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Rajsic S, Breitkopf R, Bukumiric Z, Treml B. ECMO Support in Refractory Cardiogenic Shock: Risk Factors for Mortality. J Clin Med 2022; 11:jcm11226821. [PMID: 36431298 PMCID: PMC9698852 DOI: 10.3390/jcm11226821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a specialized temporary support for patients with refractory cardiogenic shock. The true value of this potentially lifesaving modality is still a subject of debate. Therefore, we aimed to investigate the overall in-hospital mortality and identify potential risk factors for mortality. METHODS We retrospectively analyzed the data of 453 patients supported with va-ECMO over a period of 14 years who were admitted to intensive care units of a tertiary university center in Austria. RESULTS We observed in-hospital mortality of 40% for patients with refractory cardiogenic shock. Hemorrhage, ECMO initiation on weekends, higher SAPS III score, and sepsis were identified as significant risk factors for mortality. Hemorrhage was the most common adverse event (46%), with major bleeding events dominating in deceased patients. Thromboembolic events occurred in 25% of patients, followed by sepsis (18%). CONCLUSIONS Although the rates of complications are substantial, a well-selected proportion of patients with refractory cardiogenic shock can be rescued from probable death. The reported risk factors could be used to increase the awareness of clinicians towards the development of new therapeutic concepts that may reduce their incidence.
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Affiliation(s)
- Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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ECMO Predictors of Mortality: A 10-Year Referral Centre Experience. J Clin Med 2022; 11:jcm11051224. [PMID: 35268314 PMCID: PMC8911127 DOI: 10.3390/jcm11051224] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/20/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Extracorporeal membrane oxygenation (ECMO) is a specialised life support modality for patients with refractory cardiac or respiratory failure. Multiple studies strived to evaluate the benefits of ECMO support, but its efficacy remains controversial with still inconsistent and sparse information. Methods: This retrospective analysis included patients with ECMO support, admitted between January 2010 and December 2019 at a tertiary university ECMO referral centre in Austria. The primary endpoint of the study was overall all-cause three-month mortality with risk factors and predictors of mortality. Secondary endpoints covered the analysis of demographic and clinical characteristics of patients needing ECMO, including incidence and type of adverse events during support. Results: In total, 358 patients fulfilled inclusion criteria and received ECMO support due to cardiogenic shock (258, 72%), respiratory failure (88, 25%) or hypothermia (12, 3%). In total, 41% (145) of patients died within the first three months, with the median time to death of 9 (1−87) days. The multivariate analysis identified hypothermia (HR 3.8, p < 0.001), the Simplified Acute Physiology Score III (HR 1.0, p < 0.001), ECMO initiation on weekends (HR 1.6, p = 0.016) and haemorrhage during ECMO support (HR 1.7, p = 0.001) as factors with higher risk for mortality. Finally, the most frequent adverse event was haemorrhage (160, 45%) followed by thrombosis. Conclusions: ECMO is an invasive advanced support system with a high risk of complications. Nevertheless, well-selected patients can be successfully rescued from life-threatening conditions by prolonging the therapeutic window to either solve the underlying problem or install a long-term assist device. Hypothermia, disease severity, initiation on weekends and haemorrhage during ECMO support increase the risk for mortality. In the case of decision making in a setting of limited (ICU) resources, the reported risk factors for mortality may be contemplable, especially when judging a possible ECMO support termination.
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Cheng Y, Zhang Y, Tu B, Qin Y, Cheng X, Qi R, Guo W, Li D, Wu S, Zhu R, Zhao Y, Tang Y, Wu C. Association Between Base Excess and Mortality Among Patients in ICU With Acute Kidney Injury. Front Med (Lausanne) 2021; 8:779627. [PMID: 34926523 PMCID: PMC8674681 DOI: 10.3389/fmed.2021.779627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to explore the association between base excess (BE) and the risk of 30-day mortality among patients with acute kidney injury (AKI) in the intensive care unit (ICU). Methods: This retrospective study included patients with AKI from the Medical Information Mart for Intensive Care (MIMIC)-IV database. We used a multivariate Cox proportional-hazards model to obtain the hazard ratio (HR) for the risk of 30-day mortality among patients with AKI. Furthermore, we utilized a Cox proportional-hazard model with restricted cubic splines (RCS) to explore the potential non-linear associations. Results: Among the 14,238 ICU patients with AKI, BE showed a U-shaped relationship with risk of 30-day mortality for patients with AKI, and higher or lower BE values could increase the risk. Compared with normal base excess (-3~3 mEq/L), patients in different groups (BE ≤ -9 mEq/L, -9 mEq/L < BE ≤ -3 mEq/L, 3 mEq/L < BE ≤ 9 mEq/L, and BE > 9 mEq/L) had different HRs for mortality: 1.57 (1.40, 1.76), 1.26 (1.14, 1.39), 0.97 (0.83, 1.12), 1.53 (1.17, 2.02), respectively. The RCS analyses also showed a U-shaped curve between BE and the 30-day mortality risk. Conclusion: Our results suggest that higher and lower BE in patients with AKI would increase the risk of 30-day mortality. BE measured at administration could be a critical prognostic indicator for ICU patients with AKI and provide guidance for clinicians.
