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Kang JK, Darby Z, Bleck TP, Whitman GJR, Kim BS, Cho SM. Post-Cardiac Arrest Care in Adult Patients After Extracorporeal Cardiopulmonary Resuscitation. Crit Care Med 2024; 52:483-494. [PMID: 37921532 PMCID: PMC10922987 DOI: 10.1097/ccm.0000000000006102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients. DATA SOURCES A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted. STUDY SELECTION Selection includes original research, review articles, and guidelines. DATA EXTRACTION Information from relevant publications was reviewed, consolidated, and formulated into a narrative review. DATA SYNTHESIS We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/C o2 , and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes. CONCLUSIONS Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field.
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Affiliation(s)
- Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Zachary Darby
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Thomas P. Bleck
- Davee Department of Neurology, Northwestern University
Feinberg School of Medicine, Chicago IL 60611
| | - Glenn J. R. Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Bo Soo Kim
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns
Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Neurosciences Critical Care, Departments of
Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins
Hospital, Baltimore, MD
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2
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Mornese Pinna S, Sousa Casasnovas I, Olmedo M, Machado M, Juàrez Fernández M, Devesa-Cordero C, Galar A, Alvarez-Uria A, Fernández-Avilés F, García Carreño J, Martínez-Sellés M, De Rosa FG, Corcione S, Bouza E, Muñoz P, Valerio M. Nosocomial Infections in Adult Patients Supported by Extracorporeal Membrane Oxygenation in a Cardiac Intensive Care Unit. Microorganisms 2023; 11:microorganisms11041079. [PMID: 37110503 PMCID: PMC10143322 DOI: 10.3390/microorganisms11041079] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/07/2023] [Accepted: 04/16/2023] [Indexed: 04/29/2023] Open
Abstract
The use of venoarterial (VA) extracorporeal membrane oxygenation therapy (ECMO) in patients admitted to cardiac intensive care units (CICU) has increased. Data regarding infections in this population are scarce. In this retrospective study, we analyzed the risk factors, outcome, and predictors of in-hospital mortality due to nosocomial infections in patients with ECMO admitted to a single coronary intensive care unit between July 2013 and March 2019 treated with VA-ECMO for >48 h. From 69 patients treated with VA-ECMO >48 h, (median age 58 years), 29 (42.0%) patients developed 34 episodes of infections with an infection rate of 0.92/1000 ECMO days. The most frequent were ventilator-associated pneumonia (57.6%), tracheobronchitis (9.1%), bloodstream infections (9.1%), skin and soft tissue infections (9.1%), and cytomegalovirus reactivation (9.1%). In-hospital mortality was 47.8%, but no association with nosocomial infections was found (p = 0.75). The number of days on ECMO (OR 1.14, 95% CI 1.01-1.30, p = 0.029) and noninfectious complications were higher in the infected patients (OR: 3.8 95% CI = 1.05-14.1). A higher baseline creatinine value (OR: 8.2 95% CI = 1.12-60.2) and higher blood lactate level at 4 h after ECMO initiation (OR: 2.0 95% CI = 1.23-3.29) were significant and independent risk factors for mortality. Conclusions: Nosocomial infections in medical patients treated with VA-ECMO are very frequent, mostly Gram-negative respiratory infections. Preventive measures could play an important role for these patients.
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Affiliation(s)
- Simone Mornese Pinna
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
| | - Iago Sousa Casasnovas
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, 28007 Madrid, Spain
| | - María Olmedo
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
| | - Marina Machado
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
| | - Miriam Juàrez Fernández
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, 28007 Madrid, Spain
| | - Carolina Devesa-Cordero
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, 28007 Madrid, Spain
| | - Alicia Galar
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
| | - Ana Alvarez-Uria
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
| | - Francisco Fernández-Avilés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, 28007 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
| | - Jorge García Carreño
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, 28007 Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, 28007 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, A.O.U. Città della Salute e della Scienza di Torino, 10124 Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, A.O.U. Città della Salute e della Scienza di Torino, 10124 Turin, Italy
| | - Emilio Bouza
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Patricia Muñoz
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Maricela Valerio
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, 28009 Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
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3
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Ardito V, Sarucanian L, Rognoni C, Pieri M, Scandroglio AM, Tarricone R. Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses. J Cardiovasc Dev Dis 2023; 10:jcdd10040158. [PMID: 37103037 PMCID: PMC10142129 DOI: 10.3390/jcdd10040158] [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: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.
