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Leng A, Shou B, Liu O, Bachina P, Kalra A, Bush EL, Whitman GJR, Cho SM. Machine Learning from Veno-Venous Extracorporeal Membrane Oxygenation Identifies Factors Associated with Neurological Outcomes. Lung 2024:10.1007/s00408-024-00708-z. [PMID: 38814448 DOI: 10.1007/s00408-024-00708-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/14/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Neurological complications are common in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We used machine learning (ML) algorithms to identify predictors for neurological outcomes for these patients. METHODS All demographic, clinical, and circuit-related variables were extracted for adults with VV-ECMO support at a tertiary care center from 2016 to 2022. The primary outcome was good neurological outcome (GNO) at discharge defined as a modified Rankin Scale of 0-3. RESULTS Of 99 total VV-ECMO patients (median age = 48 years; 65% male), 37% had a GNO. The best performing ML model achieved an area under the receiver operating characteristic curve of 0.87. Feature importance analysis identified down-trending gas/sweep/blender flow, FiO2, and pump speed as the most salient features for predicting GNO. CONCLUSION Utilizing pre- as well as post-initiation variables, ML identified on-ECMO physiologic and pulmonary conditions that best predicted neurological outcomes.
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Affiliation(s)
- Albert Leng
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
- Division of Cardiac Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Benjamin Shou
- Division of Cardiac Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Olivia Liu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Preetham Bachina
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Heart and Vascular Institute, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Sung-Min Cho
- Divisions of Neurosciences Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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Gayen S, Dachert S, Lashari BH, Gordon M, Desai P, Criner GJ, Cardet JC, Shenoy K. Critical Care Management of Severe Asthma Exacerbations. J Clin Med 2024; 13:859. [PMID: 38337552 PMCID: PMC10856115 DOI: 10.3390/jcm13030859] [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: 01/11/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Severe asthma exacerbations, including near-fatal asthma (NFA), have high morbidity and mortality. Mechanical ventilation of patients with severe asthma is difficult due to the complex pathophysiology resulting from severe bronchospasm and dynamic hyperinflation. Life-threatening complications of traditional ventilation strategies in asthma exacerbations include the development of systemic hypotension from hyperinflation, air trapping, and pneumothoraces. Optimizing pharmacologic techniques and ventilation strategies is crucial to treat the underlying bronchospasm. Despite optimal pharmacologic management and mechanical ventilation, the mortality rate of patients with severe asthma in intensive care units is 8%, suggesting a need for advanced non-pharmacologic therapies, including extracorporeal life support (ECLS). This review focuses on the pathophysiology of acute asthma exacerbations, ventilation management including non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV), the pharmacologic management of acute asthma, and ECLS. This review also explores additional advanced non-pharmacologic techniques and monitoring tools for the safe and effective management of critically ill adult asthmatic patients.
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Affiliation(s)
- Shameek Gayen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Stephen Dachert
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Bilal H. Lashari
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Matthew Gordon
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Parag Desai
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Juan Carlos Cardet
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL 33602, USA;
| | - Kartik Shenoy
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
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Rozencwajg S, Wu EL, Heinsar S, Stevens M, Chinchilla J, Fraser JF, Pauls JP. A mock circulation loop to evaluate differential hypoxemia during peripheral venoarterial extracorporeal membrane oxygenation. Perfusion 2024; 39:66-75. [PMID: 35038287 DOI: 10.1177/02676591211056567] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) creates a retrograde flow along the aorta competing with the left ventricle (LV) in the so-called 'mixing zone' (MZ). Detecting it is essential to understand which of the LV or the ECMO flow perfuses the upper body - particularly the brain and the coronary arteries - in case of differential hypoxemia (DH). METHODS We described a mock circulation loop (MCL) that enabled experimental research on DH. We recreated the three clinical situations relevant to clinicians: where the brain is either totally perfused by the ECMO or the LV or both. In a second step, we used this model to investigate two scenarios to diagnose DH: (i) pulse pressure and (ii) thermodilution via injection of cold saline in the ECMO circuit. RESULTS The presented MCL was able to reproduce the three relevant mixing zones within the aortic arch, thus allowing to study DH. Pulse pressure was unable to detect location of the MZ. However, the thermodilution method was able to detect whether the brain was totally perfused by the ECMO or not. CONCLUSION We validated an in-vitro differential hypoxemia model of cardiogenic shock supported by VA ECMO. This MCL could be used as an alternative to animal studies for research scenarios.