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Affiliation(s)
- Yi Cheng
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - You Zhang
- Department of Nephrology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Boxiang Tu
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Yingyi Qin
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Xin Cheng
- Jinan People's Hospital Affiliated to Shandong First Medical University, Shandong, China
| | - Ran Qi
- The Second Children & Women's Healthcare of Jinan City, Shandong, China
| | - Wei Guo
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Dongdong Li
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Shengyong Wu
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Ronghui Zhu
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Yanfang Zhao
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Yuanjun Tang
- Department of Clinical Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Cheng Wu
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
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Tabatabai A, Ghneim MH, Kaczorowski DJ, Shah A, Dave S, Haase DJ, Vesselinov R, Deatrick KB, Rabin J, Rabinowitz RP, Galvagno S, O'Connor JV, Menaker J, Herr DL, Gammie JS, Scalea TM, Madathil RJ. Mortality Risk Assessment in COVID-19 Venovenous Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2021; 112:1983-1989. [PMID: 33485917 PMCID: PMC7825896 DOI: 10.1016/j.athoracsur.2020.12.050] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/18/2020] [Accepted: 12/16/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND A life-threatening complication of coronavirus disease 2019 (COVID-19) is acute respiratory distress syndrome (ARDS) refractory to conventional management. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) (VV-ECMO) is used to support patients with ARDS in whom conventional management fails. Scoring systems to predict mortality in VV-ECMO remain unvalidated in COVID-19 ARDS. This report describes a large single-center experience with VV-ECMO in COVID-19 and assesses the utility of standard risk calculators. METHODS A retrospective review of a prospective database of all patients with COVID-19 who underwent VV-ECMO cannulation between March 15 and June 27, 2020 at a single academic center was performed. Demographic, clinical, and ECMO characteristics were collected. The primary outcome was in-hospital mortality; survivor and nonsurvivor cohorts were compared by using univariate and bivariate analyses. RESULTS Forty patients who had COVID-19 and underwent ECMO were identified. Of the 33 patients (82.5%) in whom ECMO had been discontinued at the time of analysis, 18 patients (54.5%) survived to hospital discharge, and 15 (45.5%) died during ECMO. Nonsurvivors presented with a statistically significant higher Prediction of Survival on ECMO Therapy (PRESET)-Score (mean ± SD, 8.33 ± 0.8 vs 6.17 ± 1.8; P = .001). The PRESET score demonstrated accurate mortality prediction. All patients with a PRESET-Score of 6 or lowers survived, and a score of 7 or higher was associated with a dramatic increase in mortality. CONCLUSIONS These results suggest that favorable outcomes are possible in patients with COVID-19 who undergo ECMO at high-volume centers. This study demonstrated an association between the PRESET-Score and survival in patients with COVID-19 who underwent VV-ECMO. Standard risk calculators may aid in appropriate selection of patients with COVID-19 ARDS for ECMO.
