Intracranial hemorrhage in adults on ECMO

Angiotensin 1-7 restrains vascular injury of extracorporeal membrane oxygenation by inhibiting ferroptosis

BACKGROUND

Angiotensin 1-7 (Ang1-7) is the classical end product of angiotensin II, which has the effects of dilating blood vessels, protecting endothelial cells, anti-hypertension, improving cardiac function, and inhibiting atherosclerosis. We hypothesize that Ang1-7 inhibits human umbilical vein endothelial cells (HUVEC) ferroptosis through NF-κB/P53 signal pathway, and reduces extracorporeal membrane oxygenation (ECMO) vascular injury.

METHODS

Cultured HUVEC were seeded into 15 wells and randomly divided into five groups: the control group and four experimental groups (erastin, erastin + Ang1-7, erastin + Ang1-7 + Betulinic acid, erastin + Betulinic acid). After stimulation, cell viability, lactate dehydrogenase (LDH), malondialdehyde (MDA), and superoxide dismutase (SOD) activity were measured. The effects of Ang1-7 on HUVEC microstructure, antioxidant enzymes (ferritin heavy chain 1 (FTH1), cystine/glutamic acid reverse transport solute carrier family 7 members 11 (SLC7A11 or XCT), superoxide dismutase-2 (SOD-2) and glutathione peroxidase 4 (GPX4)), NF-κB, P-NF-κB, P53, and P-P53).

RESULTS

Erastin stimulation promoted HUVEC lipid peroxidation, decreased antioxidant enzyme expression, increased P-NF-κB, P53, and P-P53 expressions, and damaged HUVEC mitochondrial structure. Ang1-7 alleviated the effect of erastin on HUVEC, which was destroyed by Betulinic acid.

CONCLUSION

Angiotensin1-7 pretreatment inhibited vascular endothelial cells' ferroptosis and alleviated ECMO vessel injury through NF-κB /P53 signal pathway.

Prevalence and Risk Factors for Weaning Failure From Venovenous Extracorporeal Membrane Oxygenation in Patients With Severe Acute Respiratory Insufficiency

OBJECTIVE

Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency.

DESIGN

Single-center retrospective observational study.

SETTING

Sixteen beds medical ICU at the University Hospital Regensburg.

PATIENTS

Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients meeting our ECMO weaning criteria (Sp o2 ≥ 90% with F io2 ≤ 0.4 or Pa o2 /F io2 > 150 mm Hg, pH = 7.35-7.45, positive end-expiratory pressure ≤ 10 cm H 2 O, driving pressure < 15 cm H 2 O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90-160 mm Hg, norepinephrine < 0.2 µg/[kg*min]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co2 : odds ratio [OR] 1.05; 95% CI, 1.001-1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04-1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/L*min), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o2 and Pa o2 /F io2 during EWTs was higher in failed than successful trials.

CONCLUSIONS

Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure.

Intracranial hemorrhage in a large cohort of patients supported with veno-venous ECMO. A retrospective single-center analysis

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.

Intracranial hemorrhage in patients treated for SARS-CoV-2 with extracorporeal membrane oxygenation: A systematic review and meta-analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is routinely used in patients with severe respiratory failure and has been increasingly needed during the COVID-19 pandemic. In patients treated with ECMO, significant intracranial hemorrhage (ICH) risk exists due to circuit characteristics, anticoagulation, and disease characteristics. ICH risk may be substantially higher in COVID-19 patients than patients treated with ECMO for other indications.

METHODS

We systematically reviewed current literature regarding ICH during ECMO treatment of COVID-19. We utilized Embase, MEDLINE, and Cochrane Library databases. Meta-analysis was performed for included comparative studies. Quality assessment was performed using MINORS criteria.

RESULTS

A total of 54 studies with 4000 ECMO patients were included, all retrospective. Risk of bias was increased via MINORS score primarily due to retrospective designs. ICH was more likely in COVID-19 patients (RR 1.72, 95% CI 1.23, 2.42). Mortality among COVID patients on ECMO with ICH was 64.0%, compared with 41% in patients without ICH (RR1.9, 95% 1.44, 2.51).

CONCLUSION

This study suggests increased hemorrhage rates in COVID-19 patients on ECMO compared to similar controls. Hemorrhage reduction strategies may include atypical anticoagulants, conservative anticoagulation strategies, or biotechnology advances in circuit design and surface coatings.

Clinical impact of screening computed tomography in extracorporeal membrane oxygenation: a retrospective cohort study

BACKGROUND

Data on the prevalence and clinical impact of extrapulmonary findings at screening computed tomography (CT) on initiation of veno-venous extracorporeal membrane oxygenation (V-V ECMO) are limited. We aimed to identify the prevalence of extrapulmonary findings on screening CT following V-V ECMO initiation. We hypothesized that extrapulmonary findings would influence clinical management and outcome.

METHODS

Retrospective analysis (2011-2021) of admission screening CT including head, abdomen and pelvis with contrast of consecutive patients on initiation of V-V ECMO. CT findings identified by the attending consultant radiologist were extracted. Demographics, admission physiological and laboratory data, clinical decision-making following CT and ECMO ICU mortality were recorded from the electronic medical record. We used multivariable logistic regression and Kaplan-Meier curves to evaluate associations between extrapulmonary findings and ECMO ICU mortality.

RESULTS

Of the 833 patients receiving V-V ECMO, 761 underwent routine admission CT (91.4%). ECMO ICU length of stay was 19 days (IQR 12-23); ICU mortality at the ECMO centre was 18.9%. An incidental extrapulmonary finding was reported in 227 patients (29.8%), leading to an invasive procedure in 12/227 cases (5.3%) and a change in medical management (mainly in anticoagulation strategy) in 119/227 (52.4%). Extrapulmonary findings associated with mortality were intracranial haemorrhage (OR 2.34 (95% CI 1.31-4.12), cerebral infarction (OR 3.59 (95% CI 1.26-9.86) and colitis (OR 2.80 (95% CI 1.35-5.67).

CONCLUSIONS

Screening CT frequently identifies extrapulmonary findings of clinical significance. Newly detected intracranial haemorrhage, cerebral infarction and colitis were associated with increased ICU mortality.

Shear-induced acquired von Willebrand syndrome: an accomplice of bleeding events in adults on extracorporeal membrane oxygenation support

Extracorporeal membrane oxygenation (ECMO) is an increasingly acceptable life-saving mechanical assistance system that provides cardiac and/or respiratory support for several reversible or treatable diseases. Despite important advances in technology and clinical management, bleeding remains a significant and common complication associated with increased morbidity and mortality. Some studies suggest that acquired von Willebrand syndrome (AVWS) is one of the etiologies of bleeding. It is caused by shear-induced deficiency of von Willebrand factor (VWF). VWF is an important glycoprotein for hemostasis that acts as a linker at sites of vascular injury for platelet adhesion and aggregation under high shear stress. AVWS can usually be diagnosed within 24 h after initiation of ECMO and is always reversible after explantation. Nonetheless, the main mechanism for the defect in the VWF multimers under ECMO support and the association between AVWS and bleeding complications remains unknown. In this review, we specifically discuss the loss of VWF caused by shear induction in the context of ECMO support as well as the current diagnostic and management strategies for AVWS.

