1
|
Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
Collapse
Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
2
|
Mazzeffi M, Lin D, Gonzalez-Almada A, Stombaugh DK, Curley J, Mangunta V, Teman N, Yarboro LT, Thiele R. Outcomes of heparinized adult veno-arterial extracorporeal membrane oxygenation patients managed with low and high activated partial thromboplastin time targets: A systematic review and meta-analysis. Perfusion 2024; 39:525-535. [PMID: 36595340 DOI: 10.1177/02676591221150880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION There are no randomized controlled trials comparing low and high activated partial thromboplastin time (aPTT) targets in heparinized adult veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) patients. Our systematic review and meta-analysis summarized complication rates in adult VA ECMO patients treated with low and high aPTT targets. METHODS Studies published from January 2000 to May 2022 were identified using Pubmed, Embase, Cochrane Library, and LILACS (Latin American and Caribbean Health Sciences Literature). Studies were included if aPTT was primarily used to guide heparin anticoagulation. For the low aPTT group, we included studies where aPTT goal was ≤60 seconds and for the high aPTT group, we included studies where aPTT goal was ≥60 seconds. Proportional meta-analysis with a random effects model was used to calculate pooled complication rates for patients in the two aPTT groups. RESULTS Twelve studies met inclusion criteria (5 in the low aPTT group and 7 in the high aPTT group). The pooled bleeding complication incidence for low aPTT studies was 53.6% (95% CI = 37.4%-69.4%, I2 = 60.8%) and for high aPTT studies was 43.8% (95% CI = 21.7%-67.1%, I2 = 91.8%). No studies in the low aPTT group reported overall thrombosis incidence, while three studies in the high aPTT group reported overall thrombosis incidence. The pooled thrombosis incidence for high aPTT studies was 16.1% (95% CI = 9.0%-24.5%, I2 = 13.1%). CONCLUSIONS Adult ECMO patients managed with low and high aPTT goals appeared to have similar bleeding and other complication rates further highlighting the need for a randomized controlled trial.
Collapse
Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Dora Lin
- Department of Anesthesiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alberto Gonzalez-Almada
- Department of Anesthesiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - D Keegan Stombaugh
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Jonathan Curley
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Venkat Mangunta
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Nicholas Teman
- Department of Surgery Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, VA, USA
| | - Leora T Yarboro
- Department of Surgery Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, VA, USA
| | - Robert Thiele
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| |
Collapse
|
3
|
Davies MG, Hart JP. Current status of ECMO for massive pulmonary embolism. Front Cardiovasc Med 2023; 10:1298686. [PMID: 38179509 PMCID: PMC10764581 DOI: 10.3389/fcvm.2023.1298686] [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: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
Massive pulmonary embolism (MPE) carries significant 30-day mortality and is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Given the continued high mortality associated with MPE, there has been ongoing interest in utilizing extracorporeal membrane oxygenation (ECMO) to provide oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and RV pressure will improve outcomes. Two modalities can be employed: Veno-arterial-ECMO is a reliable process to decrease RV overload and improve RV function, thus allowing for hemodynamic stability and restoration of tissue oxygenation. Veno-venous ECMO can support oxygenation but is not designed to help circulation. Several societal guidelines now suggest using ECMO in MPE with interventional therapy. There are three strategies for ECMO utilization in MPE: bridge to definitive interventional therapy, sole therapy, and recovery after interventional treatment. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Considerable heterogeneity in studies is a significant weakness of the available literature. Applying ECMO is also associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, which must be factored into the outcomes. The application of ECMO in MPE should be combined with an aggressive pulmonary interventional program and should strictly adhere to the current selection criteria.
