Factors associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation

A risk score for predicting extracorporeal membrane oxygenation support before lung transplantation

Background

Extracorporeal membrane oxygenation (ECMO) has been increasingly used as life support for lung transplantation. However, there are no clinical risk models to predict whether ECMO support is required for lung transplantation. This study developed a simple risk score to predict the need for intraoperative ECMO in patients undergoing lung transplantation, identify high-risk patients who need ECMO support, and guide clinical interventions.

Methods

Patients, who underwent lung transplantation between January 1, 2016 and July 31, 2021, were systematically reviewed. All enrolled patients were divided in a ratio of 7:3 to establish the development and validation datasets. A risk score model was established using stepwise logistic regression and verified using bootstrapping and the split-sample method.

Results

A total of 248 patients who underwent lung transplants were enrolled. Multivariate analysis showed that the primary disease diagnosis, pulmonary artery systolic pressure, sex, surgical type, creatine kinase isoenzyme-MB, and pro-B-type natriuretic peptide were risk factors for intraoperative ECMO during lung transplantation. The risk score was established and calibrated according to these six factors, ranging from 0 to 41, with the associated prediction of intraoperative use of ECMO ranging from 1.5% to 99.7% (Hosmer-Lemeshow χ2=5.624; P=0.689). Good discrimination was verified by developing and validating the datasets (C-statistics =0.850 and 0.842, respectively). Based on the distribution of the scores, the three levels were classified as low-risk (0-10], moderate-risk (10-20], and high-risk (20-41].

Conclusions

This simple risk score model effectively predicts the need for intraoperative ECMO and stratifies high-risk patients who require ECMO support.

Prevalence of burnout among perfusionists in China: A nationwide survey

BACKGROUND

Burnout has gained increasing attention worldwide as a phenomenon that affects health care professionals. However, there is a lack of relevant research about its impact on practitioners in the field of cardiovascular perfusion in China. This study investigated the prevalence of and the factors associated with the burnout affecting perfusionists in mainland China.

METHODS

This national cross-sectional study included perfusionists from 31 provinces in mainland China. Participants were asked to complete a self-administered questionnaire, which included three parts: (1) demographic information, (2) work-related information, and (3) dissatisfaction with work and sources of pressure. The levels of burnout were calculated, and logistic regression was used to analyze the factors associated with burnout.

RESULTS

The questionnaire, created by the survey program "Questionnaire Star", was sent to 2211 perfusionists in mainland China. A final sample of 1813 perfusionists participated in the survey, with a participation rate of 82.0% (1813/2211). The prevalence of burnout and severe burnout was 86.0% (1559/1813, 95%CI: 84.3%-87.5%) and 13.3% (241/1813, 95%CI: 11.8%-15.0%), respectively. The logistic regression analysis revealed that age [20-29 years, odds ratio (OR) = 1; 30-39 years, OR = 2.009; 40-49 years, OR = 2.220], educational background (bachelor and below, OR = 1; postgraduate, OR = 1.472), and professional background (others, OR = 1; surgery, OR = 1.283; anesthesiology, OR = 2.004) were associated with burnout. We also found that age (20-29 years, OR = 1; 30-39 years, OR = 1.928), professional background (others, OR = 1; surgery, OR = 1.734; anesthesiology, OR = 2.257), annual cardiopulmonary bypass (CPB) case load in the most recent 3 years (< 50, OR = 1; 50-100, OR = 1.613; 100-300, OR = 1.702; ≥300, OR = 2.637), and income level [< 5000 (RMB/month), OR = 1; 5000-10,000, OR = 0.587; 10,000-20,000, OR = 0.366] were associated with severe burnout among perfusionists.

CONCLUSIONS

Cardiovascular perfusionists in mainland China experience high rates of burnout. Age, the professional background, annual CPB caseload in the most recent 3 years, and income level are independently associated with the burnout rates experienced by these health care professionals.

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation

OBJECTIVE

The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation.

METHODS

The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement.

RESULTS

The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively.

CONCLUSIONS

Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.

Experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: intraoperative indicators

Background/Aim: Intraoperative extracorporeal membrane oxygenation (ECMO) is being used with increasing frequency in lung transplantation. However, the factors associated with the use of intraoperative ECMO in lung transplant patients are not yet conclusive. In this study, we aimed to determine the effective factors for providing intraoperative ECMO support in patients undergoing lung transplantation. In addition, we aimed to evaluate the effect of ECMO support on morbidity and mortality. Methods: In this retrospective cohort study evaluating lung transplant patients, patients were divided into two groups: those who received intraoperative ECMO support and those who did not. Demographic data, the lung allocation score (LAS) and pulmonary arterial pressure (PAP), intraoperative data, postoperative complications, duration of mechanical ventilation (MV), length of stay (LOS) in intensive care and hospital, and mortality rates were recorded for both groups. Factors affecting entry to ECMO were analyzed by Multivariate Logistic Regression. Results: In this period, 51.9% of 87 patients who underwent lung transplantation required intraoperative ECMO. The mean age, LAS, and PAP of the ECMO group were significantly higher than the non-ECMO group (P = 0.043, P = 0.007, and P = 0.007, respectively). In multivariate analysis, it was found that lower MAP averages were a predictive parameter in intraoperative ECMO requirements (OR: 1.091; CI: 1.009-1.179; P = 0.028). The ECMO group’s mechanical ventilation time and hospital mortality were significantly higher than the other group (P = 0.004 and P = 0.025, respectively). Conclusion: Preoperative indicators of intraoperative ECMO support were determined as age, LAS, and PAP elevation. In addition, low MAP levels and high lactate levels were always determined as intraoperative indicators in lung transplantation until the transition to ECMO support.

Favorable, arduous or fatal postoperative pathway within 90 days of lung transplantation

INTRODUCTION

The maximum gain in quality of life after lung transplantation (LT) is expected between six months and one year after LT, as the occurrence of chronic lung allograft dysfunction may mask the beneficial effects beyond one year. Thus, the postoperative period could be the cornerstone of graft success. We sought to describe the factors present before postoperative admission to the ICU and associated with favorable, arduous or fatal pathway within 90 days of LT.

MATERIALS AND METHODS

We conducted a retrospective single-center study between January 2015 and December 2020. Using multinomial regression, we assessed the demographic, preoperative and intraoperative characteristics of patients associated with favorable (duration of postoperative mechanical ventilation < 3 days and alive at Day 90), arduous (duration of postoperative mechanical ventilation ≥ 3 days and alive at Day 90) or fatal (dead at Day 90) pathway within 90 days of LT.

RESULTS

A total of 269 lung transplant patients were analyzed. Maximum graft cold ischemic time ≥ 6 h and intraoperative blood transfusion ≥ 3 packed red blood cells were associated with arduous and fatal pathway at Day 90, whereas intraoperative ECMO was strongly associated with fatal pathway.

CONCLUSION

No patient demographics influenced the postoperative pathway at Day 90. Only extrinsic factors involving graft ischemia time, intraoperative transfusion, and intraoperative ECMO determined early postoperative pathway.

Intraoperative Circulatory Support in Lung Transplantation: Current Trend and Its Evidence

Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.

Case Report: Prolonged VV-ECMO (111 Days) Support in a Patient With Severe COVID-19

Venovenous extracorporeal membrane oxygenation (VV-ECMO) may be a lifesaving rescue therapy for patients with severe coronavirus disease 2019 (COVID-19). However, little is known regarding the efficacy of prolonged ECMO (duration longer than 14 days) in patients with COVID-19. In this case report, we report the successful use of prolonged VV-ECMO (111 days) in a 61-year-old man with severe COVID-19. Given the high mortality rate of severe COVID-19, this case provided evidence for use of prolonged VV-ECMO as supportive care in patients with severe COVID-19.

Extracorporeal membrane oxygenation and lung transplantation

The use of extracorporeal membrane oxygenation has had a positive impact on the outcomes after lung transplantation. Extracorporeal membrane oxygenation has a role in all phases of lung transplantation-preoperative, intraoperative, and postoperative periods. It serves as a bridge to transplantation in appropriate patients awaiting lung transplantation. Extracorporeal membrane oxygenation is used as a preferred method of cardiopulmonary support in some centres during implantation; and, after lung transplantation, it can be used to salvage the implanted lung in cases of severe primary graft dysfunction or as a planned extension of intraoperative extracorporeal membrane oxygenation onto the postoperative period. It has now gained acceptance as a mandatory tool in most lung transplant units. This article reviews the history of extracorporeal membrane oxygenation and lung transplantation, their subsequent development, and the current use of extracorporeal membrane oxygenation during lung transplantation. Our institutional practice and experience are described. The implications of the current global coronavirus disease pandemic on extracorporeal membrane oxygenation and lung transplantation are also briefly discussed.