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Affiliation(s)
- Vittoria Ardito
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Lilit Sarucanian
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
- Department of Social and Political Science, Bocconi University, 20136 Milan, Italy
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4
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Ben-Hamouda N, Ltaief Z, Kirsch M, Novy J, Liaudet L, Oddo M, Rossetti AO. Neuroprognostication Under ECMO After Cardiac Arrest: Are Classical Tools Still Performant? Neurocrit Care 2022; 37:293-301. [PMID: 35534658 DOI: 10.1007/s12028-022-01516-0] [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: 11/02/2021] [Accepted: 03/25/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND According to international guidelines, neuroprognostication in comatose patients after cardiac arrest (CA) is performed using a multimodal approach. However, patients undergoing extracorporeal membrane oxygenation (ECMO) may have longer pharmacological sedation and show alteration in biological markers, potentially challenging prognostication. Here, we aimed to assess whether routinely used predictors of poor neurological outcome also exert an acceptable performance in patients undergoing ECMO after CA. METHODS This observational retrospective study of our registry includes consecutive comatose adults after CA. Patients deceased within 36 h and not undergoing prognostic tests were excluded. Veno-arterial ECMO was initiated in patients < 80 years old presenting a refractory CA, with a no flow < 5 min and a low flow ≤ 60 min on admission. Neuroprognostication test performance (including pupillary reflex, electroencephalogram, somatosensory-evoked potentials, neuron-specific enolase) toward mortality and poor functional outcome (Cerebral Performance Categories [CPC] score 3-5) was compared between patients undergoing ECMO and those without ECMO. RESULTS We analyzed 397 patients without ECMO and 50 undergoing ECMO. The median age was 65 (interquartile range 54-74), and 69.8% of patients were men. Most had a cardiac etiology (67.6%); 52% of the patients had a shockable rhythm, and the median time to return of an effective circulation was 20 (interquartile range 10-28) minutes. Compared with those without ECMO, patients receiving ECMO had worse functional outcome (74% with CPC scores 3-5 vs. 59%, p = 0.040) and a nonsignificant higher mortality (60% vs. 47%, p = 0.080). Apart from the neuron-specific enolase level (higher in patients with ECMO, p < 0.001), the presence of prognostic items (pupillary reflex, electroencephalogram background and reactivity, somatosensory-evoked potentials, and myoclonus) related to unfavorable outcome (CPC score 3-5) in both groups was similar, as was the prevalence of at least any two such items concomitantly. The specificity of each these variables toward poor outcome was between 92 and 100% in both groups, and of the combination of at least two items, it was 99.3% in patients without ECMO and 100% in those with ECMO. The predictive performance (receiver operating characteristic curve) of their combination toward poor outcome was 0.822 (patients without ECMO) and 0.681 (patients with ECMO) (p = 0.134). CONCLUSIONS Pending a prospective assessment on a larger cohort, in comatose patients after CA, the performance of prognostic factors seems comparable in patients with ECMO and those without ECMO. In particular, the combination of at least two poor outcome criteria appears valid across these two groups.
