals, Cairo, Egypt
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Guglin M, Zucker MJ, Bazan VM, Bozkurt B, El Banayosy A, Estep JD, Gurley J, Nelson K, Malyala R, Panjrath GS, Zwischenberger JB, Pinney SP. Venoarterial ECMO for Adults. J Am Coll Cardiol 2019; 73:698-716. [DOI: 10.1016/j.jacc.2018.11.038] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 10/03/2018] [Accepted: 11/14/2018] [Indexed: 02/05/2023]
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Yuan XL, Li CS, Zhang Y, Ling JY, Zhang Q, Liang Y, Liu B, Zhao LX. Extracorporeal Membrane Oxygenation Improving Survival and Alleviating Kidney Injury in a Swine Model of Cardiac Arrest Compared to Conventional Cardiopulmonary Resuscitation. Chin Med J (Engl) 2018; 131:1840-1848. [PMID: 30058582 PMCID: PMC6071471 DOI: 10.4103/0366-6999.237406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background Acute kidney injury (AKI) frequently occurs in cardiopulmonary resuscitation patients. Studies comparing the effects of extracorporeal membrane oxygenation (ECMO) with conventional cardiopulmonary resuscitation (CCPR) on AKI were rare. This study aimed to compare the effects of ECMO with those of CCPR on survival rate and AKI and explore the underlying mechanisms in a swine model of cardiac arrest (CA). Methods Sixteen male pigs were treated with ventricular fibrillation to establish CA model and then underwent CCPR (CCPR group, n = 8) or ECMO during cardiopulmonary resuscitation (ECPR group, n = 8). The study endpoints were 6 h after return of spontaneous circulation (ROSC) or death. Serum and urine samples were collected at baseline and during the 6 h after ROSC. The biomarkers of AKI were detected by enzyme-linked immunosorbent assay. The apoptosis of renal tubular epithelial cells was discovered by transmission electron microscope (TEM) and terminal deoxynucleotidyl transferase dUTP nick end labeling assay. Apoptosis-related genes were detected by immune-staining and Western blotting. Data were compared by Student's t-test. Results All pigs in ECPR group were successfully resuscitated with a higher 6-h survival rate (8/8) compared to CCPR group (6/8). The expressions of AKI biomarkers including neutrophil gelatinase-associated lipocalin (NGAL), tissue inhibitor of metalloproteinase2 (TIMP2), insulin-like growth factor-binding protein 7 (IGFBP7), liver fatty acid-binding protein (LFABP), and kidney injury molecule1 (Kim-1) were all increased along with the time after ROSC in both groups and lower in ECPR group compared with CCPR group. Especially, products of urinary TIMP and IGFBP levels (TIMP*IGFBP) were significantly lower at ROSC4 (0.58 ± 0.10 ng2/ml2 vs. 1.18 ± 0.38 ng2/ml2, t = 4.33, P = 0.003) and ROSC6 (1.79 ± 0.45 ng2/ml2 vs. 3.00 ± 0.44 ng2/ml2, t = 5.49, P < 0.001); urinary LFABP was significantly lower at ROSC6 (0.74 ± 0.06 pg/ml vs. 0.85 ± 0.11 pg/ml, t = 2.41, P = 0.033); and urinary Kim-1 was significantly lower at ROSC4 (0.66 ± 0.09 pg/ml vs. 0.83 ± 0.06 pg/ml, t = 3.99, P = 0.002) and ROSC6 (0.73 ± 0.12 pg/ml vs. 0.89 ± 0.08 pg/ml, t = 2.82, P = 0.016). Under light microscope and TEM, the morphological injures in renal tissues were found to be improved in ECPR group. Moreover, apoptosis was also alleviated in ECPR group. Conclusions Compared with CCPR, ECMO improves survival rate and alleviates AKI in a swine model of CA. The mechanism of which might be via downregulating AKI biomarkers and apoptosis in kidney.
