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Pladet LCA, Barten JMM, Vernooij LM, Kraemer CVE, Bunge JJH, Scholten E, Montenij LJ, Kuijpers M, Donker DW, Cremer OL, Meuwese CL. Prognostic models for mortality risk in patients requiring ECMO. Intensive Care Med 2023; 49:131-141. [PMID: 36600027 PMCID: PMC9944134 DOI: 10.1007/s00134-022-06947-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To provide an overview and evaluate the performance of mortality prediction models for patients requiring extracorporeal membrane oxygenation (ECMO) support for refractory cardiocirculatory or respiratory failure. METHODS A systematic literature search was undertaken to identify studies developing and/or validating multivariable prediction models for all-cause mortality in adults requiring or receiving veno-arterial (V-A) or veno-venous (V-V) ECMO. Estimates of model performance (observed versus expected (O:E) ratio and c-statistic) were summarized using random effects models and sources of heterogeneity were explored by means of meta-regression. Risk of bias was assessed using the Prediction model Risk Of BiAS Tool (PROBAST). RESULTS Among 4905 articles screened, 96 studies described a total of 58 models and 225 external validations. Out of all 58 models which were specifically developed for ECMO patients, 14 (24%) were ever externally validated. Discriminatory ability of frequently validated models developed for ECMO patients (i.e., SAVE and RESP score) was moderate on average (pooled c-statistics between 0.66 and 0.70), and comparable to general intensive care population-based models (pooled c-statistics varying between 0.66 and 0.69 for the Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score). Nearly all models tended to underestimate mortality with a pooled O:E > 1. There was a wide variability in reported performance measures of external validations, reflecting a large between-study heterogeneity. Only 1 of the 58 models met the generally accepted Prediction model Risk Of BiAS Tool criteria of good quality. Importantly, all predicted outcomes were conditional on the fact that ECMO support had already been initiated, thereby reducing their applicability for patient selection in clinical practice. CONCLUSIONS A large number of mortality prediction models have been developed for ECMO patients, yet only a minority has been externally validated. Furthermore, we observed only moderate predictive performance, large heterogeneity between-study populations and model performance, and poor methodological quality overall. Most importantly, current models are unsuitable to provide decision support for selecting individuals in whom initiation of ECMO would be most beneficial, as all models were developed in ECMO patients only and the decision to start ECMO had, therefore, already been made.
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Affiliation(s)
- Lara C A Pladet
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jaimie M M Barten
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J H Bunge
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care Medicine, Sint Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Leon J Montenij
- Department of Intensive Care Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Marijn Kuijpers
- Department of Intensive Care Medicine, Isala Hospital Zwolle, Zwolle, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Raasveld SJ, Volleman C, Combes A, Broman LM, Taccone FS, Peters E, Ten Berg S, van den Brom CE, Thiele H, Lorusso R, Henriques JPS, Vlaar APJ. Knowledge gaps and research priorities in adult veno-arterial extracorporeal membrane oxygenation: a scoping review. Intensive Care Med Exp 2022; 10:50. [PMID: 36424482 PMCID: PMC9691798 DOI: 10.1186/s40635-022-00478-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This scoping review aims to identify and describe knowledge gaps and research priorities in veno-arterial extracorporeal membrane oxygenation (VA-ECMO). METHODS An expert panel was recruited consisting of eight international experts from different backgrounds. First, a list of priority topics was made. Second, the panel developed structured questions using population, intervention, comparison and outcomes (PICO) format. All PICOs were scored and prioritized. For every selected PICO, a structured literature search was performed. RESULTS After an initial list of 49 topics, eight were scored as high-priority. For most of these selected topics, current literature is limited to observational studies, mainly consisting of retrospective cohorts. Only for ECPR and anticoagulation, randomized controlled trials (RCTs) have been performed or are ongoing. Per topic, a summary of the literature is stated including recommendations for further research. CONCLUSIONS This scoping review identifies and presents an overview of knowledge gaps and research priorities in VA-ECMO. Current literature is mostly limited to observational studies, although with increasing attention for this patient population, more RCTs are finishing or ongoing. Translational research, from preclinical trials to high-quality or randomized controlled trials, is important to improve the standard practices in this critically ill patient population. Take-home message This scoping review identifies and presents an overview of research gaps and priorities in VA-ECMO. Translational research, from preclinical trials to high-quality or randomized controlled trials, is important to improve the standard practices in this critically ill patient population.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Carolien Volleman
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS1166-ICAN, Paris, France
- Service de Médicine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Hospital Pitié-Salpêtrière, Paris, France
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Elma Peters
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne Ten Berg
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science GmbH, Leipzig, Germany
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - José P S Henriques
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands.