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Affiliation(s)
- Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, Paris, France
| | - Eric L Wu
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - Michael Stevens
- Graduate School of Biomedical Engineering, UNSW Sydney, AU -NSW, Australia
| | - Josh Chinchilla
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- School of Engineering and Built Environment, Griffith University, Southport, AU-QLD, Australia
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Akbar AF, Shou BL, Feng CY, Zhao DX, Kim BS, Whitman G, Bush EL, Cho SM. Lower Oxygen Tension and Intracranial Hemorrhage in Veno-venous Extracorporeal Membrane Oxygenation. Lung 2023; 201:315-320. [PMID: 37086285 PMCID: PMC10578342 DOI: 10.1007/s00408-023-00618-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION AND METHODS We examined the relationship between 24-h pre- and post-cannulation arterial oxygen tension (PaO2) and arterial carbon dioxide tension (PaCO2) and subsequent acute brain injury (ABI) in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) with granular arterial blood gas (ABG) data and institutional standardized neuromonitoring. RESULTS Eighty-nine patients underwent VV-ECMO (median age = 50, 63% male). Twenty (22%) patients experienced ABI; intracranial hemorrhage (ICH) was the most common diagnosis (n = 14, 16%). Lower post-cannulation PaO2 levels were significantly associated with ICH (66 vs. 81 mmHg, p = 0.007) and a post-cannulation PaO2 level < 70 mmHg was more frequent in these patients (71% vs. 33%, p = 0.007). PaCO2 parameters were not associated with ABI. By multivariable logistic regression, hypoxemia post-cannulation increased the odds of ICH (OR = 5.06, 95% CI:1.41-18.17; p = 0.01). CONCLUSION In summary, lower oxygen tension in the 24-h post-cannulation was associated with ICH development. The precise roles of peri-cannulation ABG changes deserve further investigation, as they may influence the management of VV-ECMO patients.
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Affiliation(s)
- Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Cheng-Yuan Feng
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps, Baltimore, MD, 455, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - David X Zhao
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps, Baltimore, MD, 455, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Errol L Bush
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps, Baltimore, MD, 455, USA.
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Cvetkovic M, Chiarini G, Belliato M, Delnoij T, Zanatta P, Taccone FS, Miranda DDR, Davidson M, Matta N, Davis C, IJsselstijn H, Schmidt M, Broman LM, Donker DW, Vlasselaers D, David P, Di Nardo M, Muellenbach RM, Mueller T, Barrett NA, Lorusso R, Belohlavek J, Hoskote A. International survey of neuromonitoring and neurodevelopmental outcome in children and adults supported on extracorporeal membrane oxygenation in Europe. Perfusion 2023; 38:245-260. [PMID: 34550013 DOI: 10.1177/02676591211042563] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Adverse neurological events during extracorporeal membrane oxygenation (ECMO) are common and may be associated with devastating consequences. Close monitoring, early identification and prompt intervention can mitigate early and late neurological morbidity. Neuromonitoring and neurocognitive/neurodevelopmental follow-up are critically important to optimize outcomes in both adults and children. OBJECTIVE To assess current practice of neuromonitoring during ECMO and neurocognitive/neurodevelopmental follow-up after ECMO across Europe and to inform the development of neuromonitoring and follow-up guidelines. METHODS The EuroELSO Neurological Monitoring and Outcome Working Group conducted an electronic, web-based, multi-institutional, multinational survey in Europe. RESULTS Of the 211 European ECMO centres (including non-ELSO centres) identified and approached in 23 countries, 133 (63%) responded. Of these, 43% reported routine neuromonitoring during ECMO for all patients, 35% indicated selective use, and 22% practiced bedside clinical examination alone. The reported neuromonitoring modalities were NIRS (n = 88, 66.2%), electroencephalography (n = 52, 39.1%), transcranial Doppler (n = 38, 28.5%) and brain injury biomarkers (n = 33, 24.8%). Paediatric centres (67%) reported using cranial ultrasound, though the frequency of monitoring varied widely. Before hospital discharge following ECMO, 50 (37.6%) reported routine neurological assessment and 22 (16.5%) routinely performed neuroimaging with more paediatric centres offering neurological assessment (65%) as compared to adult centres (20%). Only 15 (11.2%) had a structured longitudinal follow-up pathway (defined followup at regular intervals), while 99 (74.4%) had no follow-up programme. The majority (n = 96, 72.2%) agreed that there should be a longitudinal structured follow-up for ECMO survivors. CONCLUSIONS This survey demonstrated significant variability in the use of different neuromonitoring modalities during and after ECMO. The perceived importance of neuromonitoring and follow-up was noted to be very high with agreement for a longitudinal structured follow-up programme, particularly in paediatric patients. Scientific society endorsed guidelines and minimum standards should be developed to inform local protocols.