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Affiliation(s)
- Xiao-Li Yuan
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Chun-Sheng Li
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yun Zhang
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Ji-Yang Ling
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Qiang Zhang
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yong Liang
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Bo Liu
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Lian-Xing Zhao
- Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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He P, Zhang S, Hu B, Wu W. Retrospective study on the effects of the prognosis of patients treated with extracorporeal membrane oxygenation combined with continuous renal replacement therapy. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:455. [PMID: 30603643 DOI: 10.21037/atm.2018.11.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Patients undergoing extracorporeal membrane oxygenation (ECMO) treatment often have severe fluid overload and electrolyte imbalances and may even suffer acute kidney injury (AKI). It is often necessary to use continuous renal replacement therapy (CRRT). In this study, we aimed to retrospectively analyze the prognosis of patients treated with ECMO combined with CRRT and to find the independent factors that affect the survival rate. Methods There were 32 patients who were treated with ECMO combined with CRRT in our hospital from January 2007 to December 2017 who were analyzed. All of the patients were divided into a survival group and death group. The clinical indicators and biochemical indexes of the two groups were observed, and their differences were compared. Multivariate logistic regression analysis was carried out to determine the independent risk factors. Results The fluid balance at ECMO day 3, SOFA score and lactate at CRRT initiation, sequential organ failure assessment (SOFA) score at ECMO weaning, CRRT duration, ECMO to CRRT interval, mechanical ventilation (MV) duration, length of ICU, and overall hospital length of stay were statistically significant (P<0.05). The clinical biochemical indexes at CRRT initiation and ECMO weaning [serum creatinine, pH, white blood cell (WBC), hemoglobin (Hb), bilirubin]; patient's age, gender and BMI; and the fluid balance at ECMO days 1 and 7 were not statistically significance (P>0.05). The fluid balance at ECMO day 3 and lactate at CRRT initiation by multivariable logistic regression analysis were independent risk factors affecting patient prognosis. Conclusions The fluid balance at ECMO day 3 and lactate at CRRT initiation are the prognosis independent risk factors for ECMO + CRRT patients.
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Affiliation(s)
- Ping He
- Cardiothoracic Surgery Department, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Shixin Zhang
- Cardiothoracic Surgery Department, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
| | - Bingyang Hu
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong 637000, China
| | - Wei Wu
- Cardiothoracic Surgery Department, Southwest Hospital, The Third Military Medical University, Chongqing 400038, China
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Cerebral Pathophysiology in Extracorporeal Membrane Oxygenation: Pitfalls in Daily Clinical Management. Crit Care Res Pract 2018; 2018:3237810. [PMID: 29744226 PMCID: PMC5878897 DOI: 10.1155/2018/3237810] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that is widely being used in centers throughout the world. However, there is a paucity of literature surrounding the mechanisms affecting cerebral physiology while on ECMO. Studies have shown alterations in cerebral blood flow characteristics and subsequently autoregulation. Furthermore, the mechanical aspects of the ECMO circuit itself may affect cerebral circulation. The nature of these physiological/pathophysiological changes can lead to profound neurological complications. This review aims at describing the changes to normal cerebral autoregulation during ECMO, illustrating the various neuromonitoring tools available to assess markers of cerebral autoregulation, and finally discussing potential neurological complications that are associated with ECMO.
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Duration of ECMO Is an Independent Predictor of Intracranial Hemorrhage Occurring During ECMO Support. ASAIO J 2017; 62:634-6. [PMID: 26978708 DOI: 10.1097/mat.0000000000000368] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We assessed the incidence and predictors of intracranial hemorrhage (ICH) occurring during extracorporeal membrane oxygenation (ECMO) support. Of 154 patients who received ECMO, 12 (7.8%) developed ICH. Patients with ICH had a longer ECMO duration (9.41 vs. 5.37 days, p = 0.007), and higher activated clotting time (activated clotting time, p= 0.016). They also experienced higher frequency of bleeding at other sites (p = 0.017) and required more platelet transfusion (p = 0.016). Multivariate analysis showed that a longer ECMO duration (odds ratio [OR] = 1.074, 95% confidence interval [CI] = 1.005-1.148, p = 0.035) is independently associated with the risk of ICH. We recommend routine neurological checks, monitoring of coagulation parameters, and attempt earlier rather than late weaning from ECMO whenever feasible.
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Oxigenação por membrana extracorporal na falência circulatória e respiratória – experiência de um centro. Rev Port Cardiol 2017; 36:833-842. [DOI: 10.1016/j.repc.2017.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/28/2016] [Accepted: 01/12/2017] [Indexed: 12/28/2022] Open
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Extracorporeal membrane oxygenation in circulatory and respiratory failure – A single-center experience. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
OBJECTIVES To describe donors after brain death with ongoing extracorporeal membrane oxygenation and to analyze the outcome of organs transplanted from these donors. DESIGN Retrospective analysis of the national information system run by the French Biomedicine Agency (CRISTAL database). SETTING National registry data of all donors after brain death in France and their organ recipients between 2007 and 2013. PATIENTS Donors after brain death and their organ recipients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, there were 22,270 brain-dead patients diagnosed in France, of whom 161 with extracorporeal membrane oxygenation. Among these patients, 64 donors on extracorporeal membrane oxygenation and 10,805 donors without extracorporeal membrane oxygenation had at least one organ retrieved. Donors on extracorporeal membrane oxygenation were significantly younger and had more severe intensive care medical conditions (hemodynamic, biological, renal, and liver insults) than donors without extracorporeal membrane oxygenation. One hundred nine kidneys, 37 livers, seven hearts, and one lung were successfully transplanted from donors on extracorporeal membrane oxygenation. We found no significant difference in 1-year kidney graft survival (p = 0.24) and function between recipients from donors on extracorporeal membrane oxygenation (92.7% [85.9-96.3%]) and matching recipients from donors without extracorporeal membrane oxygenation (95.4% [93.0-97.0%]). We also found no significant difference in 1-year liver recipient survival (p = 0.91): 86.5% (70.5-94.1) from donors on extracorporeal membrane oxygenation versus 80.7% (79.8-81.6) from donors without extracorporeal membrane oxygenation. CONCLUSIONS Brain-dead patients with ongoing extracorporeal membrane oxygenation have more severe medical conditions than those without extracorporeal membrane oxygenation. However, kidney graft survival and function were no different than usual. Brain-dead patients with ongoing extracorporeal membrane oxygenation are suitable for organ procurement.
