Veno-arterial extracorporeal membrane oxygenation for drug intoxications: A single center, 14-year experience

Anticoagulation and associated complications in veno-arterial extracorporeal membrane oxygenation in adult patients: A systematic review and meta-analysis

Objective

To describe the incidence of bleeding and thrombotic complications in VA-ECMO according to anticoagulation strategy.

Design

This systematic review and meta-analysis included randomised controlled trials (RCTs) and observational studies reporting bleeding and thrombotic complications in VA-ECMO. The incidence of primary outcomes according to anticoagulation drug and monitoring test was described.

Data sources

CENTRAL, MEDLINE, Embase and CINAHL (2010-January 2024).

Review methods

Data was extracted using Covidence. A meta-analysis of proportions was performed using STATA MP v18.1 metaprop.

Results

We included 159 studies with 21,942 patients. No studies were at low risk of bias. The incidence of major bleeding or thrombotic events was similar among heparin-, bivalirudin- and anticoagulation-free cohorts. The pooled incidence of major bleeding and thrombotic complications were 40% (95%CI 36-44, I2 = 97.12) and 17% (95%CI 14-19, I 2  = 92.60%), respectively. The most common bleeding site was thoracic. The most common ischaemic complication was limb ischaemia. The incidences of major bleeding or thrombotic events, intracranial haemorrhage and ischaemic stroke were similar among all monitoring tests. Mechanical unloading was associated with a high incidence of major bleeding events (60%, 95%CI 43-77, I2 = 93.32), and ischaemic strokes (13%, 95%CI 7-19, I2 = 81.80).

Conclusions

Available literature assessing the association between anticoagulation strategies in VA-ECMO, and bleeding and thrombosis is of limited quality. We identified a substantially higher incidence of major bleeding events than a previous meta-analysis. Limited numbers of patients anticoagulated with alternatives to heparin were reported. Patients with additional mechanical LV unloading represent a cohort at particular risk of bleeding and thrombotic complications.

Extracorporeal membrane oxygenation in cardiovascular medication poisoning. A German-wide retrospective study

Medication poisoning, resulting from the ingestion of cardiotoxic drugs, presents a significant health issue. The mortality rate remains high for patients with myocardial dysfunction refractory to conventional treatments. Venoarterial Extracorporeal Membrane Oxygenation (V-A ECMO) provides temporary support, potentially enhancing patient outcomes. This study aims to assess the efficacy of V-A ECMO in treating cardiovascular failure induced by cardiovascular medication poisoning. We utilized inpatient data from all hospitalisations in Germany from 2007 to 2022 due to cardiovascular medication poisoning treated with V-A ECMO. Patient characteristics, comorbidities, complications and application of ECMO were described descriptively and analysed for statistical significance between survivors and non-survivors. Overall, 49 patients received V-A ECMO for cardiovascular medication poisoning, with a survival rate of 63.6%. The most ingested medications were calcium-channel blockers (38.8%) and beta-adrenoceptor antagonists (34.7%). Half of non-survivors received in-hospital CPR, compared to 12.9% of survivors. Early ECMO implantation (within 24 h of admission) was common (83.7%) but did not significantly impact survival rates. A substantial number of patients presented with multiple substances ingested. V-A ECMO represents a viable option for patients experiencing cardiac failure due to medication poisoning. A structured implementation of V-A ECMO for cardiovascular medication poisoning could lead to higher survival rates.

Etiology-Based Prognosis of Extracorporeal CPR Recipients After Out-of-Hospital Cardiac Arrest: A Retrospective Multicenter Cohort Study

BACKGROUND

A better understanding of the relative contributions of various factors to patient outcomes is essential for optimal patient selection for extracorporeal CPR (ECPR) therapy for patients with out-of-hospital cardiac arrest (OHCA). However, evidence on the prognostic comparison based on the etiologies of cardiac arrest is limited.

RESEARCH QUESTION

What is the etiology-based prognosis of patients undergoing ECPR for OHCA?

STUDY DESIGN AND METHODS

This retrospective multicenter registry study involved 36 institutions in Japan and included all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. The primary etiology for OHCA was determined retrospectively from all hospital-based data at each institution. We performed a multivariable logistic regression model to determine the association between etiology of cardiac arrest and two outcomes: favorable neurologic outcome and survival at hospital discharge.

RESULTS

We identified 1,781 eligible patients, of whom 1,405 (78.9%) had cardiac arrest because of cardiac causes. Multivariable logistic regression analysis for favorable neurologic outcome showed that accidental hypothermia (adjusted OR, 5.12; 95% CI, 2.98-8.80; P < .001) was associated with a significantly higher rate of favorable neurologic outcome than cardiac causes. Multivariable logistic regression analysis for survival showed that accidental hypothermia (adjusted OR, 5.19; 95% CI, 3.15-8.56; P < .001) had significantly higher rates of survival than cardiac causes. Acute aortic dissection/aneurysm (adjusted OR, 0.07; 95% CI, 0.02-0.28; P < .001) and primary cerebral disorders (adjusted OR, 0.12; 95% CI, 0.03-0.50; P = .004) had significantly lower rates of survival than cardiac causes.

INTERPRETATION

In this retrospective multicenter cohort study, although most patients with OHCA underwent ECPR for cardiac causes, accidental hypothermia was associated with favorable neurologic outcome and survival; in contrast, acute aortic dissection/aneurysm and primary cerebral disorders were associated with nonsurvival compared with cardiac causes.

Extracorporeal cardio-pulmonary resuscitation in poisoning: A scoping review article

Background

Extracorporeal cardiopulmonary resuscitation (ECPR) represents last-line salvage therapy for poisoning-induced cardiac arrest but no review has focused on this specific area.

Objective

This scoping review sought to evaluate the survival outcomes and characteristics of published cases of ECPR for toxicological arrest, with the aim of highlighting the potential and limitations of ECPR in toxicology.Eligibility Criteria.We searched PubMed and Cochrane for eligible papers from database inception to October 1, 2022 using the keywords "toxicology", "ECLS" and "CPR". References of included publications were searched to identify additional relevant articles. Qualitative synthesis was used to summarize the evidence.

Results

85 articles were chosen: 15 case series, 58 individual cases and 12 other publications that were analyzed separately due to ambiguity. ECPR may improve survival outcomes in selected poisoned patients, although the extent of benefit is unclear. As ECPR for poisoning-induced arrest may have better prognosis compared to from other aetiologies, it is likely reasonable to apply ELSO ECPR consensus guideline recommendations to toxicological arrest.Out-of-hospital cardiac arrest alone may not be sufficient grounds to deny ECPR if effective resuscitation had been promptly instituted. Poisonings involving membrane-stabilizing agents and cardio-depressive drugs, and cardiac arrests with shockable rhythms appear to have better outcomes. ECPR may permit excellent neurologically-intact recovery despite prolonged low-flow time of up to four hours. Early ECLS activation and pre-emptive catheter placement can significantly shorten time-to-ECPR and possibly improve survival.

Conclusion

As effects of poisoning may be reversible, ECPR can potentially support poisoned patients through the critical peri-arrest state.