[The Role of the Percutaneous Impella Pump in Anesthesia and Intensive Care]

The use of temporary mechanical circulatory support (tMCS) devices and in particular the increasing use of the Impella device family has gained significant interest over the last two decades. Nowadays, its use plays a well-established key role in both the treatment of cardiogenic shock, and as a preventive and protective therapeutic option during high-risk procedures in both cardiac surgery and cardiology, such as complex percutaneous interventions (protected PCI). Thus, it is not surprising that the Impella device is more and more present in the perioperative setting and especially in patients on intensive care units. Despite the numerous advantages such as cardiac resting and hemodynamic stabilization, potential adverse events exist, which may lead to severe, but preventable complications, so that adequate education, early recognition of such events and a subsequent adequate management are crucial in patients with tMCS. This article provides an overview especially for anesthesiologists and intensivists focusing on technical basics, indications and contraindications for its use with special focus on the intra- and postoperative management. Furthermore, troubleshooting for most common complications for patients on Impella support is provided.

Activity of anticoagulant proteins on the polymer-coated and heparin-coated membranes in an extracorporeal circulation circuit

INTRODUCTION

We performed in vitro experiments using whole human blood without anticoagulants to clarify the activity of anticoagulant proteins on membranes coated with acrylate-copolymer (ACP) with a hydrophilic blood-contacting layer compared to those coated by immobilizing heparin (IHP) in extracorporeal circulation.

METHODS

Whole human blood from healthy volunteers was recirculated in two types of experimental circuits with an ACP-coated reservoir and tubes and an ACP-coated or IHP-coated membrane. To compare the fluctuation of anticoagulant proteins, the circuit pressure at the inlet and outlet of the membrane was measured every 5 min; antithrombin antigen (ATQ), antithrombin activity, protein-C quantitation (PCQ), protein-C activity, protein-S free antigen (PSQ), and protein-S activity were measured at 0, 30, 60, 120, and 180 min in each experiment (n = 5).

RESULTS

The time taken to achieve high circuit pressure (> 300 mmHg) at the inlet of the membrane was significantly shorter in the ACP-coated membrane circuit (28 ± 2.7 min) than in the IHP-coated membrane circuit (54 ± 24 min); however, the ATQ, PCQ, and PSQ at 180 min of recirculation were significantly higher in the former than in the latter (all p < .05).

CONCLUSIONS

ACP-coated membranes can prevent the consumption of anticoagulant proteins but cannot delay circuit thrombogenicity compared to IHP-coated membranes. Considering patient care during the post-extracorporeal circulation period, the use of ACP coating, which can preserve anticoagulant protein, is better in extracorporeal circulation circuits.

Veno-venous extracorporeal membrane oxygenation for the treatment of respiratory compromise

Extracorporeal membrane oxygenation for the purpose of intervening upon profound cardiovascular or pulmonary compromise has proven to be a worthy intervention. Technological advancements have allowed this mode of therapy to become more effective and widespread. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a commonly used strategy to help manage patients with pulmonary dysfunction refractory to traditional management methods. This review intends to focus upon common indications and the clinical considerations for the institution of VV-ECMO as well as some of its known complications.

A Variance in Management of ECMO-Associated Fibrin Sheaths at a Single Institution

Objective

Extracorporeal membrane oxygenation (ECMO) support for patients with cardiac or respiratory failure has been increasingly used by advanced critical care practitioners. The thromboembolic complications of ECMO have been extensively discussed and researched; however, research and discussion on the development, risks, and management of cannulae-associated fibrin sheaths are lacking.

Methods

Institutional review board approval was not required. We have presented three cases detailing the identification and individualized management of ECMO-associated fibrin sheaths at our institution. The three patients provided written informed consent for the report of their case details and imaging studies.

Results

Of our three patients with ECMO-associated fibrin sheaths, two were managed successfully with anticoagulation alone. One could not receive anticoagulation therapy and underwent inferior vena cava filter placement.

Conclusions

Fibrin sheath formation around indwelling ECMO cannulae is an unresearched complication of ECMO cannulation. We would recommend an individualized approach to the management of these fibrin sheaths and have provided three examples of successful management.

Extracorporeal Membrane Oxygenation (ECMO) for Pulmonary and/or Cardiopulmonary Support-a Brief Review and Our Experience

Extracorporeal membrane oxygenation (ECMO) is a modality utilized for partially or completely supporting the cardiac and/or pulmonary function. There are multiple vascular access techniques depending upon the necessity and the mode of ECMO used. ECMO has evolved over the years as an integral part of the cardiac care discipline. Historically, this lifesaving modality began as an extension of cardiopulmonary bypass and was associated with adverse outcomes. Currently, ECMO has evolved as an accepted and viable solution to patients with severe cardiac/respiratory/cardiorespiratory failure that is refractory to conservative management. The outcomes of patients on ECMO are dependent on multiple factors originating from demographic and pathophysiological status of patients as well as the control of homeostasis during ECMO within the acceptable range. Various studies have been published by many practitioners over past decades since the dawn of ECMO era. A brief review of such experience is summated, and a conclusion is derived about the clinical course of the patients on ECMO, while adding the author's experience about the same in a tertiary care large-volume center.

A phased intervention bundle to decrease the mortality of patients with extracorporeal membrane oxygenation in intensive care unit

Aim

To evaluate whether a phased multidimensional intervention bundle would decrease the mortality of patients with extracorporeal membrane oxygenation (ECMO) and the complication incidence.

Materials and methods

We conducted a prospective observational study in comparison with a retrospective control group in six intensive care units (ICUs) in China. Patients older than 18 years supported with ECMO between March 2018 to March 2022 were included in the study. A phased intervention bundle to improve the outcome of patients with ECMO was developed and implemented. Multivariable logistic regression modeling was used to compare the mortality of patients with ECMO and the complication incidence before, during, and up to 18 months after implementation of the intervention bundle.

Results

The cohort included 297 patients in 6 ICUs, mostly VA ECMO (68.7%) with a median (25th–75th percentile) duration in ECMO of 9.0 (4.0–15.0) days. The mean (SD) APECHII score was 24.1 (7.5). Overall, the mortality of ECMO decreased from 57.1% at baseline to 21.8% at 13–18 months after implementation of the study intervention (P < 0.001). In multivariable analysis, even after excluding the confounding factors, such as age, APECHII score, pre-ECMO lactate, and incidence of CRRT during ECMO, the intervention bundle still can decrease the mortality independently, which also remained true in the statistical analysis of V-V and V-A ECMO separately. Among all the ECMO-related complications, the incidence of bloodstream infection and bleeding decreased significantly at 13–18 months after implementation compared with the baseline. The CUSUM analysis revealed a typical learning curve with a point of inflection during the implementation of the bundle.

Conclusion

A phased multidimensional intervention bundle resulted in a large and sustained reduction in the mortality of ECMO that was maintained throughout the 18-month study period.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT05024786].