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Yukawa T, Kashiura M, Sugiyama K, Tanabe T, Hamabe Y. Neurological outcomes and duration from cardiac arrest to the initiation of extracorporeal membrane oxygenation in patients with out-of-hospital cardiac arrest: a retrospective study. Scand J Trauma Resusc Emerg Med 2017; 25:95. [PMID: 28915913 PMCID: PMC5603067 DOI: 10.1186/s13049-017-0440-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 09/11/2017] [Indexed: 11/13/2022] Open
Abstract
Background We investigated the relationship between neurological outcomes and duration from cardiac arrest (CA) to the initiation of extracorporeal membrane oxygenation (ECMO) (CA-to-ECMO) in patients with out-of-hospital cardiac arrest (OHCA) treated with extracorporeal cardiopulmonary resuscitation (ECPR) and determined the ideal time at which ECPR should be performed. Methods During the time period in which this study was conducted, 3451 patients experienced OHCA. This study finally included 79 patients aged 18 years or older whose OHCA had been witnessed and who underwent ECPR in the emergency room between January 2011 and December 2015. Our primary endpoint was survival to hospital discharge with good neurological outcomes (a cerebral performance category of 1 or 2). Results Of the 79 patients included, 11 had good neurological outcomes. The median duration from CA-to-ECMO was significantly shorter in the good neurological outcome group (33 min, interquartile range [IQR], 27–50 vs. 46 min, IQR, 42–56: p = 0.03). After controlling for potential confounders, we found that the adjusted odds ratio of CA-to-ECMO time for a good neurological outcome was 0.92 (95% confidence interval: 0.87–0.98, p = 0.007). The area under the receiver operating characteristic curve of CA-to-ECMO for predicting a good neurological outcome was 0.71, and the optimal CA-to-ECMO cutoff time was 40 min. The dynamic probability of survival with good neurological outcomes based on CA-to-ECMO time showed that the survival rate with good neurological outcome decreased abruptly from over 30% to approximately 15% when the CA-to-ECMO time exceeded 40 min. Discussion In this study, CA-to-ECMO time was significantly shorter among patients with good neurological outcomes, and significantly associated with good neurological outcomes at hospital discharge. In addition, the probability of survival with good neurological outcome decreased when the CA-to-ECMO time exceeded 40 minutes. The indication for ECPR for patients with OHCA should include several factors. However, the duration of CPR before the initiation of ECMO is a key factor and an independent factor for good neurological outcomes in patients with OHCA treated with ECPR. Therefore, the upper limit of CA-to-ECMO time should be inevitably included in the indication for ECPR for patients with OHCA. In the present study, there was a large difference in the rate of survival to hospital discharge with good neurological outcome between the patients with a CA-to-ECMO time within 40 minutes and those whose time was over 40 minutes. Based on the present study, the time limit of the duration of CPR before the initiation of ECMO might be around 40 minutes. We should consider ECPR in patients with OHCA if they are relatively young, have a witness and no terminal disease, and the initiation of ECMO is presumed to be within this time period. Conclusions The duration from CA-to-ECMO was significantly associated with good neurological outcomes. The indication for patients with OHCA should include a criterion for the ideal time to initiate ECPR.