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Affiliation(s)
- Mirjana Cvetkovic
- Cardiac Intensive Care and ECMO, Great Ormond Street Hospital for Children NHS Foundation Trust & UCL Great Ormond Street Institute of Child Health, London, UK
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,2nd Intensive Care Unit, Spedali Civili, University of Brescia, Brescia, Italy
| | - Mirko Belliato
- Second Anaesthesia and Intensive Care Unit, S. Matteo Hospital, IRCCS, Pavia, Italy
| | - Thijs Delnoij
- Department of Cardiology and Department of Intensive Care Unit, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paolo Zanatta
- Anaesthesia and Multi-Speciality Intensive Care, Integrated University Hospital of Verona, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Bruxelles, Belgium
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Nashwa Matta
- Neonatal Unit, Princess Royal Maternity, Glasgow, Scotland
| | - Carl Davis
- Surgery Unit, Royal Hospital for Children, Glasgow, Scotland
| | - Hanneke IJsselstijn
- Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthieu Schmidt
- Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Dirk W Donker
- Intensive Care Center, University Medical Centre, Utrecht, The Netherlands
| | - Dirk Vlasselaers
- Department Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Piero David
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matteo Di Nardo
- Paediatric Intensive Care, Bambino Gesù Children's Hospital, Rome, Italy
| | - Ralf M Muellenbach
- Department of Anaesthesia and Intensive Care, Klinikum Kassel GmbH, Kassel, Germany
| | | | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital and 1st Medical School, Charles University in Prague, Praha, Czech Republic
| | - Aparna Hoskote
- Cardiac Intensive Care and ECMO, Great Ormond Street Hospital for Children NHS Foundation Trust & UCL Great Ormond Street Institute of Child Health, London, UK
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Arterial Carbon Dioxide and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:1501-1507. [PMID: 35671442 PMCID: PMC9477972 DOI: 10.1097/mat.0000000000001699] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Acute brain injury (ABI) occurs frequently in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We examined the association between peri-cannulation arterial carbon dioxide tension (PaCO 2 ) and ABI with granular blood gas data. We retrospectively analyzed adult patients who underwent VA-ECMO at a tertiary care center with standardized neuromonitoring. Pre- and post-cannulation PaCO 2 were defined as the mean of all PaCO 2 values in the 12 hours before and after cannulation, respectively. Peri-cannulation PaCO 2 drop (∆PaCO 2 ) equaled pre- minus post-cannulation PaCO 2 . ABI included intracranial hemorrhage (ICH), ischemic stroke, hypoxic-ischemic brain injury, cerebral edema, seizure, and brain death. Univariable logistic regression analysis was performed for the presence of ABI. Out of 129 VA-ECMO patients (median age = 60, 63% male), 43 (33%) patients experienced ABI. Patients had a median of 11 (interquartile range: 8-14) peri-cannulation PaCO 2 values. Comparing patients with and without ABI, pre-cannulation (39 vs. 42 mm Hg; p = 0.38) and post-cannulation (37 vs. 36 mm Hg; p = 0.82) PaCO 2 were not different. However, higher pre-cannulation PaCO 2 (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.10-4.00; p = 0.02) and larger ∆PaCO 2 (OR = 2.69; 95% CI = 1.18-6.13; p = 0.02) were associated with ICH. In conclusion, in a cohort with granular arterial blood gas (ABG) data and a standardized neuromonitoring protocol, higher pre-cannulation PaCO 2 and larger ∆PaCO 2 were associated with increased prevalence of ICH.
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Govender K, Jani VP, Cabrales P. The Disconnect Between Extracorporeal Circulation and the Microcirculation: A Review. ASAIO J 2022; 68:881-889. [PMID: 35067580 DOI: 10.1097/mat.0000000000001618] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal circulation (ECC) procedures, such as cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO), take over the function of one or more organs, providing clinicians time to treat underlying pathophysiological conditions. ECMO and CPB carry significant mortality rates for patients, despite prior decades of research focused on the resulting failure of critical organs. Since the focus of these procedures is to support blood flow and provide oxygen-rich blood to tissues, a shift in research toward the effects of ECMO and CPB on the microcirculation is warranted. Along with provoking systemic responses, both procedures disrupt the integrity of red blood cells, causing release of hemoglobin (Hb) from excessive foreign surface contact and mechanical stresses. The effects of hemolysis are especially pronounced in the microcirculation, where plasma Hb leads to nitric oxide scavenging, oxidization, formation of reactive oxygen species, and inflammatory responses. A limited number of studies have investigated the implications of ECMO in the microcirculation, but more work is needed to minimize ECMO-induced reduction of microcirculatory perfusion and consequently oxygenation. The following review presents existing information on the implications of ECMO and CPB on microvascular function and proposes future studies to understand and leverage key mechanisms to improve patient outcomes.
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Affiliation(s)
- Krianthan Govender
- From the Functional Cardiovascular Engineering Laboratory, University of California, San Diego, La Jolla, California
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8
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Justus A, Burrell A, Anstey C, Cornmell G, Brodie D, Shekar K. The Association of Oxygenation, Carbon Dioxide Removal, and Mechanical Ventilation Practices on Survival During Venoarterial Extracorporeal Membrane Oxygenation. Front Med (Lausanne) 2021; 8:756280. [PMID: 34869455 PMCID: PMC8636903 DOI: 10.3389/fmed.2021.756280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/25/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction: Oxygenation and carbon dioxide removal during venoarterial extracorporeal membrane oxygenation (VA ECMO) depend on a complex interplay of ECMO blood and gas flows, native lung and cardiac function as well as the mechanical ventilation strategy applied. Objective: To determine the association of oxygenation, carbon dioxide removal, and mechanical ventilation practices with in-hospital mortality in patients who received VA ECMO. Methods: Single center, retrospective cohort study. All consecutive patients who received VA ECMO in a tertiary ECMO referral center over a 5-year period were included. Data on demographics, ECMO and ventilator support details, and blood gas parameters for the duration of ECMO were collected. A multivariable logistic time-series regression model with in-hospital mortality as the primary outcome variable was used to analyse the data with significant factors at the univariate level entered into the multivariable regression model. Results: Overall, 52 patients underwent VA ECMO: 26/52 (50%) survived to hospital discharge. The median PaO2 for the duration of ECMO support was 146 mmHg [IQR 131-188] and PaCO2 was 37.2 mmHg [IQR 35.3, 39.9]. Patients who survived to hospital discharge had a significantly lower median PaO2 (117 [98, 140] vs. 154 [105, 212] mmHg, P = 0.04) and higher median PaCO2 (38.3 [36.1, 41.1] vs. 36.3 [34.5, 37.8] mmHg, p = 0.03). Survivors also had significantly lower median VA ECMO blood flow rate (EBFR, 3.6 [3.3, 4.2] vs. 4.3 [3.8, 5.2] L/min, p = < 0.001) and greater measured minute ventilation (7.04 [5.63, 8.35] vs. 5.32 [4.43, 6.83] L/min, p = 0.01). EBFR, PaO2, PaCO2, and minute ventilation, however, were not independently associated with death in a multivariable analysis. Conclusion: This exploratory analysis in a small group of VA ECMO supported patients demonstrated that hyperoxemia was common during VA ECMO but was not independently associated with increased mortality. Survivors also received lower EBFR and had greater minute ventilation, but this was also not independently associated with survival. These findings highlight that interactions between EBFR, PaO2, and native lung ventilation may be more relevant than their individual association with survival. Further research is indicated to determine the optimal ECMO and ventilator settings on outcomes in VA ECMO.