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Key Words
- ards, acute respiratory distress syndrome
- cards, coronavirus disease 2019 acute respiratory distress syndrome
- covid-19, coronavirus disease 2019 (covid-19)
- ecmo, extracorporeal membrane oxygenation
- elso, extracorporeal life support organization
- fio2, fractional inspired oxygen
- paco2, arterial partial pressure of carbon dioxide
- pao2, arterial partial pressure of oxygen
- pao2/fio2, ratio of arterial oxygen partial pressure to fractional inspired oxygen
- preset-score, prediction of survival on ecmo therapy score
- resp, respiratory ecmo survival prediction
- saps, simplified acute physiology
- sofa, sequential organ failure assessment
- vv-ecmo, venovenous extracorporeal membrane oxygenation
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Affiliation(s)
- Ali Tabatabai
- Division of Pulmonary and Critical Care, Department of Medicine, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Mira H Ghneim
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aakash Shah
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Sagar Dave
- Department of Surgery, Program in Trauma, University of Maryland Medical Center, Baltimore, Maryland
| | - Daniel J Haase
- Department of Emergency Medicine, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, University of Maryland at Baltimore, Baltimore, Maryland
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph Rabin
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ronald P Rabinowitz
- Division of Infectious Diseases, Department of Medicine, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Samuel Galvagno
- Department of Anesthesiology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - James V O'Connor
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jay Menaker
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel L Herr
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - James S Gammie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Thomas M Scalea
- Department of Surgery, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ronson J Madathil
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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5
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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Marinacci LX, Mihatov N, D'Alessandro DA, Villavicencio MA, Roy N, Raz Y, Thomas SS. Extracorporeal cardiopulmonary resuscitation (ECPR) survival: A quaternary center analysis. J Card Surg 2021; 36:2300-2307. [PMID: 33797800 DOI: 10.1111/jocs.15550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/08/2021] [Accepted: 03/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for nonresponders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR. AIM To describe a single-center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm. METHODS A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate the origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine the association of patient and arrest characteristics with survival. RESULTS Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n = 12). Twenty-six patients died on ECMO (55.3%) while nine patients (19.1%) survived decannulation but died before discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status. CONCLUSIONS Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multiinstitutional studies are needed to determine evidenced-based criteria for ECPR deployment.
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Affiliation(s)
- Lucas X Marinacci
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nino Mihatov
- Division of Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - David A D'Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yuval Raz
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sunu S Thomas
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
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7
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Belliato M, Epis F, Cremascoli L, Ferrari F, Quattrone MG, Fisser C, Malfertheiner MV, Taccone FS, Di Nardo M, Broman LM, Lorusso R. Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study. MEMBRANES 2021; 11:membranes11010030. [PMID: 33401668 PMCID: PMC7824596 DOI: 10.3390/membranes11010030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022]
Abstract
Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, p < 0.001), plateau pressure (27 vs. 21 cmH2O, p = 0.012), driving pressure (11 vs. 8 cmH2O, p = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, p < 0.001), and tidal volume adjusted to patient ideal body weight (VT/IBW, 5.5 vs. 4.0 mL/kg, p = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, p = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmH2O, p = 0.048) and VT/IBW (3.0 vs. 4.0 mL/kg, p = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.
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Affiliation(s)
- Mirko Belliato
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Francesco Epis
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- Correspondence: ; Tel.: +39-0382-503524
| | - Luca Cremascoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Fiorenza Ferrari
- 1st Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, 36100 Vicenza, Italy
| | - Maria Giovanna Quattrone
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Christoph Fisser
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Maximilian Valentin Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Brussels, 1070 Brussels, Belgium;
| | - Matteo Di Nardo
- Pediatric Intensive Care, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, and Department of Physiology and Pharmacology, Karolinska Institutet, 171 64 Solna (Stockholm), Sweden;
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
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Lee HK, Kim HS, Ha SO, Park S, Lee HS, Lee SK, Lee SH. Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study. Scand J Trauma Resusc Emerg Med 2020; 28:41. [PMID: 32448260 PMCID: PMC7245644 DOI: 10.1186/s13049-020-00733-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Therapeutic extracorporeal membrane oxygenation (ECMO) is a challenging procedure in patients who have experienced severe trauma. Particularly, patients with traumatic lung injury and posttraumatic acute respiratory distress syndrome (ARDS) have a high risk of bleeding during this procedure. This study aimed to determine the safety and feasibility of ECMO in patients with traumatic ARDS. Methods We retrospectively reviewed medical records and investigated the clinical outcomes of ECMO in 42 patients with traumatic ARDS, among whom near-drowning (42.9%) was the most frequent cause of injury. Results Thirty-four of 42 patients (81%) survived and were discharged after a median hospital stay of 23 days. A multivariate analysis identified a lactate level (odds ratio: 1.493, 95% confidence interval: 1.060–2.103, P = 0.022) and veno-venous (VV) ECMO (odds ratio: 0.075, 95% confidence interval: 0.006–0.901, P = 0.041) as favorable independent predictors of survival in patients with traumatic ARDS who underwent ECMO. The optimal cut off value for pre-ECMO lactate level was 10.5 mmol/L (area under the curve = 0.929, P = 0.001). In Kaplan-Meier analysis, the survival rate at hospital discharge was significant higher among the patients with a pre-ECMO lactate level of 10.5 mmol/L or less compared with patients with pre-ECMO lactate level greater than 10.5 mmol/L (93.8% versus 40.0%, respectively; P = 0.01). Conclusions ECMO yielded excellent survival outcomes, particularly in patients with low pre-treatment lactate levels who received VV ECMO. Therefore, ECMO appears safe and highly feasible in a carefully selected population of trauma patients.