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Affiliation(s)
- Takahiro Yukawa
- Trauma and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 23-15 Kohtohbashi, 4-Chome, Sumida-ku, Tokyo, 130-8575, Japan.
| | - Masahiro Kashiura
- Trauma and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 23-15 Kohtohbashi, 4-Chome, Sumida-ku, Tokyo, 130-8575, Japan
| | - Kazuhiro Sugiyama
- Trauma and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 23-15 Kohtohbashi, 4-Chome, Sumida-ku, Tokyo, 130-8575, Japan
| | - Takahiro Tanabe
- Trauma and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 23-15 Kohtohbashi, 4-Chome, Sumida-ku, Tokyo, 130-8575, Japan
| | - Yuichi Hamabe
- Trauma and Critical Care Center, Tokyo Metropolitan Bokutoh Hospital, 23-15 Kohtohbashi, 4-Chome, Sumida-ku, Tokyo, 130-8575, Japan
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Rückert F, Steinke T, Flöther L, Bucher M, Metz D, Frantz S, Charitos EI, Treede H, Raspé C. Predictors for quality of life of patients with a portable out-of-centre-implanted extracorporeal membrane oxygenation device. Interact Cardiovasc Thorac Surg 2017; 24:542-548. [PMID: 28040752 DOI: 10.1093/icvts/ivw398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/19/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives Despite progress in the treatment of cardiopulmonary organ failure, the mortality rate for patients with acute respiratory distress syndrome (ARDS) and cardiogenic shock remains high. Extracorporeal membrane oxygenation (ECMO) is a promising treatment option, but long-term outcomes and health-related quality of life (HRQOL) are unknown. Methods Detailed information related to pre- and post-device data and outcomes from a consecutive sample of 71 patients treated with ECMO was analysed. Long-term survivors were given a detailed follow-up examination after a median time of 31 months that included multiple scoring systems for HRQOL assessment. Results Seventy-one patients received a portable out-of-centre-implanted ECMO system. The survival rate at hospital discharge was 48%. Median HRQOL scores were 80% on the Karnofsky index (normal ≥80%), 80% on the Euroqol-5D (normal ≥75%) and 73.1% on the quality-of-life index (normal ≥70%). Mental scores were 96.7% on the Mini-Mental State Examination (normal ≥90.0%), 77.8% on the DemTect (normal ≥72.0%), 87.0% on the test for early detection of dementia with depression demarcation (TFDD; normal ≥74.0%) and confirmed good mental state and HRQOL for patients at follow-up. Univariate analysis for in-hospital mortality indicated that ventilation time before device implantation, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, higher lactate level at the time of ECMO implantation and female gender were associated with adverse outcomes. Conclusions In our cohort of patients, survivors of out-of-hospital ECMO implantation demonstrated good mental and quality-of-life conditions with well-recovered cardiopulmonary function during long-term follow-up. The indicators for adverse outcomes, pre-implantation lactate levels, pre-ventilation time and APACHE II score, should be considered before implantation of an ECMO device. Clinical trial This study is registered at DRKS (Deutsches Register Klinischer Studien) under the code DRKS00009735 and was submitted to the WHO.
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Affiliation(s)
- Florian Rückert
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany.,Department of Cardiac Surgery, Halle-Wittenberg University, Halle (Saale), Germany
| | - Thomas Steinke
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
| | - Lilit Flöther
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
| | - Michael Bucher
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
| | - Dietrich Metz
- Department of Cardiac Surgery, Halle-Wittenberg University, Halle (Saale), Germany
| | - Stefan Frantz
- Department of Internal Medicine III, Halle-Wittenberg University, Halle (Saale), Germany
| | | | - Hendrik Treede
- Department of Cardiac Surgery, Halle-Wittenberg University, Halle (Saale), Germany
| | - Christoph Raspé
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle (Saale), Germany
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Juo YY, Skancke M, Sanaiha Y, Mantha A, Jimenez JC, Benharash P. Efficacy of Distal Perfusion Cannulae in Preventing Limb Ischemia During Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. Artif Organs 2017; 41:E263-E273. [DOI: 10.1111/aor.12942] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/20/2017] [Accepted: 03/03/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Yen-Yi Juo
- Center for Advanced Surgical and Interventional Technology (CASIT); University of California, Los Angeles; Los Angeles CA
- Department of Surgery; University of California; Los Angeles CA
- Department of Surgery; George Washington University; Washington DC
| | - Matthew Skancke
- Department of Surgery; George Washington University; Washington DC
| | - Yas Sanaiha
- Department of Surgery; University of California; Los Angeles CA
| | - Aditya Mantha
- Medical School, University of California, Irvine; Irvine CA, USA
| | - Juan C. Jimenez
- Department of Surgery; University of California; Los Angeles CA
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Wong JK, Melvin AL, Joshi DJ, Lee CY, Archibald WJ, Angona RE, Tchantchaleishvili V, Massey HT, Hicks GL, Knight PA. Cannulation-Related Complications on Veno-Arterial Extracorporeal Membrane Oxygenation: Prevalence and Effect on Mortality. Artif Organs 2017; 41:827-834. [PMID: 28589655 DOI: 10.1111/aor.12880] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/01/2016] [Accepted: 09/23/2016] [Indexed: 11/29/2022]