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Affiliation(s)
- Angelo Justus
- Adult Intensive Care, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Chris Anstey
- School of Medicine, Griffith University, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - George Cornmell
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, United States
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Timing, Outcome, and Risk Factors of Intracranial Hemorrhage in Acute Respiratory Distress Syndrome Patients During Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 49:e120-e129. [PMID: 33323749 DOI: 10.1097/ccm.0000000000004762] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intracranial hemorrhage is a serious complication in patients receiving venovenous extracorporeal membrane oxygenation during treatment of the acute respiratory distress syndrome. We analyzed timing, outcome, and risk factors of intracranial hemorrhage in patients on venovenous extracorporeal membrane oxygenation. DESIGN Retrospective cohort study. SETTING Single acute respiratory distress syndrome referral center. PATIENTS Patients receiving venovenous extracorporeal membrane oxygenation were identified from a cohort of 1,044 patients with acute respiratory distress syndrome. Patients developing an intracranial hemorrhage during venovenous extracorporeal membrane oxygenation therapy were compared with patients without evidence for intracranial hemorrhage. The primary objective was to assess the association of intracranial hemorrhage with 60-day mortality. Further objectives included the identification of risk factors for intracranial hemorrhage and the evaluation of clinical cutoff values. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 444 patients treated with venovenous extracorporeal membrane oxygenation, 49 patients (11.0% [95% CI, 8.3-14.4%]) developed an intracranial hemorrhage. The median time to intracranial hemorrhage occurrence was 4 days (95% CI, 2-7 d). Patients who developed an intracranial hemorrhage had a higher 60-day mortality compared with patients without intracranial hemorrhage (69.4% [54.4-81.3%] vs 44.6% [39.6-49.6%]; odds ratio 3.05 [95% CI, 1.54-6.32%]; p = 0.001). A low platelet count, a high positive end expiratory pressure, and a major initial decrease of Paco2 were identified as independent risk factors for the occurrence of intracranial hemorrhage. A platelet count greater than 100/nL and a positive end expiratory pressure less than or equal to 14 cm H2O during the first 7 days of venovenous extracorporeal membrane oxygenation therapy as well as a decrease of Paco2 less than 24 mm Hg during venovenous extracorporeal membrane oxygenation initiation were identified as clinical cutoff values to prevent intracranial hemorrhage (sensitivity 91% [95% CI, 82-99%], 94% [85-99%], and 67% [48-81%], respectively). CONCLUSIONS Intracranial hemorrhage occurs early during venovenous extracorporeal membrane oxygenation and is a determinant for 60-day mortality. Appropriate adjustment of identified modifiable risk factors might lower the prevalence of intracranial hemorrhage during venovenous extracorporeal membrane oxygenation therapy.