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Affiliation(s)
- Nawfel Ben-Hamouda
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland. .,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Zied Ltaief
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Cardiovascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Jan Novy
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Andrea O Rossetti
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
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5
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Predictors of Mortality in Patients Treated with Veno-Arterial ECMO for Cardiogenic Shock Complicating Acute Myocardial Infarction: a Systematic Review and Meta-Analysis. J Cardiovasc Transl Res 2021; 15:227-238. [PMID: 34081255 DOI: 10.1007/s12265-021-10140-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mortality for patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains high. This meta-analysis aims to identify factors that predict higher risk of mortality after VA-ECMO for AMI. METHODS We meta-analyzed mortality after VA-ECMO for CS complicating AMI and the effect of factors from systematically selected studies published after 2009. RESULTS 72 studies (10,276 patients) were included with a pooled mortality estimate of 58 %. With high confidence in estimates, failure to achieve TIMI III flow and left main culprit were identified as factors associated with higher mortality. With low-moderate confidence, older age, high BMI, renal dysfunction, increasing lactate, prothrombin activity < 50%, VA-ECMO implantation after revascularization, and non-shockable ventricular arrythmias were identified as factors associated with mortality. CONCLUSION These results provide clinicians with a framework for selecting patients for VA-ECMO for CS complicating AMI.
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6
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Vascular Complications of Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Regression Analysis. Crit Care Med 2021; 48:e1269-e1277. [PMID: 33105148 DOI: 10.1097/ccm.0000000000004688] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Perform a systematic review and meta-analysis of vascular complications associated with extracorporeal membrane oxygenation and identify prognostic and predictive factors. DATA SOURCES Systematic search for publications reporting vascular complications on extracorporeal membrane oxygenation, published from 1972 to January 31, 2020, was conducted via PubMed, Scopus, and Embase. STUDY SELECTION Of 4,076 references screened, 47 studies with 6,583 patients were included in final analyses. Studies with fewer than 10 patients were excluded. DATA EXTRACTION Relevant data, including demographics, comorbidities, extracorporeal membrane oxygenation and cannulation characteristics, occurrence rates of early and late vascular complications, patient outcomes, and use of distal perfusion cannula, were extracted from selected articles into an excel sheet specifically designed for this review. DATA SYNTHESIS Random-effects meta-analyses and meta-regression analyses were undertaken. Overall pooled estimate of vascular complications in our meta-analysis was 29.5% (95% CI, 23.6-35.9%). Two-thousand three-hundred forty-seven vascular complications in 6,124 venoarterial extracorporeal membrane oxygenation patients compared with 95 in 459 venovenous extracorporeal membrane oxygenation patients (odds ratio, 2.35; 95% CI, 1.87-2.96; p < 0.0001) were analyzed. Successful weaning off extracorporeal membrane oxygenation occurred in 60.6% of pooled patients; 46.2% were eventually discharged. Pooled prevalences of vascular complications like significant bleeding, limb ischemia, and cannula site bleeding were 15.4% (95% CI, 8.6-23.7%), 12.6% (95% CI, 10.0-15.5%), and 12.6% (95% CI, 9.6-18.5%), respectively. Meta-analysis showed that the use of distal perfusion cannula was associated with lower odds of limb ischemia (odds ratio, 1.93; 95% CI, 1.17-2.47; p = 0.03) Meta-regression showed that male sex, smoking, advanced age, and comorbidities contributed to higher in-hospital mortality, while distal perfusion cannula was protective. CONCLUSIONS Nearly a third of patients on extracorporeal membrane oxygenation develop vascular complications; elderly males with comorbidities appear vulnerable. The use of distal perfusion cannulas caused significant reduction in limb ischemia and mortality.
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7
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Wang H, Chen C, Li B, Cheng Z, Wang Z, Huang X, Xian M, Zhuang J, Chen J, Zhou C, Deng Y. Nomogram to predict survival outcome of patients with veno-arterial extracorporeal membrane oxygenation after refractory cardiogenic shock. Postgrad Med 2021; 134:37-46. [PMID: 33945393 DOI: 10.1080/00325481.2021.1925562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: This study aims to develop a nomogram model to predict the survival of refractory cardiogenic shock (RCS) patients that received veno-arterial extracorporeal membrane oxygenation (VA-ECMO).Methods: A total of 235 and 209 RCS patients were supported with VA-ECMO from January 2018 to December 2019 in Guangdong Provincial People's Hospital, and from January 2020 to December 2020 in four third-grade and class-A hospitals were a development cohort (DC) and validation cohort (VC), respectively. Finally, 137 and 98 patients were included in the DC and VC. Multivariate logistic regression analysis was used to identify variables, and only these independent risk factors were used to establish the nomogram model. The receiver operating characteristic curve (ROC), calibration plot, decision curve, and clinical impact curves were used to evaluate the nomogram's discriminative ability, predictive accuracy, and clinical application value.Results: Pre-ECMO cardiogenic arrest (pre-ECA), lactate (Lac), inotropic score (IS), and modified nutrition risk in the critically ill score (mNUTRIC score) were incorporated into the nomogram. This showed good discrimination in the DC, with an area under ROC (AUROC) and a 95% confidence interval (CI) of 0.959 (0.911-0.986). The AUROC (95% CI) of the VC was 0.928 (0.858-0.971). The calibration plots of the DC and VC presented good calibration results. The decision curve and clinical impact curve of the nomogram provided improved benefits for RCS patients.Conclusions: This study established a prediction nomogram composed of pre-ECA, Lac, IS, and mNUTRIC scores that could help clinicians to predict the survival probability at hospital discharge precisely and rapidly for RCS patients that received VA-ECMO.