Abstract
Cannulation-related complications are a known source of morbidity in patients supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Despite its prevalence, little is known regarding the outcomes of patients who suffer such complications. This is a single institution review of cannulation-related complications and its effect on mortality in patients supported on VA-ECMO from January 2010-2015 using three cannulation strategies: axillary, femoral, and central. Complications were defined as advanced if they required major interventions (fasciotomy, amputation, site conversion). Patients were divided into two groups (complication present vs. not present) and Kaplan-Meier analysis was performed to determine any differences in their survival distributions. There were 103 patients supported on VA-ECMO: 41 (40%), 36 (35%), and 26 (25%) were cannulated via axillary, femoral, and central access, respectively. Cannulation-related complications occurred in 33 (32%) patients and this did not differ significantly between either axillary (34%), femoral (36%), or central (23%) strategies (P = 0.52). The most common complications encountered were hemorrhage and limb ischemia in 19 (18%) and 11 (11%) patients. Hemorrhagic complications did not differ between groups (P = 0.37), while limb ischemia and hyperperfusion were significantly associated with femoral and axillary cannulation, at a rate of 25% (P < 0.01) and 15% (P = 0.01), respectively. There was no difference in the incidence of advanced complications between cannulation groups: axillary (12%) vs. femoral (14%) vs. central (8%; P = 0.75). In addition, no increase in mortality was noted in patients who developed a cannulation-related complication by Kaplan-Meier estimates (P = 0.37). Cannulation-related complications affect a significant proportion of patients supported on VA-ECMO but do not differ in incidence between different cannulation strategies and do not affect patient mortality. Improved efforts at preventing these complications need to be developed to avoid the additional morbidity in an already critical patient population.
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Affiliation(s)
- Joshua K Wong
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Amber L Melvin
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Devang J Joshi
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Candice Y Lee
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - William J Archibald
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Ron E Angona
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Howard T Massey
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - George L Hicks
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter A Knight
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Elella RA, Habib E, Mokrusova P, Joseph P, Aldalaty H, Ahmadi MA, Halees ZA. Incidence and outcome of acute kidney injury by the pRIFLE criteria for children receiving extracorporeal membrane oxygenation after heart surgery. Ann Saudi Med 2017; 37:201-206. [PMID: 28578358 PMCID: PMC6150581 DOI: 10.5144/0256-4947.2017.201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common in patients treated with extracorporeal membrane oxygenation (ECMO). The RIFLE criteria demonstrate clinical relevance for diagnosing AKI and classifying its severity. OBJECTIVES To systematically define the incidence, clinical course and outcome of AKI using the pediatric pRIFLE criteria. DESIGN Retrospective, medical records review. SETTINGS Pediatric cardiac surgical intensive care units at a tertiary care hospital in Riyadh. PATIENTS AND METHODS We reviewed the records of all pediatric patients that underwent cardiac surgery and required ECMO postoperatively between 1 January 2011 and 1 January 2016. AKI was classified according to the pRIFLE criteria 48 hours after ECMO initiation. Demographics and concomitant therapies for all patients were collected. MAIN OUTCOME MEASURE(S) Outcome was assessed by recovery from AKI at time of discharge, ICU stay and mortality. RESULTS Fifty-nine patients needed ECMO after cardiac surgery during the study period. Their mean (SD) age and weight was 11.0 (16.5) month and 5.5 (3.6) kg, respectively. All patients had a central venoarterial ECMO inserted. Fifty-three patients (90%) developed AKI after ECMO initiation. The majority of patients (57%) were categorized as pRIFLE-Failure, having a higher mortality rate (28/34 patients, 82%) in comparison to the pRIFLE-Injury and pRIFLE-Risk groups. Twenty-nine patients (49%) required either peritoneal dialysis (PD), or renal replacement therapy (RRT) or both. For AKI vs non-AKI patients, there was a statistically significant difference between mean (SD) ECMO duration (9.0 [8.00] vs 6.0 [2.0] days; P=.02) and ICU stay (37.0 [41.0] vs 21.0 [5.0] days; P=.03), respectively. The overall mortality rate was 58%, with a significant difference (P=.03) between AKI and non-AKI groups. All the patients who survived had normal creatinine clearance at hospital discharge. CONCLUSION There is a high incidence of AKI in pediatric patients requiring ECMO after cardiac surgery, and it is associated with higher mortality, increased ECMO duration, and increased ventilator days. LIMITATIONS Single-center retrospective analysis and the small sample size limited the precision of our estimates in sub-populations.