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Affiliation(s)
- Hong Kyu Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea.
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwaseong-si, Gyeonggi-do, South Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea
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Predictive survival factors of the traumatically injured on venovenous extracorporeal membrane oxygenation: A Bayesian model. J Trauma Acute Care Surg 2019; 88:153-159. [DOI: 10.1097/ta.0000000000002457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Volume-Outcome Relationships in Extracorporeal Membrane Oxygenation: Retrospective Analysis of Administrative Data From Pennsylvania, 2007-2015. ASAIO J 2019; 64:450-457. [PMID: 29076948 DOI: 10.1097/mat.0000000000000675] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This article seeks to understand whether a volume-outcome relationship exists in adult extracorporeal membrane oxygenation (ECMO). We examined primary administrative discharge data from the Pennsylvanian Health Care Cost Containment Council for all 2,948 consecutive adults treated with ECMO in Pennsylvania between January 1, 2007, and December 31, 2015. We used a well-fitting backwards stepwise logistic regression to obtain patient-level predicted mortality. Number of cases and risk-adjusted mortality was aggregated by calendar quarter and by hospital. Graphical and correlation analysis was used to understand the volume-outcome relationship, focusing separately on the impact of a hospital's current scale (annual volume of adult ECMO) and a hospital's cumulative experience (total cumulative volume of adult ECMO since starting operations). We found that more than 9 years, there was essentially no reduction in overall risk-adjusted mortality in the state. For individual hospitals, once institutions had as few as 50 cases' total experience or performed just 10 cases annually, there was no clear improvement in outcomes. Patients in hospitals with fewer than 50 cases ever performed appeared objectively less sick compared with patients in hospital with more experience. We conclude that there is little evidence of volume-outcome relationships in adult ECMO in this state, although we acknowledge that the absence of clinical chart data limits these conclusions.
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Lee HS, Kim HS, Lee SH, Lee SA, Hwang JJ, Park JB, Kim YH, Moon HJ, Lee WS. Clinical implications of the initial SAPS II in veno-arterial extracorporeal oxygenation. J Thorac Dis 2019; 11:68-83. [PMID: 30863575 DOI: 10.21037/jtd.2018.12.20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Prediction of survival and weaning probability in VA ECMO (veno-arterial extracorporeal membrane oxygenation) patients could be of great benefit for real-time decision making on VA ECMO initiation in critical ill patients. We investigated whether the SAPS II score would be a real-time determinant for VA ECMO initiation and could be a predictor of survival and weaning probability in patients on VA ECMO. Methods Between January 1, 2010 and December 31, 2014, VA ECMO was carried out on 135 adult patients suffering from primary cardiogenic shock. To avoid selection bias, we excluded respiratory failure patients treated with VV or other types of ECMO. Successful VA ECMO weaning was defined as weaning, followed by stable survival for more than 48 hours. Survival after VA ECMO was defined as successful weaning and treatment of the underlying medical condition, followed by discharge without any further events. Results A total of 135 patients consisted of 41 women and 94 men, with a mean age of 59.4±16.5 years. Fifty-three patients had successful weaning, and 35 survived and were discharged uneventfully. Compared to the non-survivors, the survivors showed a lower SAPS II (67.77±20.79 vs. 90.29±13.31, P<0.001), a lower SOFA score (12.63±3.49 vs. 15.33±2.28, P<0.001), a lower predicted death rate (71.12±30.51 vs. 94.00±9.36, P<0.001), a higher initial ipH (7.14±0.22 vs. 6.98±0.15, P<0.001), and a lower initial lactate level (7.09±4.93 vs. 12.11±4.84, P<0.001). The average duration of hospital stay in the successful vs. failed weaning groups was 33.43±27.41 vs. 6.35±8.71 days, and the average duration of ICU stay in the successful vs. failed weaning groups was 20.60±16.88 vs. 5.39±5.95 days. By multivariate logistic regression analysis of initial parameters for VA ECMO assistance, the simplified acute physiology score II (SAPS II) (OR =1.1019, P=0.0389), ipH (OR =0.0010, P=0.0452), and hospital stay (OR =0.8140, P=0.001) had an association with in-hospital mortality on VA ECMO. The initial SAPS II score [area under the curve (AUC) =0.821] demonstrated significantly superior prediction of VA ECMO mortality than age (AUC =0.697), SOFA score (AUC =0.701), ipH (AUC =0.551), and the other parameters. By multivariable CoX regression analysis of survival, only the SAPS II score proved to have statistical significance (hazard ratio, 1.0423; 95% CI, 1.0083-1.0775; P=0.01). Conclusions Although the precise predictive scoring systems for VA ECMO still remains one of the most difficult challenges to ECMO physicians, the SAPS II score could provide valuable information on prognosis to patient himself, family members and caretakers, and might help physicians increase the survival rate and might avoid a waste of healthcare resources.