Predictive ability of viscoelastic testing using ClotPro® for short-term outcome in patients with severe Covid-19 ARDS with or without ECMO therapy: a retrospective study

BACKGROUND

SARS-CoV-2 infections are suspected to trigger the coagulation system through various pathways leading to a high incidence of thromboembolic complications, hypercoagulation and impaired fibrinolytic capacity were previously identified as potentially mechanisms. A reliable diagnostic tool for detecting both is still under discussion. This retrospective study is aimed to examine the prognostic relevance of early viscoelastic testing compared to conventional laboratory tests in COVID-19 patients with acute respiratory distress syndrome (ARDS).

METHODS

All mechanically ventilated patients with COVID-19 related ARDS treated in our intensive care unit (ICU) between January and March 2021 were included in this study. Viscoelastic testing (VET) was performed using the ClotPro® system after admission to our ICU. Prevalence of thromboembolic events was observed by standardized screening for venous and pulmonary thromboembolism using complete compression ultrasound and thoracic computed tomography pulmonary angiography at ICU admission, respectively. We examined associations between the severity of ARDS at admission to our ICU, in-hospital mortality and the incidence of thromboembolic events comparing conventional laboratory analysis and VET. ECMO related coagulopathy was investigated in a subgroup analysis. The data were analyzed using the Mann-Whitney U test.

RESULTS

Of 55 patients enrolled in this study, 22 patients required treatment with ECMO. Thromboembolic complications occurred in 51% of all patients. Overall hospital mortality was 55%. In patients with thromboembolic complications, signs of reduced fibrinolytic capacity could be detected in the TPA assay with prolonged lysis time, median 460 s (IQR 350-560) vs 359 s (IQR 287-521, p = 0.073). Patients with moderate to severe ARDS at admission to our ICU showed increased maximum clot firmness as a sign of hypercoagulation in the EX-test (70 vs 67 mm, p < 0.05), FIB-test (35 vs 24 mm, p < 0.05) and TPA-test (52 vs 36 mm, p < 0.05) as well as higher values of inflammatory markers (CRP, PCT and IL6). ECMO patients suffered more frequently from bleeding complications (32% vs 15%).

CONCLUSION

Although, the predictive value for thromboembolic complications or mortality seems limited, point-of-care viscoelastic coagulation testing might be useful in detecting hypercoagulable states and impaired fibrinolysis in critically ill COVID-19 ARDS patients and could be helpful in identifying patients with a potentially very severe course of the disease.

HEROES V-A-HEmoRrhagic cOmplications in veno-arterial Extracorporeal life Support-Development and internal validation of a multivariable prediction model in adult patients

BACKGROUND

Risk factors for bleeding complications during extracorporeal life support (ECLS) indicated for cardiac support remain poorly investigated. The aim is to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving veno-arterial (V-A) ECLS.

METHODS

Data of the Extracorporeal Life Support Organization registry of adult patients undergoing V-A ECLS between 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-A ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the prediction model. Performance of the model was tested by discriminative ability and calibration with receiver operator characteristic, area under the curve, and visual inspection of the calibration plot. Internal validation was performed to detect overfitting of the model.

RESULTS

In total 28 767 adult patients were included, of which 29.0% developed bleeding complications. Sex, body mass index, surgical cannulation, pre-ECLS respiratory and hemodynamic variables, pre-ECLS support and interventions, and different type of diagnosis were included in the prediction model. This prediction model showed a predictive capability with an AUC of 0.66.

CONCLUSION

The model is based on the largest cohort of V-A ECLS patients and is the best available predictive model for bleeding events given the predictors that are available in V-A ECLS compared to current literature. The model can help in identifying patients at high risk for bleeding complications and will help in developing further research and decision-making in terms of anticoagulation management. External validation is warranted to extrapolate this model in the clinical setting.

Intracranial haemorrhage in adult patients on venoarterial extracorporeal membrane oxygenation

AIMS

Intracranial haemorrhage (ICH) is one of the most serious complications of adult patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and is associated with increased morbidity and mortality. However, the prevalence and risk factors of ICH in this cohort are still insufficiently understood. We hypothesized that a considerable proportion of patients undergoing VA-ECMO support suffer from ICH and that specific risk factors are associated with the occurrence of ICH. Therefore, the purpose of this study was to further investigate the prevalence and associated mortality as well as to identify risk factors for ICH in VA-ECMO patients.

METHODS AND RESULTS

We conducted a retrospective multicentre study including adult patients (≥18 years) treated with VA-ECMO in cardiac intensive care units (ICUs) at five German clinical sites between January 2016 and March 2020, excluding patients with ICH upon admission. Differences in baseline characteristics and clinical outcome between VA-ECMO patients with and without ICH were analysed and risk factors for ICH were identified. Among the 598 patients included, 70/598 (12%) developed ICH during VA-ECMO treatment. In-hospital mortality in patients with ICH was 57/70 (81%) and 1-month mortality 60/70 (86%), compared to 332/528 (63%) (P = 0.002) and 340/528 (64%) (P < 0.001), respectively, in patients without ICH. Intracranial haemorrhage was positively associated with diabetes mellitus [odds ratio (OR) 2, 95% confidence interval (CI) 1.11-3.56; P = 0.020] and lactate (per mmol/L) (OR 1.06, 95% CI 1.01-1.11; P = 0.020), and negatively associated with platelet count (per 100 G/L) (OR 0.32, 95% CI 0.15-0.59; P = 0.001) and fibrinogen (per 100 mg/dL) (OR 0.64, 95% CI 0.49-0.83; P < 0.001).

CONCLUSION

Intracranial haemorrhage was associated with a significantly higher mortality rate. Diabetes mellitus and lactate were positively, platelet count, and fibrinogen level negatively associated with the occurrence of ICH. Thus, platelet count and fibrinogen level were revealed as potentially modifiable, independent risk factors for ICH. The findings address an area with limited data, provide information about risk factors and the epidemiology of ICH, and may be a starting point for further investigations to develop effective strategies to prevent and treat ICH.

Acquired bleeding disorders

Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.

Risk Factors for Bleeding Complications during Venovenous Extracorporeal Membrane Oxygenation as a Bridge to Recovery

Background

Bleeding complications during venovenous extracorporeal membrane oxygenation (V‐V ECMO) can be critical. However, there is limited information on the associated risk factors. This study investigated the risk factors for bleeding complications during V‐V ECMO as a bridge to recovery.

Methods

This single‐center retrospective study enrolled 59 patients (bleeding and non‐bleeding groups) who received V‐V ECMO from 2012 to 2020, to evaluate whether peak activated partial thromboplastin time (APTT) value, lowest platelet count, and mobilization to sitting on the edge of the bed during V‐V ECMO were risk factors for bleeding complications, defined according to the Extracorporeal Life Support Organization guidelines. Age, sex, body mass index, Sequential Organ Failure Assessment score, and ECMO duration before bleeding complications were covariates in the multivariate logistic regression analysis.

Results

Thirty‐one (53%) participants experienced 36 bleeding complications; the ECMO cannulation site, gastrointestinal tract, and nasopharyngeal region were the most common bleeding sites. The use of transfusion products and length of ECMO and intensive care unit stay were significantly and medical costs were non‐significantly increased in the bleeding group. Peak APTT (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05, p < 0.01) was significantly associated whereas the lowest platelet count (OR 0.96, 95% CI 0.82–1.13, p = 0.66) was unassociated with bleeding complications during ECMO. Achieving mobilization (OR 0.14, 95% CI 0.02–1.17, p = 0.07) decreased the trend of risk for bleeding complications.