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Affiliation(s)
- Raja Abou Elella
- Dr. Raja Abou Elella, Heart Center Cardiac ICU, King Faisal Specialist Hospital and Research Centre,, PO Box 3354,, Riyadh 11211 T: +966500707495, ORCID: http://orcid.org/0000-0001-6820-4307
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Lahmer T, Mayr U, Rasch S, Batres Baires G, Schmid RM, Huber W. In-parallel connected intermittent hemodialysis through ECMO does not affect hemodynamic parameters derived from transpulmonary thermodilution. Perfusion 2017; 32:702-705. [DOI: 10.1177/0267659117707816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: We report a case of renal replacement therapy (RRT) during extracorporeal membrane oxygenation (ECMO) via a single venous access and analyze the feasibility of transpulmonary thermodilution (TPTD) for hemodynamic monitoring. Case report: ECMO and RRT connected into the ECMO-extracorporeal circuit were performed via a single venous access because of multiple venous thromboses. An indicator for TPTD and pulse contour analysis (PCA) was applied into the central venous catheter (CVC) placed in the right vena jugularis. TPTD and PCA demonstrated comparable cardiac index. Discussion: Congruent data for TPTD and PCA could be observed during TPTD and PCA measurements before ECMO, after ECMO and during ECMO and RRT. This might be explained by high blood flow having the lowest impact on TPTD by venous drainage in the femoral vein/distal vena cava and the TPTD indicator injection using the jugular CVC, as reported in our case. Conclusion: Hemodynamic monitoring using TPTD and PCA during ECMO/RRT is feasible and provides reliable results.
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Affiliation(s)
- Tobias Lahmer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Ulrich Mayr
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Sebastian Rasch
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Gonzalo Batres Baires
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
| | - Wolfgang Huber
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Germany
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Factors associated with mortality risk in critical care patients treated with veno-arterial extracorporeal membrane oxygenation. Heart Lung 2017; 46:137-142. [PMID: 28318620 DOI: 10.1016/j.hrtlng.2017.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 01/13/2017] [Accepted: 02/09/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To identify factors associated with mortality in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and to validate the discrimination of the risk assessment tools to predict mortality. BACKGROUND VA-ECMO is a rescue therapy for patients with life-threatening cardiac failure, but mortality remains high. METHODS In this retrospective study, we reviewed the medical records of adult patients who underwent VA-ECMO in an intensive care unit of a university hospital, between 2009 and 2013. RESULTS VA-ECMO was performed in 89 patients, with a median duration of 116 h. The survival rate until hospital discharge was 27%. The pre-ECMO simplified acute physiology score (SAPS) II and diabetes mellitus were significant predictors of hospital mortality. The optimal prognostic SAPS II score was 81 overall, 80 in patients with diabetes, and 84 in those without diabetes. CONCLUSIONS Our findings indicate that high pre-ECMO SAPS II score and diabetes are risk factors for mortality in patients who undergo VA-ECMO.
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Sheth KN, Nourollahzadeh E. Neurologic complications of cardiac and vascular surgery. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:573-592. [PMID: 28190436 DOI: 10.1016/b978-0-444-63599-0.00031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This chapter will provide an overview of the major neurologic complications of common cardiac and vascular surgeries, such as coronary artery bypass grafting and carotid endarterectomy. Neurologic complications after cardiac and vascular surgeries can cause significant morbidity and mortality, which can negate the beneficial effects of the intervention. Some of the complications to be discussed include ischemic and hemorrhagic stroke, seizures, delirium, cognitive dysfunction, cerebral hyperperfusion syndrome, cranial nerve injuries, and peripheral neuropathies. The severity of these complications can range from mild to lethal. The etiology of complications can include a variety of mechanisms, which can differ based on the type of cardiac or vascular surgery that is performed. Our knowledge about neuropathology, prevention, and management of surgical complications is growing and will be discussed in this chapter. It is imperative for clinicians to be familiar with these complications in order to narrow the differential diagnosis, start early management, anticipate the natural history, and improve outcomes.
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Affiliation(s)
- K N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.