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Affiliation(s)
- Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Hallym University Dongtan Medical Center, Gyeonggi-do, Republic of Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Hallym University Medical Center. Gyeonggi-do, Republic of Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Hallym University, Hallym University Medical Center. Gyeonggi-do, Republic of Korea
| | - Song Am Lee
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea
| | - Jae Joon Hwang
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea
| | - Jae Bum Park
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Seoul Hospital, Seoul, Republic of Korea
| | - Yo Han Kim
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, Chungju-si, Chungbuk, Republic of Korea
| | - Hyoung Ju Moon
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, Chungju-si, Chungbuk, Republic of Korea
| | - Woo Surng Lee
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Konkuk University, Konkuk University Chungju Hospital, Chungju-si, Chungbuk, Republic of Korea
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Abstract
Extracorporeal membrane oxygenation (ECMO) support is a life-saving but complex technique for patients suffering from severe cardiac or pulmonary dysfunction. Increasingly greater utilization in the last 15 years means that a suite of mortality risk analytics is both feasible for researchers and required by clinicians, patients, administrators, and insurers. We argue that to date, research into such risk analytics has been insufficient and does not adequately reflect the various indications and configurations of extracorporeal life support (ECLS). We propose a path to address these challenges and ensure that clinicians and researchers obtain robust, specific, risk analytics.
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Clinical risk factors of extracorporeal membrane oxygenation support in older adults. PLoS One 2018; 13:e0195445. [PMID: 29624620 PMCID: PMC5889174 DOI: 10.1371/journal.pone.0195445] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/22/2018] [Indexed: 11/19/2022] Open
Abstract
Background The ageing population and the expected increase in the number of elderly patients make an evidence-based assessment of Extracorporeal Membrane Oxygenation (ECMO) therapy in old patients progressively more important. Veno-arterial (VA) ECMO results for patient aged <65 years is well known. However, the risk profile and in-hospital prognosis of advanced age patients with ECMO still need more investigation. The aim of this study was to identify risk factors that predicted the outcomes for elderly patients who received VA-ECMO. Methods In this retrospective study, medical records for patients with ECMO aged 65 years and over were collected between 2009 and 2012 at a tertiary hospital. Results A total of 99 patients (mean age: 76.4±6.4 years) were included. The most common condition requiring VA-ECMO support was cardiogenic shock. Among survivors on VA-ECMO, 28 (28.3%) patients were successfully weaned from support. Thirteen (13.1%) patients were successfully discharged. We found that cardiogenic shock (OR = 3.158, P = 0.013), acute physiology and chronic health evaluation II (APACHE II) score (OR = 1.147, P<0.001), and simplified acute physiology score II (SAPS II) score (OR = 1.054, P = 0.001) were risk factors associated with survival on VA-ECMO. By using the areas under the receiver operating characteristic (AUC) curve, the APACHE II score and SAPS II score displayed acceptable discriminative power (AUC 0.722; 0.715, respectively). Conclusion Our findings indicate that the risk of mortality increases with cardiogenic shock, higher APACHE II score, and higher SAPS II score. These risk factors can be utilized as potential predictors to identify the potential candidates for ECMO support.
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Pappalardo F, Montisci A. What is extracorporeal cardiopulmonary resuscitation? J Thorac Dis 2017; 9:1415-1419. [PMID: 28740646 DOI: 10.21037/jtd.2017.05.33] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Federico Pappalardo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Montisci
- Cardiothoracic Centre, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy
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15
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Factors associated with mortality risk in critical care patients treated with veno-arterial extracorporeal membrane oxygenation. Heart Lung 2017; 46:137-142. [PMID: 28318620 DOI: 10.1016/j.hrtlng.2017.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 01/13/2017] [Accepted: 02/09/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To identify factors associated with mortality in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and to validate the discrimination of the risk assessment tools to predict mortality. BACKGROUND VA-ECMO is a rescue therapy for patients with life-threatening cardiac failure, but mortality remains high. METHODS In this retrospective study, we reviewed the medical records of adult patients who underwent VA-ECMO in an intensive care unit of a university hospital, between 2009 and 2013. RESULTS VA-ECMO was performed in 89 patients, with a median duration of 116 h. The survival rate until hospital discharge was 27%. The pre-ECMO simplified acute physiology score (SAPS) II and diabetes mellitus were significant predictors of hospital mortality. The optimal prognostic SAPS II score was 81 overall, 80 in patients with diabetes, and 84 in those without diabetes. CONCLUSIONS Our findings indicate that high pre-ECMO SAPS II score and diabetes are risk factors for mortality in patients who undergo VA-ECMO.