Conclusions

Peak APTT might be an independent modifiable factor for bleeding complications during V‐V ECMO. The protective effect of mobilization during V‐V ECMO requires further investigation.

Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support Over the Past Two Decades—Extracorporeal Life Support Organization Registry Analysis

OBJECTIVES

Data about inhospital outcomes in bleeding complications during extracorporeal life support (ECLS) have been poorly investigated.

DESIGN

Retrospective observational study.

SETTING

Patients reported in Extracorporeal Life Support Organization Registry.

PATIENTS

Data of 53.644 adult patients (greater than or equal to 18 yr old) mean age 51.4 ± 15.9 years, 33.859 (64.5%) male supported with single ECLS run between 01.01.2000 and 31.03.2020, and 19.748 cannulated for venovenous (V-V) ECLS and 30.696 for venoarterial (V-A) ECLS.

INTERVENTIONS

Trends in bleeding complications, bleeding risk factors, and mortality.

MEASUREMENT AND MAIN RESULTS

Bleeding complications were reported in 14.786 patients (27.6%), more often in V-A ECLS compared with V-V (30.0% vs 21.9%; p < 0.001). Hospital survival in those who developed bleeding complications was lower in both V-V ECLS (49.6% vs 66.6%; p < 0.001) and V-A ECLS (33.9 vs 44.9%; p < 0.001). Steady decrease in bleeding complications in V-V and V-A ECLS was observed over the past 20 years (coef., -1.124; p < 0.001 and -1.661; p < 0.001). No change in mortality rates was reported over time in V-V or V-A ECLS (coef., -0.147; p = 0.442 and coef., -0.195; p = 0.139).Multivariate regression revealed advanced age, ecls duration, surgical cannulation, renal replacement therapy, prone positioning as independent bleeding predictors in v-v ecls and female gender, ecls duration, pre-ecls arrest or bridge to transplant, therapeutic hypothermia, and surgical cannulation in v-a ecls.

CONCLUSIONS

A steady decrease in bleeding over the last 20 years, mostly attributable to surgical and cannula-site-related bleeding has been found in this large cohort of patients receiving ECLS support. However, there is not enough data to attribute the decreasing trends in bleeding to technological refinements alone. Especially reduction in cannulation site bleeding is also due to changes in timing, patient selection, and ultrasound guided percutaneous cannulation. Other types of bleeding, such as CNS, have remained stable, and overall bleeding remains associated with a persistent increase in mortality.

COVID-19 and Intracranial Hemorrhage: A Multicenter Case Series, Systematic Review and Pooled Analysis

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) profoundly impacts hemostasis and microvasculature. In the light of the dilemma between thromboembolic and hemorrhagic complications, in the present paper, we systematically investigate the prevalence, mortality, radiological subtypes, and clinical characteristics of intracranial hemorrhage (ICH) in coronavirus disease (COVID-19) patients.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review of the literature by screening the PubMed database and included patients diagnosed with COVID-19 and concomitant ICH. We performed a pooled analysis, including a prospectively collected cohort of critically ill COVID-19 patients with ICH, as part of the PANDEMIC registry (Pooled Analysis of Neurologic Disorders Manifesting in Intensive Care of COVID-19).

RESULTS

Our literature review revealed a total of 217 citations. After the selection process, 79 studies and a total of 477 patients were included. The median age was 58.8 years. A total of 23.3% of patients experienced the critical stage of COVID-19, 62.7% of patients were on anticoagulation and 27.5% of the patients received ECMO. The prevalence of ICH was at 0.85% and the mortality at 52.18%, respectively.

CONCLUSION

ICH in COVID-19 patients is rare, but it has a very poor prognosis. Different subtypes of ICH seen in COVID-19, support the assumption of heterogeneous and multifaceted pathomechanisms contributing to ICH in COVID-19. Further clinical and pathophysiological investigations are warranted to resolve the conflict between thromboembolic and hemorrhagic complications in the future.

Intracranial Hemorrhages on Extracorporeal Membrane Oxygenation: Differences Between COVID-19 and Other Viral Acute Respiratory Distress Syndrome

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is a potentially lifesaving procedure in acute respiratory distress syndrome (ARDS) due to COVID-19. Previous studies have shown a high prevalence of clinically silent cerebral microbleeds in patients with COVID-19. Based on this fact, together with the hemotrauma and the requirement of therapeutic anticoagulation on ECMO support, we hypothesized an increased risk of intracranial hemorrhages (ICHs). We analyzed ICH occurrence rate, circumstances and clinical outcome in patients that received ECMO support due to COVID-19-induced ARDS in comparison to viral non-COVID-19-induced ARDS intracerebral hemorrhage.

DESIGN

Multicenter, retrospective analysis between January 2010 and May 2021.

SETTING

Three tertiary care ECMO centers in Germany and Switzerland.

PATIENTS

Two-hundred ten ARDS patients on ECMO support (COVID-19, n = 142 vs viral non-COVID, n = 68).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Evaluation of ICH occurrence rate, parameters of coagulation and anticoagulation strategies, inflammation, and ICU survival. COVID-19 and non-COVID-19 ARDS patients showed comparable disease severity regarding Sequential Organ Failure Assessment score, while the oxygenation index before ECMO cannulation was higher in the COVID group (82 vs 65 mm Hg). Overall, ICH of any severity occurred in 29 of 142 COVID-19 patients (20%) versus four of 68 patients in the control ECMO group (6%). Fifteen of those 29 ICH events in the COVID-19 group were classified as major (52%) including nine fatal cases (9/29, 31%). In the control group, there was only one major ICH event (1/4, 25%). The adjusted subhazard ratio for the occurrence of an ICH in the COVID-19 group was 5.82 (97.5% CI, 1.9-17.8; p = 0.002). The overall ICU mortality in the presence of ICH of any severity was 88%.

CONCLUSIONS

This retrospective multicenter analysis showed a six-fold increased adjusted risk for ICH and a 3.5-fold increased incidence of ICH in COVID-19 patients on ECMO. Prospective studies are needed to confirm this observation and to determine whether the bleeding risk can be reduced by adjusting anticoagulation strategies.

Clinical Features and Risk Factors Analysis for Hemorrhage in Adults on ECMO

Background: The use of extracorporeal membrane oxygenation (ECMO) to support critically ill patients with cardiorespiratory dysfunction has increased over the last decades. However, hemorrhagic complications occur frequently during ECMO support, and this has a significant impact on morbidity and mortality. Thus, this study aimed to identify the risk factors for hemorrhage in patients receiving ECMO.