| | - E Nourollahzadeh
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA
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Kuroki N, Abe D, Iwama T, Sugiyama K, Akashi A, Hamabe Y, Aonuma K, Sato A. Prognostic effect of estimated glomerular filtration rate in patients with cardiogenic shock or cardiac arrest undergoing percutaneous veno-arterial extracorporeal membrane oxygenation. J Cardiol 2016; 68:439-446. [DOI: 10.1016/j.jjcc.2015.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/07/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
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Tran BG, De La Cruz K, Grant S, Meltzer J, Benharash P, Dave R, Ardehali A, Shemin R, Depasquale E, Nsair A. Temporary Venoarterial Extracorporeal Membrane Oxygenation: Ten-Year Experience at a Cardiac Transplant Center. J Intensive Care Med 2016; 33:288-295. [DOI: 10.1177/0885066616654451] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Advances in extracorporeal membrane oxygenation (ECMO) have enabled rapid deployment in a wide range of clinical settings. We report our experience with venoarterial (VA) ECMO in adult patients over 10 years and aim to identify predictors of mortality. Design: This is a retrospective analysis of all adult patients undergoing VA ECMO at a tertiary care center from January 1, 2004, to December 31, 2013. Results: A total of 224 consecutive cases were reviewed. Eighty (35.7%) patients survived to discharge and 144 (64.3%) patients died. Patients requiring ECMO for heart transplant graft failure had lower mortality (51.6%) compared to all other etiologies (69.1%; P = .02). Forty-two percent (94 of the 224) of the patients required cardiopulmonary resuscitation (CPR) preceding ECMO and had higher rate of in-hospital mortality (74.5%) compared with patients without cardiac arrest (56.9%; P = .01). Patients with less than 30 minutes of CPR had a mortality rate of 40.0% compared to 91.4% for CPR > 30 minutes ( P = .001). In all, 24.1% of patients (54 of the 224) experienced ECMO-associated complications without significant increase in mortality, and 22.3% (50 of the 224) of the patients were transitioned to ventricular assist devices (VADs) or transplant. Patients bridged to a VAD including left ventricular assist devices and biventricular assist devices had a mortality rate of 56.1% versus 22.2% when bridged directly to transplant ( P = .01). Paradoxically, patients with an ejection fraction (EF) > 35% had a higher mortality compared to patients with an EF < 35% (75.3% vs 49.4%, respectively, P = .001). Conclusion: Extracorporeal membrane oxygenation in patients with heart transplant graft failure had the best outcome. In patients who had cardiac arrest, prolonged CPR > 30 minutes was associated with very high mortality. Paradoxically, patients with EF > 35% had a higher mortality than patients with EF < 35%, likely reflecting patients with diastolic heart failure or noncardiac causes necessitating ECMO. For transplant candidates, direct bridge from ECMO to transplant could achieve a very good outcome.
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Affiliation(s)
- Bao G. Tran
- Department of Cardiology, University of California, Los Angeles, CA, USA
| | - Kim De La Cruz
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Stuart Grant
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Joseph Meltzer
- Department of Anesthesiology, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Ravi Dave
- Department of Cardiology, University of California, Los Angeles, CA, USA
| | - Abbas Ardehali
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Richard Shemin
- Department of Surgery, University of California, Los Angeles, CA, USA
| | - Eugene Depasquale
- Department of Cardiology, University of California, Los Angeles, CA, USA
| | - Ali Nsair
- Department of Cardiology, University of California, Los Angeles, CA, USA
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46
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Tanaka D, Hirose H, Cavarocchi N, Entwistle JW. The Impact of Vascular Complications on Survival of Patients on Venoarterial Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2016; 101:1729-34. [DOI: 10.1016/j.athoracsur.2015.10.095] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/16/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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47
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Omar HR, Mirsaeidi M, Shumac J, Enten G, Mangar D, Camporesi EM. Incidence and predictors of ischemic cerebrovascular stroke among patients on extracorporeal membrane oxygenation support. J Crit Care 2016; 32:48-51. [DOI: 10.1016/j.jcrc.2015.11.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 10/09/2015] [Accepted: 11/14/2015] [Indexed: 11/17/2022]
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Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an effective therapy for patients with reversible cardiac and/or respiratory failure. Acute kidney injury (AKI) often occurs in patients supported with ECMO; it frequently evolves into chronic kidney damage or end-stage renal disease and is associated with a reported 4-fold increase in mortality rate. Although AKI is generally due to the hemodynamic alterations associated with the baseline disease, ECMO itself may contribute to maintaining kidney dysfunction through several mechanisms. SUMMARY AKI may be related to conditions derived from or associated with extracorporeal therapy, leading to a reduction in renal oxygen delivery and/or to inflammatory damage. In particular, during pathological conditions requiring ECMO, the biological defense mechanisms maintaining central perfusion by a reduction of perfusion to peripheral organs (such as the kidney) have been identified as pretreatment and patient-related risk factors for AKI. Hormonal pathways are also impaired in patients supported with ECMO, leading to failures in mechanisms of renal homeostasis and worsening fluid overload. Finally, inflammatory damage, due to the primary disease, heart and lung crosstalk with the kidney or associated with extracorporeal therapy itself, may further increase the susceptibility to AKI. Renal replacement therapy can be integrated into the main extracorporeal circuit during ECMO to provide for optimal fluid management and removal of inflammatory mediators. KEY MESSAGES AKI is frequently observed in patients supported with ECMO. The pathophysiology of the associated AKI is chiefly related to a reduction in renal oxygen delivery and/or to inflammatory damage. Risk factors for AKI are associated with a patient's underlying disease and ECMO-related conditions.