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Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Terenzi P, Cozzolino M, Bernardo P, Peris A. Lactate and Echocardiography Before Veno-Venous Extracorporeal Membrane Oxygenation Support. Heart Lung Circ 2017; 27:99-103. [PMID: 28343949 DOI: 10.1016/j.hlc.2017.02.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 02/01/2017] [Accepted: 02/06/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lactate has been recognised as a prognostic factor in several critical conditions. Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is a well-established therapy in patients with Acute Respiratory Disease Syndrome (ARDS) unresponsive to conventional therapy and echocardiography pre ECMO initiation has been recently reported to help in risk stratifying these patients. METHODS We assessed whether the detection of hyperlactataemia could be associated with the presence of left ventricle (LV) or right ventricle (RV) dysfunction in 121 consecutive patients with refractory ARDS. RESULTS The mortality rate was 42.9% (52/121). Higher dosages of norepinephrine and dobutamine were administered to non survivors (p=0.023 and p=0.047, respectively) who showed significantly higher levels of lactate (p=0.002). At echocardiography, non survivors showed higher values of systolic pulmonary artery pressure (sPAP) (p=0.05) and a higher incidence of RV dysfunction (as indicated by lower Tricuspid Annular Plane Excursion (TAPSE)) and RV dilatation (p=0.001). At multivariate logistic regression analysis, the following variables were independent predictors of death: body mass index (BMI) (OR: 0.914, 95%CI 0.857-0.975, p=0.006), RV dilatation (OR: 0.239, 95%CI 0.101-0.561, p=0.001) and lactate (OR: 1.292, 95%CI 1.015-1.645, p=0.038). Lactate values were directly correlated with the simplified acute physiology score (SAPS) II (r=0.38, p<0.001), while they showed an indirect correlation with left ventricular ejection fraction (LVEF) (r=-0.24, p=0.009) and TAPSE (r=-0.21, p=0.024). CONCLUSIONS In refractory ARDS, hyperlactataemia before VVV-ECMO identified a subset of patients at higher risk of death, being an independent predictor of in-Intensive Care Unit (ICU) mortality. Lactate values are mainly related to disease severity (as indicated by SAPS II) and haemodynamic impairment (as inferred by LVEF) and RV failure, as (indicated by TAPSE).
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Giovanni Cianchi
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Stefano Batacchi
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Paolo Terenzi
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Morena Cozzolino
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Pasquale Bernardo
- Intensive Care Unit of Heart and Vessels Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Richardson A(SC, Schmidt M, Bailey M, Pellegrino VA, Rycus PT, Pilcher DV. ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12-years. Resuscitation 2017; 112:34-40. [DOI: 10.1016/j.resuscitation.2016.12.009] [Citation(s) in RCA: 211] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/10/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
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Kim HS, Ha SO, Han SJ, Kim HS, Lee SH, Jung KS, Park S. Extracorporeal Membrane Oxygenation Support in Trauma Versus Nontrauma Patients with Noninfectious Acute Respiratory Failure. Artif Organs 2016; 41:431-439. [PMID: 27892596 DOI: 10.1111/aor.12794] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/19/2016] [Accepted: 05/26/2016] [Indexed: 01/19/2023]
Abstract
The utility of extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) of noninfectious origin remains unclear. Data on patients with ARDS of noninfectious origin who underwent ECMO were reviewed retrospectively. We compared the pre-ECMO characteristics and hospital outcomes of patients with traumatic and nontraumatic ARDS. In total, 23 patients (trauma, n = 9; nontrauma, n = 14) were included in the study. The mean patient age was 42 years, there were three females, and the mean pre-ECMO Simplified Acute Physiologic Score (SAPS) II was 60.0 (49.0-71.0). The hemoglobin level was lower and the prothrombin time (PT) more prolonged, prior to initiation of ECMO, in traumatic compared with nontraumatic ARDS patients. During the first 48 h of ECMO support, the coagulation parameters did not differ between the two groups, but the platelet counts, PT, and activated partial thromboplastin time indicated that coagulopathy was developing in all patients. The hospital and 28-day mortality rates were 21.7 and 13.0%, respectively, and serious neurological outcomes (cerebral performance category [CPC] of three points or more) developed in 26.1% of all patients; however, the extent of such outcomes did not differ between traumatic and nontraumatic ARDS patients. Upon multivariate analysis, the pre-ECMO SAPS II tended to be associated with composite events (i.e., hospital death and/or a CPC of three points or more) (P = 0.051). Additionally, a history of hypertension and an elevated pre-ECMO SAPS II were significant risk factors for serious neurological outcomes among hospital survivors (n = 18). In conclusion, ECMO support can be associated with favorable outcomes in patients with ARDS of noninfectious origin, irrespective of whether the ARDS is associated with trauma. The pre-ECMO SAPS II and a history of hypertension may be independent risk factors for poor outcomes.