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10
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Akoumianaki E, Jonkman A, Sklar MC, Georgopoulos D, Brochard L. A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea. Ann Intensive Care 2021; 11:107. [PMID: 34250563 PMCID: PMC8273031 DOI: 10.1186/s13613-021-00897-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/30/2021] [Indexed: 12/16/2022] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (ECMO) is a helpful intervention in patients with severe refractory hypoxemia either because mechanical ventilation cannot ensure adequate oxygenation or because lung protective ventilation is not feasible. Since ECMO is a highly invasive procedure with several, potentially devastating complications and its implementation is complex and expensive, simpler and less invasive therapeutic options should be first exploited. Low tidal volume and driving pressure ventilation, prone position, neuromuscular blocking agents and individualized ventilation based on transpulmonary pressure measurements have been demonstrated to successfully treat the vast majority of mechanically ventilated patients with severe hypoxemia. Veno-venous ECMO has a place in the small portion of severely hypoxemic patients in whom these strategies fail. A combined analysis of recent ARDS trials revealed that ECMO was used in only 2.15% of patients (n = 145/6736). Nevertheless, ECMO use has sharply increased in the last decade, raising questions regarding its thoughtful use. Such a policy could be harmful both for patients as well as for the ECMO technique itself. This narrative review attempts to describe together the practical approaches that can be offered to the sickest patients before going to ECMO, as well as the rationale and the limitations of ECMO. The benefit and the drawbacks associated with ECMO use along with a direct comparison with less invasive therapeutic strategies will be analyzed.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Annemijn Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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11
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Khan IR, Gu Y, George BP, Malone L, Conway KS, Francois F, Donlon J, Quazi N, Reddi A, Ho CY, Herr DL, Johnson MD, Parikh GY. Brain Histopathology of Adult Decedents After Extracorporeal Membrane Oxygenation. Neurology 2021; 96:e1278-e1289. [PMID: 33472914 DOI: 10.1212/wnl.0000000000011525] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To test the hypothesis that brain injury is more common and varied in patients receiving extracorporeal membrane oxygenation (ECMO) than radiographically observed, we described neuropathology findings of ECMO decedents and associated clinical factors from 3 institutions. METHODS We conducted a retrospective multicenter observational study of brain autopsies from adult ECMO recipients. Pathology findings were examined for correlation with demographics, clinical data, ECMO characteristics, and outcomes. RESULTS Forty-three decedents (n = 13 female, median age 47 years) received autopsies after undergoing ECMO for acute respiratory distress syndrome (n = 14), cardiogenic shock (n = 14), and cardiac arrest (n = 15). Median duration of ECMO was 140 hours, most decedents (n = 40) received anticoagulants; 60% (n = 26) underwent venoarterial ECMO, and 40% (n = 17) underwent venovenous ECMO. Neuropathology was found in 35 decedents (81%), including microhemorrhages (37%), macrohemorrhages (35%), infarctions (47%), and hypoxic-ischemic brain injury (n = 17, 40%). Most pathology occurred in frontal neocortices (n = 43 occurrences), basal ganglia (n = 33), and cerebellum (n = 26). Decedents with hemorrhage were older (median age 57 vs 38 years, p = 0.01); those with hypoxic brain injury had higher Sequential Organ Failure Assessment scores (8.0 vs 2.0, p = 0.04); and those with infarction had lower peak Paco2 (53 vs 61 mm Hg, p = 0.04). Six of 9 patients with normal neuroimaging results were found to have pathology on autopsy. The majority underwent withdrawal of life-sustaining therapy (n = 32, 74%), and 2 of 8 patients with normal brain autopsy underwent withdrawal of life-sustaining therapy for suspected neurologic injury. CONCLUSION Neuropathological findings after ECMO are common, varied, and associated with various clinical factors. Further study on underlying mechanisms is warranted and may guide ECMO management.
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Affiliation(s)
- Imad R Khan
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY.
| | - Yang Gu
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Benjamin P George
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Laura Malone
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Kyle S Conway
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Fabienne Francois
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Jack Donlon
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Nadim Quazi
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Ashwin Reddi
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Cheng-Ying Ho
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Daniel L Herr
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Mahlon D Johnson
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Gunjan Y Parikh
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
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Zayat R, Kalverkamp S, Grottke O, Durak K, Dreher M, Autschbach R, Marx G, Marx N, Spillner J, Kersten A. Role of extracorporeal membrane oxygenation in critically Ill COVID-19 patients and predictors of mortality. Artif Organs 2020; 45:E158-E170. [PMID: 33236373 PMCID: PMC7753822 DOI: 10.1111/aor.13873] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 12/18/2022]
Abstract
The role of extracorporeal membrane oxygenation (ECMO) in the management of critically ill COVID‐19 patients remains unclear. Our study aims to analyze the outcomes and risk factors from patients treated with ECMO. This retrospective, single‐center study includes 17 COVID‐19 patients treated with ECMO. Univariate and multivariate parametric survival regression identified predictors of survival. Nine patients (53%) were successfully weaned from ECMO and discharged. The incidence of in‐hospital mortality was 47%. In a univariate analysis, only four out of 83 pre‐ECMO variables were significantly different; IL‐6, PCT, and NT‐proBNP were significantly higher in non‐survivors than in survivors. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score was significantly higher in survivors. After a multivariate parametric survival regression, IL‐6, NT‐proBNP and RESP scores remained significant independent predictors, with hazard ratios (HR) of 1.069 [95%‐CI: 0.986‐1.160], P = .016 1.001 [95%‐CI: 1.000‐1.001], P = .012; and .843 [95%‐CI: 0.564‐1.260], P = .040, respectively. A prediction model comprising IL‐6, NT‐proBNP, and RESP score showed an area under the curve (AUC) of 0.87, with a sensitivity of 87.5% and 77.8% specificity compared to an AUC of 0.79 for the RESP score alone. The present study suggests that ECMO is a potentially lifesaving treatment for selected critically ill COVID‐19 patients. Considering IL‐6 and NT‐pro‐BNP, in addition to the RESP score, may enhance outcome predictions.