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Affiliation(s)
- Huifang Wang
- The Second School of Clinical Medicine, Southern Medical University, Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Chunbo Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Binfei Li
- Department of Anesthesiology, Zhongshan People's Hospital, Zhongshan, Guangdong, China
| | - Zhou Cheng
- Department of Anesthesiology, Zhongshan People's Hospital, Zhongshan, Guangdong, China
| | - Zeng Wang
- Department of Critical Care Medicine, Maoming People's Hospital, Maoming, Guangdong, China
| | - Xiangwei Huang
- Department of Critical Care Medicine, Maoming People's Hospital, Maoming, Guangdong, China
| | - Minghai Xian
- Department of Extracorporeal Circulation, Gaozhou People's Hospital, Gaozhou, Guangdong, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Chengbin Zhou
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yiyu Deng
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, The Second School of Clinical Medicine, Southern Medical University, Gaozhou, Guangdong, China
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8
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Caniato F, Andrei V, Bernardo P, Agostini C, Cappelli F, Stefano PL, Olivotto I, Pieroni M, Bolognese L, Di Mario C. Cardiogenic Shock in Obstructive Hypertrophic Cardiomyopathy Plus Apical Ballooning: Management With VA-ECMO and Myectomy. JACC Case Rep 2021; 3:433-437. [PMID: 34317552 PMCID: PMC8311032 DOI: 10.1016/j.jaccas.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 04/28/2023]
Abstract
A patient with known obstructive hypertrophic cardiomyopathy developed worsening left ventricular outflow tract obstruction, severe mitral regurgitation, and apical ballooning leading to cardiogenic shock, a combination in which treatment of each component could worsen the others. Emergency veno-arterial extracorporeal membrane oxygenation, levosimendan, and noradrenaline transiently restored adequate systemic perfusion and gas exchange. Surgical myectomy offered a more definitive solution. (Level of Difficulty: Intermediate.).
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Key Words
- AF, atrial fibrillation
- CS, cardiogenic shock
- EF, ejection fraction
- HCM, hypertrophic cardiomyopathy
- HF, heart failure
- LVOTO, left ventricular outflow tract obstruction
- MR, mitral regurgitation
- SAM, systolic anterior movement
- TTE, transthoracic echocardiography
- VA-ECMO, veno-arterial extracorporeal membrane oxygenation
- acute heart failure
- cardiac assist devices
- cardiomyopathy
- inotropes
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Affiliation(s)
- Flavia Caniato
- Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
- Address for correspondence: Dr. Flavia Caniato, Cardiac Intensive Care Unit, Careggi University Hospital, Largo G. Alessandro Brambilla, 3, 50134 Florence, Italy.