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Affiliation(s)
- Gianluca Villa
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Vicenza, Italy; Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Nevin Katz
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md., USA
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
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Zhao Y, Xing J, Du Z, Liu F, Jia M, Hou X. Extracorporeal cardiopulmonary resuscitation for adult patients who underwent post-cardiac surgery. Eur J Med Res 2015; 20:83. [PMID: 26459158 PMCID: PMC4603352 DOI: 10.1186/s40001-015-0179-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 09/30/2015] [Indexed: 11/10/2022] Open
Abstract
Background Refractory cardiac arrest (CA) occasionally develops in patients after cardiac surgery. Objective To examine the clinical outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) in adult patients with post-cardiotomy CA. Methods This was a retrospective study of the 9-year experience (from January 2004 to May 2012) of the Beijing Anzhen Hospital with ECPR in adult patients with post-cardiotomy CA. At this hospital, a dedicated ECPR team is available 24/7 for emergency cases requiring ECPR. Demographic data, biochemical data, survival, morbidity, and complications were examined before, during, and after ECPR. Outcomes were compared between survivors and non-survivors. Results Twenty-four adult patients (19 men and 5 women; mean age: 59.3 ± 11.9 years) received ECPR support for post-cardiotomy CA. The cardiac surgery procedures included coronary artery bypass grafting (n = 20, 83.3 %), valvular surgery alone (n = 2, 8.3 %), and correction of congenital heart defects (n = 2, 8.3 %). The mean extracorporeal membrane oxygenation (ECMO) duration was 115.23 ± 70.17 h. Twenty-one patients received ECPR after intra-aortic balloon pump, and three patients received ECPR directly. The main cause of mortality was multiple system organ failure (n = 12, 50.0 %). Approximately one-half of non-survivors had severe neurologic impairments. Among 16 patients who were weaned off ECMO support, eight patients survived to hospital discharge. Conclusions ECPR can be effective for partial cardiopulmonary support to resuscitate adult patients suffering from refractory CA after cardiac surgery. Improvement in outcomes of patients who received ECPR requires a multidisciplinary approach to protect organ function and limit organ injury before and during cardiac support.
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Affiliation(s)
- Yanyan Zhao
- Department of Extracorporeal Circulation, Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, 100029, China.
| | - Jialin Xing
- Department of Extracorporeal Circulation, Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, 100029, China.
| | - Zhongtao Du
- Department of Extracorporeal Circulation, Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, 100029, China.
| | - Feng Liu
- Department of Extracorporeal Circulation, Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, 100029, China.
| | - Ming Jia
- Department of Extracorporeal Circulation, Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, 100029, China.
| | - Xiaotong Hou
- Department of Extracorporeal Circulation, Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing, 100029, China.
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50
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Han SS, Kim HJ, Lee SJ, Kim WJ, Hong Y, Lee HY, Song SY, Jung HH, Ahn HS, Ahn IM, Baek H. Effects of Renal Replacement Therapy in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis. Ann Thorac Surg 2015; 100:1485-95. [PMID: 26341602 DOI: 10.1016/j.athoracsur.2015.06.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
Abstract
The use of renal replacement therapy (RRT) in patients receiving extracorporeal membrane oxygenation (ECMO) is increasing, but the effect of RRT on ECMO is controversial. We performed a meta-analysis to determine whether RRT is related to higher mortality in patients receiving ECMO. We searched MEDLINE, EMBASE, the Cochrane Library, and KoreaMed and found 43 observational studies with 21,624 patients receiving ECMO and then compared inpatient mortality rates of patients receiving ECMO both with and without RRT. The risk ratio (RR) of mortality between patients receiving RRT and those not receiving RRT tended to decrease as the mortality of the group not receiving RRT increased. Among patients with RRT use rates of 30% and higher, the overall mortality rates for all patients receiving ECMO tended to decrease. We found that the increase in the RR for RRT tended to be greater the longer the initiation of RRT was delayed. We suggest that in patients receiving ECMO who have high RRT use rates, RRT may decrease mortality rates.
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Affiliation(s)
- Seon-Sook Han
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seung Joon Lee
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Woo Jin Kim
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Youngi Hong
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hui-Young Lee
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Seo-Young Song
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hae Hyuk Jung
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Division of Nephrology, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Il Min Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea; Department of Literary Arts, Brown University, Providence, Rhode Island
| | - Hyunjeong Baek
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea; Division of Nephrology, School of Medicine, Kangwon National University, Chuncheon-si, Kangwon-do, Republic of Korea.
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