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Affiliation(s)
- Rashad Zayat
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Sebastian Kalverkamp
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Oliver Grottke
- Department of Anesthesiology, RWTH University Hospital Aachen, Aachen, Germany
| | - Koray Durak
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, RWTH University Hospital Aachen, Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care Medicine, RWTH University Hospital Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Angiology and Intensive Care, RWTH University Hospital Aachen, Aachen, Germany
| | - Jan Spillner
- Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Alex Kersten
- Department of Cardiology, Angiology and Intensive Care, RWTH University Hospital Aachen, Aachen, Germany
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Cavayas YA, Munshi L, Del Sorbo L, Fan E. The Early Change in Pa CO2 after Extracorporeal Membrane Oxygenation Initiation Is Associated with Neurological Complications. Am J Respir Crit Care Med 2020; 201:1525-1535. [PMID: 32251606 DOI: 10.1164/rccm.202001-0023oc] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Large decreases in PaCO2 that occur when initiating extracorporeal membrane oxygenation (ECMO) in patients with respiratory failure may cause cerebral vasoconstriction and compromise brain tissue perfusion.Objectives: To determine if the magnitude of PaCO2 correction upon ECMO initiation is associated with an increased incidence of neurological complications in patients with respiratory failure.Methods: We conducted a multicenter, international, retrospective cohort study using the Extracorporeal Life Support Organization Registry, including adults with respiratory failure receiving ECMO via any mode between 2012 and 2017. The relative change in PaCO2 in the first 24 hours was calculated as (24-h post-ECMO PaCO2 - pre-ECMO PaCO2)/pre-ECMO PaCO2. The primary outcome was the occurrence of neurological complications, defined as seizures, ischemic stroke, intracranial hemorrhage, or brain death.Measurements and Main Results: We included 11,972 patients, 88% of whom were supported with venovenous ECMO. The median relative change in PaCO2 was -31% (interquartile range, -46% to -12%). Neurological complications were uncommon overall (6.9%), with a low incidence of seizures (1.1%), ischemic stroke (1.9%), intracranial hemorrhage (3.5%), and brain death (1.6%). Patients with a large relative decrease in PaCO2 (>50%) had an increased incidence of neurological complications compared with those with a smaller decrease (9.8% vs. 6.4%; P < 0.001). A large relative decrease in PaCO2 was independently associated with neurological complications after controlling for previously described risk factors (odds ratio, 1.7; 95% confidence interval, 1.3 to 2.3; P < 0.001).Conclusions: In patients receiving ECMO for respiratory failure, a large relative decrease in PaCO2 in the first 24 hours after ECMO initiation is independently associated with an increased incidence of neurological complications.
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Affiliation(s)
- Yiorgos Alexandros Cavayas
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, and.,Département de Médecine, Hôpital du Sacré-Coeur de Montréal, and.,Département de Chirurgie, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; and
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, and
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, and
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Cavayas YA, Del Sorbo L, Munshi L, Sampson C, Fan E. Intracranial hemorrhage on extracorporeal membrane oxygenation: an international survey. Perfusion 2020; 36:161-170. [PMID: 32579070 DOI: 10.1177/0267659120932705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Intracranial hemorrhage is one of the most dreaded complications associated with extracorporeal membrane oxygenation. However, robust data to guide clinical practice are lacking. We aimed to describe the current perceptions and practices surrounding the risk, prevention, diagnosis, management, and prognosis of intracranial hemorrhage in patients on extracorporeal membrane oxygenation. METHODS We conducted an international, cross-sectional survey of adult extracorporeal membrane oxygenation centers using a self-administered electronic questionnaire sent to medical directors and program coordinators of all 290 adult centers member of the Extracorporeal Life Support Organization. RESULTS There were 143 respondents (49%). The median proportion of patients having neuroimaging performed was only 1-25% in venovenous-extracorporeal membrane oxygenation patients and 26-50% in venoarterial-extracorporeal membrane oxygenation and extracorporeal cardiopulmonary resuscitation. The majority of participants (58%) tolerated a PaO2 < 60 mm Hg on venovenous-extracorporeal membrane oxygenation. Lower PaO2 targets were inversely correlated with the reported incidence of intracranial hemorrhage (r =-0.247; p = 0.024). In patients with intracranial hemorrhage, most participants reported stopping anticoagulation, and median targets for blood product administration were 70,000-99,000 platelets/µL, 1.5-1.9 of international normalized ratio, and 1.6-2.0 g/L of fibrinogen. CONCLUSION We found significant heterogeneity in the perceptions and practices. This underlines the need for more research to appropriately guide patient management. Importantly, neuroimaging was performed only in a minority of patients. Considering the important management implications reported by most centers when intracranial hemorrhage is diagnosed, perhaps clinicians should consider widening their indications for early neuroimaging.
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Affiliation(s)
- Yiorgos Alexandros Cavayas
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada.,Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada.,Montreal Heart Institute, Montreal, QC, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada
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15
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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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Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) use has exploded over the last decade. However, it remains invasive and associated with significant complications, including tamponade, infection, thrombosis, gas embolism and bleeding. The most dreaded complication is intracranial hemorrhage (ICH). In this article, we review the literature on the incidence, diagnosis, risk factors, pathophysiology, prognosis, prevention and management of ICH in adults on ECMO. MAIN FINDINGS We found a high incidence of ICH in the literature with a poor prognosis. Important risk factors included pre-ECMO cardiac arrest, sepsis, influenza, renal failure, renal replacement therapy, hemolysis and thrombocytopenia. The optimal anticoagulation strategy is still uncertain. As platelet dysfunction and depletion appear to play an important role in the pathogenesis of ICH in patients on ECMO, a liberal platelet transfusion strategy may be advised. Prompt computed tomography (CT) diagnosis is of great importance as interventions to limit hematoma expansion and secondary neurological injury are most effective if instituted early. Transporting patients to the radiology department can be performed safely while on ECMO. A strategy combining screening CT on admission with a heparin-free period of extracorporeal support was demonstrated to be safe in VV-ECMO patients and resulted in a better prognosis compared to similar cohorts in the literature. CONCLUSION Despite major technological improvements and all the experience gained in adults, ECMO remains associated with a high incidence of ICH. There are still wide gaps in our understanding of the disease. Optimal management strategies that minimize the risk of ICH and improve prognosis need to be further studied.