Methods: Our retrospective study included 60 patients, who were admitted to the Taihe Hospital in Shiyan City, Hubei Province, China from February 2017 to October 2020. About 18 patients developed hemorrhagic complications, and 42 patients did not demonstrate such complications. Data regarding patient demography, laboratory tests, and clinical manifestations prior to ECMO were collected to analyze their clinical features. Univariable and multivariable logistic analyses were used to explore the risk factors for hemorrhage in adults on ECMO. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the binary logistic model. The amount of blood transfusions was compared between the two groups, and the activated partial thromboplastin time (APTT), platelet count, and hemoglobin level before the initiation of ECMO.

Results: Logistic analysis showed that a longer duration of ECMO support, higher APTT, and lower platelet count prior to ECMO were independent risk factors for hemorrhage in adults on ECMO. In addition, we found that the cannula site was the most common bleeding site. Most bleeding events occurred within the first 3 days of ECMO therapy. After the ECMO initiation, APTT was prolonged while the platelet count and hemoglobin levels were decreased. The amount of blood transfusion was significantly higher in the hemorrhage group than in the non-hemorrhage group.

Conclusions: Clinicians should evaluate the risk of hemorrhage based on the coagulation function of patients, underlying disease, and the duration of ECMO support. In the first 3 days during ECMO support, special attention should be given to the cannula site, mucosal, and dermal regions, and digestive tract to detect any signs of hemorrhage. Moreover, increasing the platelet count transfusion threshold and accurately determining the amount of blood transfusion required may prevent bleeding events.

Association of COVID-19 with Intracranial Hemorrhage during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A 10-Year Retrospective Observational Study

Extracorporeal membrane oxygenation (ECMO) is potentially lifesaving for patients with acute respiratory distress syndrome (ARDS) but may be accompanied by serious adverse events, including intracranial hemorrhage (ICRH). We hypothesized that ICRH occurs more frequently in patients with COVID-19 than in patients with ARDS of other etiologies. We performed a single-center retrospective analysis of adult patients treated with venovenous (vv-) ECMO for ARDS between January 2011 and April 2021. Patients were included if they had received a cranial computed tomography (cCT) scan during vv-ECMO support or within 72 h after ECMO removal. Cox regression analysis was used to identify factors associated with ICRH. During the study period, we identified 204 patients with vv-ECMO for ARDS, for whom a cCT scan was available. We observed ICRH in 35.4% (n = 17/48) of patients with COVID-19 and in 16.7% (n = 26/156) of patients with ARDS attributable to factors other than COVID-19. COVID-19 (HR: 2.945; 95%; CI: 1.079–8.038; p = 0.035) and carboxyhemoglobin (HR: 0.330; 95%; CI: 0.135–0.806; p = 0.015) were associated with ICRH during vv-ECMO. In patients receiving vv-ECMO, the incidence of ICRH is doubled in patients with COVID-19 compared to patients suffering from ARDS attributable to other causes. More studies on the association between COVID-19 and ICRH during vv-ECMO are urgently needed to identify risk patterns and targets for potential therapeutic interventions.

HEROES V-V-HEmorRhagic cOmplications in Veno-Venous Extracorporeal life Support-Development and internal validation of multivariable prediction model in adult patients

BACKGROUND

During extracorporeal life support (ECLS), bleeding is one of the most frequent complications, associated with high morbidity and increased mortality, despite continuous improvements in devices and patient care. Risk factors for bleeding complications in veno-venous (V-V) ECLS applied for respiratory support have been poorly investigated. We aim to develop and internally validate a prediction model to calculate the risk for bleeding complications in adult patients receiving V-V ECLS support.

METHODS

Data from adult patients reported to the extracorporeal life support organization (ELSO) registry between the years 2010 and 2020 were analyzed. The primary outcome was bleeding complications recorded during V-V ECLS. Multivariable logistic regression with backward stepwise elimination was used to develop the predictive model. The performance of the model was tested by discriminative ability and calibration with receiver operating characteristic curves and visual inspection of the calibration plot.

RESULTS

In total, 18 658 adult patients were included, of which 3 933 (21.1%) developed bleeding complications. The prediction model showed a prediction of bleeding complications with an AUC of 0.63. Pre-ECLS arrest, surgical cannulation, lactate, pO₂ , HCO₃ , ventilation rate, mean airway pressure, pre-ECLS cardiopulmonary bypass or renal replacement therapy, pre-ECLS surgical interventions, and different types of diagnosis were included in the prediction model.

CONCLUSIONS

The model is based on the largest cohort of V-V ECLS patients and reveals the most favorable predictive value addressing bleeding events given the predictors that are feasible and when compared to the current literature. This model will help identify patients at risk of bleeding complications, and decision making in terms of anticoagulation and hemostatic management.

Nonhematologic and Hematologic Factors in Spontaneous Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage is defined as nontraumatic bleeding into the brain without vascular malformations or presence of tumor. It occurs in about a third of all strokes and has a high mortality and morbidity. Risk factors that determine the outcome are incompletely understood. Known factors include older age, male gender, Asian ethnicity, hypertension, and comorbidity such as inherited or acquired bleeding diathesis and use of antithrombotic drugs. Likewise, the clinical characteristics of the hematoma such as location and volume of the hematoma and other imaging features are also important. Hematoma extension or expansion is a complication with an unfavorable outcome. Recognition of risk factors for hematoma expansion and measures to prevent it, such as blood pressure lowering, will improve the outcome. Enhanced diagnostic methods, especially in imaging techniques developed over the past decade, have not only led to a better understanding of the pathophysiology of spontaneous intracerebral hemorrhage but also of the factors that influence hematoma expansion. An improved knowledge is essential to better management, minimizing hematoma expansion and leading to a healthier outcome.

Neurologic Complications in Adult Post-cardiotomy Cardiogenic Shock Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Cohort Study

Background: This study aims to describe the prevalence of neurologic complications and hospital outcome in adult post-cardiotomy cardiogenic shock (PCS) patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support and factors associated with such adverse events.

Methods: Four hundred and fifteen adult patients underwent cardiac surgery and received V-A ECMO for more than 24 h because of PCS. Patients were divided into two groups: those who developed a neurological complication and those who did not (control group). Multivariable logistic regression was performed to identify factors independently associated with neurologic complications.

Results: Neurologic complications occurred in 87 patients (21.0%), including cerebral infarction in 33 patients (8.0%), brain death in 30 patients (7.2%), seizures in 14 patients (3.4%), and intracranial hemorrhage in 11 (2.7%) patients. In-hospital mortality in patients with neurologic complications was 90.8%, compared to 52.1% in control patients (p < 0.001). In a multivariable model, the lowest systolic blood pressure (SBP) level pre-ECMO (OR, 0.89; 95% CI: 0.86–0.93) and aortic surgery combined with coronary artery bypass grafting (OR, 9.22; 95% CI: 2.10–40.55) were associated with overall neurologic complications. Age (OR, 1.06; 95% CI: 1.01–1.12) and lowest SBP (OR, 0.81; 95% CI: 0.76–0.87) were correlative factors of brain death. Coagulation disorders (OR, 9.75; 95% CI: 1.83–51.89) and atrial fibrillation (OR, 12.19; 95% CI: 1.22–121.61) were shown to be associated independently with intracranial hemorrhage, whereas atrial fibrillation (OR, 8.15; 95% CI: 1.31–50.62) was also associated with cerebral infarction.