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Martucci G, Arcadipane A, Tuzzolino F, Occhipinti G, Panarello G, Carcione C, Bertani A, Conaldi PG, Miceli V. Circulating miRNAs as Promising Biomarkers to Evaluate ECMO Treatment Responses in ARDS Patients. MEMBRANES 2021; 11:membranes11080551. [PMID: 34436314 PMCID: PMC8398026 DOI: 10.3390/membranes11080551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/14/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) has increased in the last decade. However, mortality remains high, and the complexity of ECMO requires individualized treatment. There are some biomarkers to monitor progression and predict clinical outcomes of ARDS. This project aims to advance the management of ARDS patients treated with ECMO by exploring miRNA expression in whole blood. The analysis was conducted on two groups with different length of ECMO: Group A (longer runs) and group B (shorter runs). We analyzed miRNAs before ECMO cannulation, and at 7 and 14 days of ECMO support. Our results showed that in the group B patients, 11 deregulated miRNAs were identified, and showed an opposite trend of expression compared to the group A patients. In silico analysis revealed that these 11 miRNAs were related to processes involved in the pathogenesis and evolution of ARDS. This scenario could represent homeostatic mechanisms by which, in ECMO responsive patients, pathways activated during ARDS progression are switched-off. Circulating miRNAs could represent promising biomarkers to monitor the evolution of ARDS under ECMO support. Further studies may shed light on this topic to improve a personalized approach in such a complex setting of patients.
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Affiliation(s)
- Gennaro Martucci
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | - Antonio Arcadipane
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | - Fabio Tuzzolino
- Research Department, IRCCS-ISMETT, 90127 Palermo, Italy; (F.T.); (P.G.C.)
| | - Giovanna Occhipinti
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | - Giovanna Panarello
- Anesthesia and Intensive Care Department, IRCCS-ISMETT, 90127 Palermo, Italy; (G.M.); (A.A.); (G.O.); (G.P.)
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, 90127 Palermo, Italy;
| | | | - Vitale Miceli
- Research Department, IRCCS-ISMETT, 90127 Palermo, Italy; (F.T.); (P.G.C.)
- Correspondence: ; Tel.: +39-091-219-2430
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Lee HH, Hong SJ, Ahn CM, Yang JH, Gwon HC, Kim JS, Kim BK, Ko YG, Choi D, Hong MK, Jang Y. Clinical Implications of Thrombocytopenia at Cardiogenic Shock Presentation: Data from a Multicenter Registry. Yonsei Med J 2020; 61:851-859. [PMID: 32975059 PMCID: PMC7515787 DOI: 10.3349/ymj.2020.61.10.851] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Thrombocytopenia (platelet count <150×10³/μL) is associated with poor outcomes in various critical illness settings. However, the prognostic value of platelet count in patients with cardiogenic shock (CS) remains unclear. MATERIALS AND METHODS We enrolled 1202 patients between January 2014 and December 2018 from a multicenter retrospective-prospective cohort registry of CS. Clinical characteristics and treatment outcomes were compared between the patients with and without thrombocytopenia. RESULTS At presentation with CS, 244 (20.3%) patients had thrombocytopenia. The patients with thrombocytopenia had lower blood pressure, hemoglobin level, and worse liver and renal functions compared to the patients without. During hospitalization, the patients with thrombocytopenia had more frequent gastrointestinal bleeding (10.5% vs. 3.8%, p=0.009), sepsis (8.3% vs. 2.6%, p=0.013), requirement of renal replacement therapy (36.5% vs. 18.9%, p<0.001), requirement of mechanical ventilation (65.2% vs. 54.4%, p=0.003), longer intensive care unit stay (8 days vs. 4 days, p<0.001), and thirty-day mortality (40.2% vs. 28.5%, p<0.001) compared to those without. In addition, the platelet count was an independent predictor of 30-day mortality (per 103/μL decrease; adjusted hazard ratio: 1.002, 95% confidence interval: 1.000-1.003, p=0.021). CONCLUSION Thrombocytopenia at CS presentation was associated with worse clinical findings, higher frequencies of complications, and longer stay at the intensive care unit. Also, thrombocytopenia was independently associated with increased 30-day mortality. (Clinical trial registration No. NCT02985008).
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Affiliation(s)
- Hyeok Hee Lee
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Jin Hong
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chul Min Ahn
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Sun Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong Ki Hong
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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