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Affiliation(s)
- Yiorgos Alexandros Cavayas
- 1 Department of Critical Care, Sacré-Coeur Hospital, Montreal, Quebec, Canada.,2 Interdepartmental Division of Critical Care, Toronto General Hospital, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- 2 Interdepartmental Division of Critical Care, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eddy Fan
- 2 Interdepartmental Division of Critical Care, Toronto General Hospital, Toronto, Ontario, Canada
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Fletcher-Sandersjöö A, Thelin EP, Bartek J, Broman M, Sallisalmi M, Elmi-Terander A, Bellander BM. Incidence, Outcome, and Predictors of Intracranial Hemorrhage in Adult Patients on Extracorporeal Membrane Oxygenation: A Systematic and Narrative Review. Front Neurol 2018; 9:548. [PMID: 30034364 PMCID: PMC6043665 DOI: 10.3389/fneur.2018.00548] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/19/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Intracranial hemorrhage (ICH) is a common complication in adults treated with extracorporeal membrane oxygenation (ECMO). Objectives: The aim of this study was to conduct a systematic review of the literature on the incidence, outcome and predictors of ECMO-associated ICH in adult patients, supplemented by a narrative review of its pathophysiology, management and future perspectives. Methods: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and www.clinicaltrials.gov were systematically searched. Studies that reported incidence, outcome or predictors of ECMO-associated ICH in adults (≥18 years) were eligible for inclusion. Results: Twenty five articles were included in the systematic review. The incidence of ECMO-associated ICH varied between 1.8 and 21 %. Mortality rates in ICH-cohorts varied between 32 and 100 %, with a relative risk of mortality of 1.27–4.43 compared to non-ICH cohorts. An increased risk of ICH was associated with ECMO-duration, antithrombotic therapy, altered intrinsic coagulation, renal failure, need of blood products, rapid hypercapnia at ECMO initiation, and even pre-ECMO morbidity. Conclusions: ICH is a common complication in adults treated with ECMO and associated with increased mortality. Treating an ICH during ECMO represents a balance between pro- and anticoagulatory demands. Neurosurgical treatment is associated with severe morbidity, but has been successful in selected cases. Future studies should aim at investigating the validity and feasibility of non-invasive monitoring in early detection of ECMO-associated ICH.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Broman
- ECMO Center Karolinska, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Marko Sallisalmi
- ECMO Center Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | | | - Bo-Michael Bellander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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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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Lorusso R. Extracorporeal life support and neurologic complications: still a long way to go. J Thorac Dis 2017; 9:E954-E956. [PMID: 29266103 DOI: 10.21037/jtd.2017.09.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
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Neurologic Injury in Adults Supported With Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure. Crit Care Med 2017; 45:1389-1397. [DOI: 10.1097/ccm.0000000000002502] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Extracorporeal membrane oxygenation (ECMO) is a pivotal bridge to recovery for cardiopulmonary failure in children. Besides its life-saving quality, it is often associated with severe system-related complications, such as hemolysis, inflammation, and thromboembolism. Novel oxygenator and pump systems may reduce such ECMO-related complications. The ExMeTrA oxygenator is a newly designed pediatric oxygenator with an integrated pulsatile pump minimizing the priming volume and reducing the surface area of blood contact. The aim of our study was to investigate the feasibility and safety of this new ExMeTrA (expansion mediated transport and accumulation) oxygenator in an animal model. During 6 h of extracorporeal circulation (ECC) in pigs, parameters of the hemostatic system including coagulation, platelets and complement activation, and flow rates were investigated. A nonsignificant trend in C3 consumption, thrombin-antithrombin-III (TAT) complex formation and a slight trend in hemolysis were detected. During the ECC, the blood flow was constantly at 500 ml/min using only flexible silicone tubes inside the oxygenator as pulsatile pump. Our data clearly indicate that the hemostatic markers were only slightly influenced by the ExMeTrA oxygenator. Additionally, the oxygenator showed a constant quality of blood flow. Therefore, this novel pediatric oxygenator shows the potential to be used in pediatric and neonatal support with ECMO.