Conclusions: Neurologic complications in adult PCS patients undergoing V-A ECMO support are frequent and associated with higher in-hospital mortality. Identified risk factors of neurologic complications might help to improve ECMO management and might reduce their occurrence.

Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support

BACKGROUND

Temporary mechanical circulatory support (tMCS) devices are used for patients with severe cardiac or respiratory failure; however, these patients are at high risk for clotting and bleeding. The best method to monitor heparin in these patients has not been established.

OBJECTIVE

To determine the risks for bleeding and clotting while monitoring heparin with either anti-Xa or activated clotting time (ACT) in tMCS patients.

METHODS

A retrospective cohort study was conducted on tMCS patients who received heparin adjusted according to an anti-Xa or ACT protocol. The primary outcome was incidence of major bleeding. Pertinent secondary outcomes were individual components of the primary outcome, clotting events, and time to therapeutic range.

RESULTS

There were 103 patients included in the study: 53 in the ACT group and 50 in the anti-Xa group. Overall, there were 30 (56.6%) patients with major bleeding in the ACT group, compared with 16 (32%) patients in the anti-Xa group (P = 0.017). An anti-Xa-based protocol was associated with a decreased hazard of major bleeding (hazard ratio = 0.388 [0.215-0.701]; P = 0.002) in the univariate analysis. In the multivariable analysis, an anti-Xa protocol remained associated with a significantly lower hazard of bleeding. Findings were similar when broken down into more discrete subgroups of the entire cohort, extracorporeal membrane oxygenation life support (ECMO), and non-ECMO groups.

CONCLUSION AND RELEVANCE

Anti-Xa monitoring was associated with a lower hazard of bleeding during tMCS compared to an ACT-based protocol. Further studies should evaluate if anti-Xa monitoring should be preferentially used in tMCS.

Texture analysis based on U-Net neural network for intracranial hemorrhage identification predicts early enlargement

BACKGROUND AND OBJECTIVE

Early hemorrhage enlargement in hypertensive cerebral hemorrhage indicates a poor prognosis. This study aims to predict the early enlargement of cerebral hemorrhage through the intelligent texture analysis of cerebral hemorrhage after segmentation.

METHODS

A total of 54 patients with hypertensive intracerebral hemorrhage were selected and divided into enlarged hematoma (enlarged group) and non-enlarged hematoma (negative group). The U-Net Neural network model and contour recognition were used to extract the brain parenchymal region, and Mazda texture analysis software was used to extract regional features. The texture features were reduced by Fisher coefficient (Fisher), classification error probability combined average correlation coefficients (POE + ACC), and mutual information (MI) to select the best feature parameters. B11 module was used to analyze the selected features. The misclassified rate of feature parameters screened by different dimensionality reduction methods was calculated.

RESULTS

The neural network based on U-Net can accurately identify the lesion of cerebral hemorrhage. Among the 54 patients, 18 were in the enlarged group and 36 in the negative group. The parameters of gray level co-occurrence matrix and gray level run length matrix can be used to predict the enlargement of intracerebral hemorrhage. Among the features screened by Fisher, POE + ACC and MI, the texture features of MI showed the lowest misclassified rate, which was 0.

CONCLUSION

The texture analysis based on U-Net neural network is helpful to predict the early expansion of hypertensive cerebral hemorrhage, and the parameters of gray level co-occurrence matrix and gray level run length matrix under MI dimensionality reduction have the most excellent predictive value.

Evaluation of Anti-Activated Factor X Activity and Activated Partial Thromboplastin Time Relations and Their Association with Bleeding and Thrombosis during Veno-Arterial ECMO Support: A Retrospective Study

BACKGROUND

We aimed to investigate the relationship between anti-activated Factor X (anti-FXa) and activated Partial Thromboplastin Time (aPTT), and its modulation by other haemostasis co-variables during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We further investigated their association with serious bleeding and thrombotic complications.

METHODS

This retrospective single-center study included 265 adults supported by VA-ECMO for refractory cardiogenic shock from January 2015 to June 2019. The concordance of anti-FXa and aPTT and their correlations were assessed in 1699 paired samples. Their independent associations with serious bleeding or thrombotic complications were also analysed in multivariate analysis.

RESULTS

The concordance rate of aPTT with anti-FXa values was 50.7%, with 39.3% subtherapeutic aPTT values. However, anti-FXa and aPTT remained associated (β = 0.43 (95% CI 0.4-0.45) 10^-2 IU/mL, p < 0.001), with a significant modulation by several biological co-variables. There was no association between anti-FXa nor aPTT values with serious bleeding or with thrombotic complications.

CONCLUSION

During VA-ECMO, although anti-FXa and aPTT were significantly associated, their values were highly discordant with marked sub-therapeutic aPTT values. These results should favour the use of anti-FXa. The effect of biological co-variables and the failure of anti-FXa and aPTT to predict bleeding and thrombotic complications underline the complexity of VA-ECMO-related coagulopathy.

Brain Injury in Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach

Extracorporeal membrane oxygenation (ECMO) represents an established technique to provide temporary cardiac and/or pulmonary support. ECMO, in veno-venous, veno-arterial or in extracorporeal carbon dioxide removal modality, is associated with a high rate of brain injuries. These complications have been reported in 7 to 15% of adults and 20% of neonates, and are associated with poor survival. Thromboembolic events, loss of cerebral autoregulation, alteration of the blood-brain barrier, and hemorrhage related to anticoagulation represent the main causes of severe brain injury during ECMO. The most frequent forms of acute neurological injuries in ECMO patients are intracranial hemorrhage (2-21%), ischemic stroke (2-10%), seizures (2-6%), and hypoxic-ischemic brain injury; brain death may also occur in this population. Other frequent complications are infarction (1-8%) and cerebral edema (2-10%), as well as neuropsychological and psychiatric sequelae, including posttraumatic stress disorder.

Anti-Xa activity and hemorrhagic events under extracorporeal membrane oxygenation (ECMO): a multicenter cohort study

BACKGROUND

Hemorrhagic events remain a major concern in patients under extracorporeal membrane oxygenation (ECMO) support. We tested the association between anticoagulation levels and hemorrhagic events under ECMO using anti-Xa activity monitoring.

METHODS

We performed a retrospective multicenter cohort study in three ECMO centers. All adult patients treated with veno-venous (VV)- or veno-arterial (VA)-ECMO in 6 intensive care units between September 2017 and August 2019 were included. Anti-Xa activities were collected until a hemorrhagic event in the bleeding group and for the duration of ECMO in the non-bleeding group. All dosages were averaged to obtain means of anti-Xa activity for each patient, and patients were compared according to the occurrence or not of bleeding.

RESULTS

Among 367 patients assessed for eligibility, 121 were included. Thirty-five (29%) presented a hemorrhagic complication. In univariate analysis, anti-Xa activities were significantly higher in the bleeding group than in the non-bleeding group, both for the mean anti-Xa activity (0.38 [0.29-0.67] vs 0.33 [0.22-0.42] IU/mL; p = 0.01) and the maximal anti-Xa activity (0.83 [0.47-1.46] vs 0.66 [0.36-0.91] IU/mL; p = 0.05). In the Cox proportional hazard model, mean anti-Xa activity was associated with bleeding (p = 0.0001). By Kaplan-Meier analysis with the cutoff value at 0.46 IU/mL obtained by ROC curve analysis, the probability of survival under ECMO without bleeding was significantly lower when mean anti-Xa was > 0.46 IU/mL (p = 0.0006).