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Affiliation(s)
| | | | - Sang Jin Han
- Division of Cardiology, Department of Internal Medicine
| | - Hyun-Sook Kim
- Division of Cardiology, Department of Internal Medicine
| | | | - Ki-Suck Jung
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
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Chen WC, Huang KY, Yao CW, Wu CF, Liang SJ, Li CH, Tu CY, Chen HJ. The modified SAVE score: predicting survival using urgent veno-arterial extracorporeal membrane oxygenation within 24 hours of arrival at the emergency department. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:336. [PMID: 27769308 PMCID: PMC5075192 DOI: 10.1186/s13054-016-1520-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/30/2016] [Indexed: 01/21/2023]
Abstract
Background Although many risk models have been tested in patients who undergo extracorporeal membrane oxygenation, few have been assessed for patients who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support in the emergency department (ED). This study aimed to successfully predict outcomes of patients with cardiac or noncardiac failure who received VA-ECMO in the ED within 24 hours of arrival at the ED. Method This retrospective, observational cohort study included 154 patients, who were classified as cardiac (n = 127) and noncardiac (n = 27) patients and received VA-ECMO within 24 hours after arrival at the China Medical University Hospital ED in Taiwan between January 2009 and September 2014. We recorded mechanical ventilation settings, arterial blood gases, laboratory parameters including plasma lactate level, requirement of catecholamines, and risk scores at time of ECMO initiation. ECMO and mechanical ventilation support duration, length of stay in the hospital, and 90-day mortality data were also examined. Results The overall mortality rate was 64.9 %. We used “survival after veno-arterial ECMO (SAVE)” scores to assess survival prediction in survival and nonsurvival groups, which was statistically different (–3.2 vs. –8.3, p <0.001). According to multivariate Cox proportional regression of survival, lactate (hazard ratio [HR] = 1.01, 95 % confidence interval [CI], 1.01–1.01, p <0.001) and SAVE score (HR = 0.92, [95 % CI, 0.88–0.96], p = 0.001) were independent predictors of outcome. Excellent discrimination (area under curve (AUC) = 0.843) was observed when lactate and SAVE score were combined, which we referred to as “the modified SAVE score.” Conclusions Modified SAVE scores improved outcome prediction for patients who underwent urgent VA-ECMO in the ED.
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Affiliation(s)
- Wei-Cheng Chen
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Kuo-Yang Huang
- Division of Chest Medicine, Department of Internal Medicine, Yuanlin Christian Hospital, Changhua, Taiwan
| | - Chih-Wei Yao
- Division of Chest Medicine, Department of Internal Medicine, Everan Hospital, Taichung, Taiwan
| | - Cing-Feng Wu
- Division of Cardiovascular Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Shinn-Jye Liang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Chia-Hsiang Li
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Chih-Yeh Tu
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan
| | - Hung-Jen Chen
- Division of Pulmonary and Critical Care, Department of Internal Medicine, China Medical University Hospital, No. 2, Yude Road, North District, Taichung City, 40402, Taiwan. .,Department of Respiratory Therapy, China Medical University, Taichung, Taiwan.