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Luyt CE, Bréchot N, Demondion P, Jovanovic T, Hékimian G, Lebreton G, Nieszkowska A, Schmidt M, Trouillet JL, Leprince P, Chastre J, Combes A. Brain injury during venovenous extracorporeal membrane oxygenation. Intensive Care Med 2016; 42:897-907. [PMID: 27007107 DOI: 10.1007/s00134-016-4318-3] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/09/2016] [Indexed: 01/19/2023]
Abstract
PURPOSE The frequency of neurological events and their impact on patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) are unknown. We therefore study the epidemiology, risk factors, and impact of cerebral complications occurring in VV-ECMO patients. METHODS Observational study conducted in a tertiary referral center (2006-2012) on patients developing a neurological complication (ischemic stroke or intracranial bleeding) while on VV-ECMO versus those who did not, and a systematic review on this topic. RESULTS Among 135 consecutive patients who had received VV-ECMO, 18 (15 assessable) developed cerebral complications on ECMO: cerebral bleeding in 10 (7.5 %), ischemic stroke in 3 (2 %), or diffuse microbleeds in 2 (2 %), occurring after respective medians (IQR) of 3 (1-11), 21 (10-26), and 36 (8-63) days post-ECMO onset. Intracranial bleeding was independently associated with renal failure at intensive care unit admission and rapid PaCO2 decrease at ECMO initiation, but not with age, comorbidities, or hemostasis disorders. Seven (70 %) patients with intracranial bleeding and one (33 %) with ischemic stroke died versus 40 % of patients without neurological event. A systematic review found comparable intracranial bleeding rates (5 %). CONCLUSIONS Neurological events occurred frequently in patients on VV-ECMO. Intracranial bleeding, the most frequent, occurred early and was associated with higher mortality. Because it was independently associated with rapid hypercapnia decrease, the latter should be avoided at ECMO onset, but its exact role remains to be determined. These findings may have major implications for the care of patients requiring VV-ECMO.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Nicolas Bréchot
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pierre Demondion
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Tamara Jovanovic
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ania Nieszkowska
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Matthieu Schmidt
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Jean-Louis Trouillet
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean Chastre
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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Swol J, Belohlávek J, Haft JW, Ichiba S, Lorusso R, Peek GJ. Conditions and procedures for in-hospital extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR) of adult patients. Perfusion 2015; 31:182-8. [PMID: 26081929 DOI: 10.1177/0267659115591622] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR; ECPR) has been repeatedly published as non-randomized studies, mainly case series and case reports. The aim of this article is to support physicians, perfusionists, nurses and extracorporeal membrane oxygenation (ECMO) specialists who regularly perform ECPR or are willing to start an ECPR program by establishing standards for safe and efficient ECPR procedures. This article represents the experience and recommendations of physicians who provide ECPR routinely. Based on its survival and outcome rates, ECPR can be considered when determining the optimal treatment of patients who require CPR. The successful performance of ECLS cannulation during CPR is a life-saving measure and has been associated with improved outcome (including neurological outcome) after CPR. We summarize the general structure of an ECLS team and describe the cannulation procedure and the approaches for post-resuscitation care. The differences in hospital organizations and their regulations may result in variations of this model.
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Affiliation(s)
- Justyna Swol
- Surgical Critical Care, Department of Surgery, Surgical Intensive Care Unit, University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - Jan Belohlávek
- Coronary Care Unit, 2nd Department of Medicine, Cardiovascular Medicine, General Teaching Hospital, Charles University in Prague, Prague, Czech Republic
| | - Jonathan W Haft
- Department of Community and Emergency Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shingo Ichiba
- Cardiac Surgery & Anesthesia, Extra Corporeal Life Support Program, Cardiovascular Intensive Care Units, University of Michigan Health System, Ann Arbor, MI, USA
| | - Roberto Lorusso
- U.O. Cardiochirugia-Spedali Civili, Piazzale Spedali Civili, Brescia, Italy
| | - Giles J Peek
- Cardiothoracic Surgery & ECMO, East Midlands Congenital Heart Centre, Paediatric & Adult ECMO Programme, Glenfield Hospital, Leicester, UK
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[Veno-arterial extracorporeal membrane oxygenation. Indications, limitations and practical implementation]. Anaesthesist 2015; 63:625-35. [PMID: 25074647 DOI: 10.1007/s00101-014-2362-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Due to the technical advances in pumps, oxygenators and cannulas, veno-arterial extracorporeal membrane oxygenation (va-ECMO) or extracorporeal life support (ECLS) has been widely used in emergency medicine and intensive care medicine for several years. An accepted indication is peri-interventional cardiac failure in cardiac surgery (postcardiotomy low cardiac output syndrome). Furthermore, especially the use of va-ECMO for other indications in critical care medicine, such as in patients with severe sepsis with septic cardiomyopathy or in cardiopulmonary resuscitation has tremendously increased. The basic indications for va-ECMO are therapy refractory cardiac or cardiopulmonary failure. The fundamental purpose of va-ECMO is bridging the function of the lungs and/or the heart. Consequently, this support system does not represent a causal therapy by itself; however, it provides enough time for the affected organ to recover (bridge to recovery) or for the decision for a long-lasting organ substitution by a ventricular assist device or by transplantation (bridge to decision). Although the outcome for bridged patients seems to be favorable, it should not be forgotten that the support system represents an invasive procedure with potentially far-reaching complications. Therefore, the initiation of these systems needs a professional and experienced (interdisciplinary) team, sufficient resources and an individual approach balancing the risks and benefits. This review gives an overview of the indications, complications and contraindications for va-ECMO. It discusses its advantages in organ transplantation and transport of critically ill patients. The reader will learn the differences between peripheral and central cannulation and how to monitor and manage va-ECMO.
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