| | - Valentina Andrei
- Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Pasquale Bernardo
- Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Cecilia Agostini
- Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | | | - Carlo Di Mario
- Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
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9
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Mitra S, Ling RR, Tan CS, Shekar K, MacLaren G, Ramanathan K. Concurrent Use of Renal Replacement Therapy during Extracorporeal Membrane Oxygenation Support: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10020241. [PMID: 33440805 PMCID: PMC7827381 DOI: 10.3390/jcm10020241] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Patients supported with extracorporeal membrane oxygenation (ECMO) often receive renal replacement therapy (RRT). We conducted this systematic review and meta-analysis (between January 2000 and September 2020) to assess outcomes in patients who received RRT on ECMO. Random-effects meta-analyses were performed using R 3.6.1 and certainty of evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The primary outcome was pooled mortality. The duration of ECMO support and ICU/hospital lengths of stay were also investigated. Meta-regression analyses identified factors associated with mortality. A total of 5896 adult patients (from 24 observational studies and 1 randomised controlled trial) were included in this review. Overall pooled mortality due to concurrent use of RRT while on ECMO from observational studies was 63.0% (95% CI: 56.0–69.6%). In patients receiving RRT, mortality decreased by 20% in the last five years; the mean duration of ECMO support and ICU and hospital lengths of stay were 9.33 days (95% CI: 7.74–10.92), 15.76 days (95% CI: 12.83–18.69) and 28.47 days (95% CI: 22.13–34.81), respectively, with an 81% increased risk of death (RR: 1.81, 95% CI: 1.56–2.08, p < 0.001). RRT on ECMO was associated with higher mortality rates and a longer ICU/hospital stay compared to those without RRT. Future research should focus on minimizing renal dysfunction in ECMO patients and define the optimal timing of RRT initiation.
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Affiliation(s)
- Saikat Mitra
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119228, Singapore; (G.M.); (K.R.)
- Correspondence:
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119077, Singapore;
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD 4032, Australia;
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119228, Singapore; (G.M.); (K.R.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119228, Singapore; (G.M.); (K.R.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
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Miroz JP, Ben-Hamouda N, Bernini A, Romagnosi F, Bongiovanni F, Roumy A, Kirsch M, Liaudet L, Eckert P, Oddo M. Neurological Pupil index for Early Prognostication After Venoarterial Extracorporeal Membrane Oxygenation. Chest 2019; 157:1167-1174. [PMID: 31870911 DOI: 10.1016/j.chest.2019.11.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/19/2019] [Accepted: 11/30/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation therapy (VA-ECMO) after refractory cardiogenic shock or cardiac arrest has significant morbidity and mortality. Early outcome prediction is crucial in this setting, but data on neuroprognostication are limited. We examined the prognostic value of clinical neurologic examination, using an automated device for the quantitative measurement of pupillary light reactivity. METHODS An observational cohort of sedated, mechanically ventilated VA-ECMO patients was analyzed during the early phase after ECMO insertion (first 72 h). Using the NPi-200 automated infrared pupillometer, pupillary light reactivity was assessed repeatedly (every 12 h) by calculating the Neurological Pupil index (NPi). Trends of NPi over time were correlated to 90-day mortality, and the prognostic performance of the NPi, alone and in combination with the 12-h PREDICT VA-ECMO score, was evaluated. RESULTS One hundred consecutive patients were studied (51 with refractory cardiogenic shock and 49 with refractory cardiac arrest; 12-h PREDICT VA-ECMO, 40%; observed 90-day survival, 43%). Nonsurvivors (n = 57) had significantly lower NPi than did survivors at all time points (all P < .01). Abnormal NPi (< 3, at any time from 24 to 72 h) was 100% specific for 90-day mortality, with 0% false positives. Adding the 12-h PREDICT VA-ECMO score to the NPi provided the best prognostic performance (specificity, 100% [95% CI, 92%-100%]; sensitivity, 60% [95% CI, 46%-72%]; area under the receiver operating characteristic curve, 0.82). CONCLUSIONS Quantitative NPi alone had excellent ability to predict a poor outcome from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased the sensitivity of outcome prediction, while maintaining 100% specificity.
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Affiliation(s)
- John-Paul Miroz
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland; Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Adriano Bernini
- Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Federico Romagnosi
- Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Filippo Bongiovanni
- Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Aurélien Roumy
- Department of Heart and Vessels, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Department of Heart and Vessels, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Philippe Eckert
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland
| | - Mauro Oddo
- Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland; Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland.
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