CONCLUSION

In critically ill patients under ECMO, mean anti-Xa activity was an independent risk factor for hemorrhagic complications. Anticoagulation targets could be revised downward in both VV- and VA-ECMO.

Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review

Purpose

Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists.

Recent findings

The most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death. These result from events prior to initiation of ECMO, failure of ECMO to provide adequate oxygen delivery, and/or complications that occur during ECMO. ECMO survivors also experience neurological and psychological sequelae similar to other survivors of critical illness.

Summary

Since many of the risk factors for neurologic injury cannot be easily mitigated, early diagnosis and intervention are crucial to limit morbidity and mortality from neurologic injury during ECMO.

Observational cohort study of neurological involvement among patients with SARS-CoV-2 infection

BACKGROUND

A growing number of reports suggest that infection with SARS-CoV-2 often leads to neurological involvement; however, data on the incidence and severity are limited to mainly case reports and retrospective studies.

METHODS

This prospective, cross-sectional study of 102 SARS-CoV-2 PCR positive patients investigated the frequency, type, severity and risk factors as well as underlying pathophysiological mechanisms of neurological involvement (NIV) in COVID-19 patients.

RESULTS

Across the cohort, 59.8% of patients had NIV. Unspecific NIV was suffered by 24.5%, mainly general weakness and cognitive decline or delirium. Mild NIV was found in 9.8%; most commonly, impaired taste or smell. Severe NIV was present in 23.5%; half of these suffered cerebral ischaemia. Incidence of NIV increased with respiratory symptoms of COVID-19. Mortality was higher with increasing NIV severity. Notably, 83.3% with severe NIV had a pre-existing neurological co-morbidity. All cerebrospinal fluid (CSF) samples were negative for SARS-CoV-2 RNA, and SARS-CoV-2 antibody quotient did not suggest intrathecal antibody synthesis. Of the patients with severe NIV, 50% had blood-brain barrier (BBB) disruption and showed a trend of elevated interleukin levels in CSF. Antibodies against neuronal and glial epitopes were detected in 35% of the patients tested.

CONCLUSION

Cerebrovascular events were the most frequent severe NIV and severe NIV was associated with high mortality. Incidence of NIV increased with respiratory symptoms and NIV and pre-existing neurological morbidities were independent risk factors for fatality. Inflammatory involvement due to BBB disruption and cytokine release drives NIV, rather than direct viral invasion. These findings might help physicians define a further patient group requiring particular attention during the pandemic.

Heparin-free adventitia pulmonary oxygenation in the treatment of trauma complicated with severe pulmonary infection: a case report

The application of Venovenous (VV) extracorporeal membrane oxygenation (ECMO) in trauma and patients with severe bleeding tendency has been controversial. However, VV ECMO without anticoagulation contributes to reducing the risk of bleeding during ECMO maintenance. VV ECMO serves critical roles in therapy of patients with severe pulmonary infection and failure in conventional therapy. The common peripheral catheterization approach for VV ECMO is femoral vein-internal jugular vein catheterization, and bilateral femoral vein catheterization can also achieve the purpose of respiratory support for patients with limited cervical catheterization. In this case report, we described a patient with post-traumatic cervical spinal cord injury and severe pulmonary infection who was successfully treated with heparin-free intravenous ECMO.

Clinical management and outcome of adult patients with extracorporeal life support device-associated intracerebral hemorrhage-a neurocritical perspective and grading

Intracerebral hemorrhage (ICH) is a devastating complication in patients treated with extracorporeal membrane oxygenation (ECMO) due to respiratory or cardiac issues. Neurosurgical evaluation and management of such cases has only insufficiently been studied. We conducted a retrospective, cohort study of adult patients treated with ECMO between January 2007 and January 2017 in a tertiary healthcare center. Demographics, clinical data, coagulation status, ICH characteristics, and treatment modalities were analyzed. The primary outcome parameter was defined as mortality caused by ICH during ECMO. 525 patients with ECMO therapy were eligible for analysis. An overall incidence for any type of intracranial bleeding of 12.3% was found. Small hemorrhages accounted for 6.4% and acute subdural and epidural hematoma for 1.2%. Twenty-four (4.6%) patients developed ICH, and 11 patients (46%) died due to the ICH. Mortality was significantly higher in patients with larger ICH volumes (86.8 ± 34.8 ml vs 9.9 ± 20.3 ml, p < 0.001), intraventricular hemorrhage (83% vs 8%, p = 0.01), and a fluid level inside the ICH (75% vs 31%, p = 0.04). All patients were classified according to the bleeding pattern on the initial CT scan into 3 types. Patients with type 1 bleeding were statistically more likely to die (p < 0.001). In 15 out of 24 patients (63%), correction of the coagulation status was possible within 12 h after ICH onset. Seven out of 9 patients (78%) without early coagulation correction died compared to 2 out of 15 patients (13%), in whom early coagulation correction was successful (p = 0.01). This is the first study evaluating the course and management of patients experiencing an ICH under ECMO therapy and establishing an ICH classification based on the bleeding patterns. Early correction of the coagulation is of paramount importance in the treatment of these patients.

Impact of therapeutic hypothermia on bleeding events in adult patients treated with extracorporeal life support peri-cardiac arrest

PURPOSE

Whether therapeutic hypothermia (TH) adds to the risk of bleeding in patients on extracorporeal life support (ECLS) peri-cardiac arrest remains unknown.

MATERIAL AND METHODS

Single center retrospective study on patients receiving veno-arterial ECLS peri-cardiac arrest ± TH at 32-34 °C (January 2009-December 2015).

PRIMARY OUTCOME

major bleeding (including intracerebral hemorrhage, ICH) < 72 h of cardiac arrest. Logistic regression and marginal structural models were used to analyze associations with major bleeding.

RESULTS

Of 66 patients receiving ECLS, 36 were treated with TH. Major bleeding occurred in 14 patients (39%) treated with ECLS+TH and in 17 patients (57%) with ECLS alone. ICH was reported in 3 (8%) and one patient (3%), respectively. There was no difference in mortality, but lung injury occurred more often in ECLS+TH. A platelet count <60 × 10⁹/L but not TH was associated with major bleeding (including ICH). The estimated causal risk ratio of TH on the occurrence of major bleeding (including ICH) at 72 h post cardiac arrest was 0.95 (95%CI 0.62-1.45).

CONCLUSIONS

Bleeding complications were common in our study. However, TH (32-34 °C) was not associated with an increased risk of major bleeding in patients on ECLS peri-cardiac arrest.

The Early Change in PaCO2 after Extracorporeal Membrane Oxygenation Initiation Is Associated with Neurological Complications

Rationale: Large decreases in Pa_CO2 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 Pa_CO2 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 Pa_CO2 in the first 24 hours was calculated as (24-h post-ECMO Pa_CO2 - pre-ECMO Pa_CO2)/pre-ECMO Pa_CO2. 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 Pa_CO2 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 Pa_CO2 (>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 Pa_CO2 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 Pa_CO2 in the first 24 hours after ECMO initiation is independently associated with an increased incidence of neurological complications.