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Allyn J, Ferdynus C, Bohrer M, Dalban C, Valance D, Allou N. Simplified Acute Physiology Score II as Predictor of Mortality in Intensive Care Units: A Decision Curve Analysis. PLoS One 2016; 11:e0164828. [PMID: 27741304 PMCID: PMC5065161 DOI: 10.1371/journal.pone.0164828] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/01/2016] [Indexed: 01/05/2023] Open
Abstract
Background End-of-life decision-making in Intensive care Units (ICUs) is difficult. The main problems encountered are the lack of a reliable prediction score for death and the fact that the opinion of patients is rarely taken into consideration. The Decision Curve Analysis (DCA) is a recent method developed to evaluate the prediction models and which takes into account the wishes of patients (or surrogates) to expose themselves to the risk of obtaining a false result. Our objective was to evaluate the clinical usefulness, with DCA, of the Simplified Acute Physiology Score II (SAPS II) to predict ICU mortality. Methods We conducted a retrospective cohort study from January 2011 to September 2015, in a medical-surgical 23-bed ICU at University Hospital. Performances of the SAPS II, a modified SAPS II (without AGE), and age to predict ICU mortality, were measured by a Receiver Operating Characteristic (ROC) analysis and DCA. Results Among the 4.370 patients admitted, 23.3% died in the ICU. Mean (standard deviation) age was 56.8 (16.7) years, and median (first-third quartile) SAPS II was 48 (34–65). Areas under ROC curves were 0.828 (0.813–0.843) for SAPS II, 0.814 (0.798–0.829) for modified SAPS II and of 0.627 (0.608–0.646) for age. DCA showed a net benefit whatever the probability threshold, especially under 0.5. Conclusion DCA shows the benefits of the SAPS II to predict ICU mortality, especially when the probability threshold is low. Complementary studies are needed to define the exact role that the SAPS II can play in end-of-life decision-making in ICUs.
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Affiliation(s)
- Jérôme Allyn
- Intensive care unit, Saint-Denis University Hospital, Saint-Denis, Reunion Island, France
| | - Cyril Ferdynus
- Unité de Soutien Méthodologique, Saint-Denis University Hospital, Saint-Denis, Reunion Island, France.,INSERM, CIC 1410, Saint-Pierre, Reunion Island, France
| | - Michel Bohrer
- Department of Medical Information, Saint-Denis University Hospital, Saint-Denis, Reunion Island, France
| | - Cécile Dalban
- Unité de Soutien Méthodologique, Saint-Denis University Hospital, Saint-Denis, Reunion Island, France
| | - Dorothée Valance
- Intensive care unit, Saint-Denis University Hospital, Saint-Denis, Reunion Island, France
| | - Nicolas Allou
- Intensive care unit, Saint-Denis University Hospital, Saint-Denis, Reunion Island, France
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Choi MJ, Ha SO, Kim HS, Park S, Han SJ, Lee SH. The Simplified Acute Physiology Score II as a Predictor of Mortality in Patients Who Underwent Extracorporeal Membrane Oxygenation for Septic Shock. Ann Thorac Surg 2016; 103:1246-1253. [PMID: 27743640 DOI: 10.1016/j.athoracsur.2016.07.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) for patients with septic shock is controversial. The outcomes are favorable in children but heterogeneous in adults. The present study aimed to analyze the outcomes of adult patients who underwent ECMO for septic shock, and to determine the factors associated with prognosis. METHODS We respectively reviewed the medical records of patients who underwent ECMO for septic shock between January 2007 and December 2013. Patients were divided into survivor and nonsurvivor groups based on survival to hospital discharge. The patient characteristics before and during ECMO were compared between the groups. Independent risk factors for mortality were evaluated using multivariate logistic regression, receiver-operating characteristic curves, and Kaplan-Meier analysis. RESULTS Twenty-eight patients were treated with venoarterial (n = 21), venovenous (n = 4), or venoarteriovenous (n = 3) mode ECMO. The overall survival rate to hospital discharge was 35.7%. The Simplified Acute Physiology Score II (SAPS II) and prealbumin were predictors of survival to hospital discharge. The optimal cutoff value for SAPS II was 80 (area under the curve 0.80, p = 0.010). Kaplan-Meier survival curves showed that the cumulative survival rate at hospital discharge and at 54-month follow-up was significantly higher among patients with SAPS II of 80 or less compared with patients with SAPS II greater than 80 (66.7% versus 12.5% and 58.3% versus 12.5%, respectively; p = 0.001). CONCLUSIONS It is still difficult to conclude whether ECMO should be recommended as therapy for adult patients with septic shock. However, a SAPS II score of 80 or less may be an indicator of favorable outcomes with the use of ECMO.
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Affiliation(s)
- Myung Jin Choi
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Chuncheon-si, Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea.
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
| | - Sang Jin Han
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, Korea
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