Clinical and Imaging Characteristics in Patients with SARS-CoV-2 Infection and Acute Intracranial Hemorrhage

BACKGROUND AND PURPOSE

Intracranial hemorrhage has been observed in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19), but the clinical, imaging, and pathophysiological features of intracranial bleeding during COVID-19 infection remain poorly characterized. This study describes clinical and imaging characteristics of patients with COVID-19 infection who presented with intracranial bleeding in a European multicenter cohort.

METHODS

This is a multicenter retrospective, observational case series including 18 consecutive patients with COVID-19 infection and intracranial hemorrhage. Data were collected from February to May 2020 at five designated European special care centers for COVID-19. The diagnosis of COVID-19 was based on laboratory-confirmed diagnosis of SARS-CoV-2. Intracranial bleeding was diagnosed on computed tomography (CT) of the brain within one month of the date of COVID-19 diagnosis. The clinical, laboratory, radiologic, and pathologic findings, therapy and outcomes in COVID-19 patients presenting with intracranial bleeding were analyzed.

RESULTS

Eighteen patients had evidence of acute intracranial bleeding within 11 days (IQR 9-29) of admission. Six patients had parenchymal hemorrhage (33.3%), 11 had subarachnoid hemorrhage (SAH) (61.1%), and one patient had subdural hemorrhage (5.6%). Three patients presented with intraventricular hemorrhage (IVH) (16.7%).

CONCLUSION

This study represents the largest case series of patients with intracranial hemorrhage diagnosed with COVID-19 based on key European countries with geospatial hotspots of SARS-CoV-2. Isolated SAH along the convexity may be a predominant bleeding manifestation and may occur in a late temporal course of severe COVID-19.

Neurologically Devastating Intraparenchymal Hemorrhage in COVID-19 Patients on Extracorporeal Membrane Oxygenation: A Case Series

BACKGROUND AND IMPORTANCE

Extracorporeal membrane oxygenation (ECMO) represents a life-saving therapy in cases of refractory hypoxia and has been utilized in patients suffering from the most severe forms of coronavirus disease 2019 (COVID-19). A strikingly high mortality rate of 94% was described in early reports of patients with COVID-19 transitioned to ECMO. Later case reports and series demonstrating successful recovery from COVID-19 after ECMO have revived interest in this therapeutic modality, including the recent approval of ECMO for COVID-19 patients by the Food and Drug Administration (FDA). Here, we present the first reports of devastating intracranial hemorrhage as a complication of veno-venous (VV) ECMO in two COVID-19 patients.

CLINICAL PRESENTATION

We performed a retrospective analysis of 2 cases of devastating intracranial hemorrhage in patients on VV-ECMO for the treatment of COVID-19. Collected data included clinical history, laboratory results, treatment, and review of all available imaging. Both patients demonstrated activated partial thromboplastin times (aPTT) within an appropriate therapeutic range. No risk factors that clearly predicted likelihood of this complication were identified.

CONCLUSION

Understanding the complications of ECMO in this cohort and developing therapeutic algorithms to aid in optimal patient selection will be critical in the limited resource setting experienced as a result of global pandemic. We propose the use of head computed tomography (CT) to identify devastating neurological complications as early as possible, aiding in the resource allocation of ECMO machines to the most appropriately selected patients.

Intracranial hemorrhage on extracorporeal membrane oxygenation: an international survey

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.

Acquired bleeding disorders

Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.

Hematologic concerns in extracorporeal membrane oxygenation

This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.

Intracranial Hemorrhage in Hospitalized Patients: An Infrequently Studied Condition with High Mortality

BACKGROUND

Intracranial hemorrhage (ICH) may occur in patients admitted to the hospital for unrelated medical conditions, resulting in prolonged hospitalization and worse prognosis. We aim to assess the clinical presentation and outcomes of in-hospital ICH compared to patients with ICH presenting from the community.

METHODS

We conducted a retrospective analysis of all acute stroke alerts diagnosed with ICH in an urban academic hospital over a 4-year period. Demographics, clinical presentation, use of antithrombotic therapy, and presence of coagulopathy were recorded. ICH score and a sequential organ failure assessment score were calculated during the initial assessment. Initial head computed tomography was reviewed to determine ICH subtype, location, and volume of the hematoma. In-hospital mortality and discharge disposition were used as surrogate of clinical outcome.

RESULTS

From the 1965 stroke alert cases analyzed over the studied years, 145 (7.4%) were diagnosed with ICH. Overall, the mean age was 62.9 ± 13.9 and 53.7% were women. Thirty-two patients (22%) developed ICH in the inpatient setting and 113 (78%) presented from the community. Systolic blood pressure at presentation was lower in the in-hospital group (p < 0.01). Inpatients who developed ICH were more likely than community ICH patients to be on combination of antiplatelet agents (21.9% vs. 5.3%, p < 0.05) or therapeutic heparinoids (21.9% vs. 0.9%, p < 0.01). Also, In-hospital ICH patients had a higher rate of spontaneous or iatrogenic coagulopathy (65.6% vs. 10.6%, p < 0.01) and thrombocytopenia (31.3% vs. 1.8%, p < 0.01). Lobar hemorrhages were more prevalent in the in-hospital group (82.6% vs. 39.1%, p < 0.01) and the mean hematoma volume was higher (40.9 ± 43.1 mL vs. 24.1 ± 30.4 mL; p < 0.02). Median ICH score in the in-hospital group was not statistically different from the emergency department group: 2 (IQR: 0-3) versus 1 (IQR: 0-3). When comparing patients with in-hospital ICH and those from the community, the short-term mortality was higher in the former group (81% vs. 31%, p < 0.01). The incidence of withdrawal of life-sustaining therapies as a proximate mechanism of death was higher, but not statistically significant, in the in-hospital group (86% vs. 61%).

CONCLUSION

ICH is a critical complication in the inpatient setting, predominantly occurring in already ill patients with underlying spontaneous or iatrogenic coagulopathy. Large volume lobar intraparenchymal hemorrhage is a common radiographic finding. ICH is frequently a catastrophic event and powerfully weighs in with end-of-life discussion, resulting in high short-term mortality rate.

Clinical complications during veno-arterial extracorporeal membrane oxigenation in post-cardiotomy and non post-cardiotomy shock: still the achille's heel

Extracorporeal membrane oxygenation (ECMO) is life-saving for potentially reversible heart failure and respiratory injuries not responsive to conventional therapies. Technological innovations have produced over the years significant improvements in ECMO devices (pump, cannula design and oxygenator) and have allowed a better risk/benefit profile. Alongside with recognized advantages in the treatment of very sick patients, ECMO remains an invasive procedure for mechanical circulatory support (MCS) and it is associated with complications that strongly influence the prognosis. Current review was designed to provide a comprehensive outline on ECMO complications, analyzing risk factors and strategies of management, focusing on adult population undergoing veno-arterial ECMO (VA-ECMO) therapy.