Collapse
Affiliation(s)
- Mark G. Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
- Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX, United States
| | - Joseph P. Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| |
Collapse
|
4
|
Zhao J, Cui P, Zhou Z, Niu B, Pan C. Treatment of malignant airway stenosis with extracorporeal membrane oxygenation under low-dose anticoagulation: A case report. Heliyon 2023; 9:e23210. [PMID: 38144268 PMCID: PMC10746480 DOI: 10.1016/j.heliyon.2023.e23210] [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: 06/07/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023] Open
Abstract
The occurrence of airway obstruction due to severe stenosis from lung cancer poses a significant risk of asphyxia. Although the placement of a metallic stent may relieve the obstruction, the procedure is associated with a high risk of asphyxia. To mitigate this risk, extracorporeal membrane pulmonary oxygenation (ECMO) has been proposed to temporarily substitute for cardiopulmonary function during the procedure. However, the use of systemic anticoagulation with heparin during ECMO may increase the likelihood of bleeding during surgery. This case report describes a successful treatment of a patient with malignant central airway obstruction through low-dose heparin veno-venous ECMO. This approach resulted in reduced intraoperative bleeding and invasive operation time, allowing for prompt postoperative withdrawal and recovery.
Collapse
Affiliation(s)
- Jingsha Zhao
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
- Department of Intensive Care Unit, Pujiang People's Hospital, Chengdu, Sichuan, China
| | - Peng Cui
- Department of Cardiovascular, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Ziwei Zhou
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Bin Niu
- Department of Respiratory, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Chuanliang Pan
- Department of Intensive Care Unit, The Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| |
Collapse
|
5
|
Chen H, Liu J, Wu L, Ji C, Li T, Wang G. Heparin-free veno-venous extracorporeal membrane oxygenation in non-trauma patients with difficult airways for surgery. Chin Med J (Engl) 2023; 136:1251-1252. [PMID: 37026859 PMCID: PMC10278753 DOI: 10.1097/cm9.0000000000002651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Indexed: 04/08/2023] Open
Affiliation(s)
- Hongya Chen
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Jinsheng Liu
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Lili Wu
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Cunliang Ji
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Tong Li
- Department of Intensive Care Unit, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Guyan Wang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| |
Collapse
|
6
|
Li CMF, Densy Deng X, Ma YF, Dawson E, Li C, Wang DY, Huong L, Gofton T, Nagpal AD, Slessarev M. Neurologic Complications of Patients With COVID-19 Requiring Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. Crit Care Explor 2023; 5:e0887. [PMID: 36998530 PMCID: PMC10047608 DOI: 10.1097/cce.0000000000000887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
In COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO), our primary objective was to determine the frequency of intracranial hemorrhage (ICH). Secondary objectives were to estimate the frequency of ischemic stroke, to explore association between higher anticoagulation targets and ICH, and to estimate the association between neurologic complications and in-hospital mortality. DATA SOURCES We searched MEDLINE, Embase, PsycINFO, Cochrane, and MedRxiv databases from inception to March 15, 2022. STUDY SELECTION We identified studies that described acute neurological complications in adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requiring ECMO. DATA EXTRACTION Two authors independently performed study selection and data extraction. Studies with 95% or more of its patients on venovenous or venoarterial ECMO were pooled for meta-analysis, which was calculated using a random-effects model. DATA SYNTHESIS Fifty-four studies (n = 3,347) were included in the systematic review. Venovenous ECMO was used in 97% of patients. Meta-analysis of ICH and ischemic stroke on venovenous ECMO included 18 and 11 studies, respectively. The frequency of ICH was 11% (95% CI, 8-15%), with intraparenchymal hemorrhage being the most common subtype (73%), while the frequency of ischemic strokes was 2% (95% CI, 1-3%). Higher anticoagulation targets were not associated with increased frequency of ICH (p = 0.06). In-hospital mortality was 37% (95% CI, 34-40%) and neurologic causes ranked as the third most common cause of death. The risk ratio of mortality in COVID-19 patients with neurologic complications on venovenous ECMO compared with patients without neurologic complications was 2.24 (95% CI, 1.46-3.46). There were insufficient studies for meta-analysis of COVID-19 patients on venoarterial ECMO. CONCLUSIONS COVID-19 patients requiring venovenous ECMO have a high frequency of ICH, and the development of neurologic complications more than doubled the risk of death. Healthcare providers should be aware of these increased risks and maintain a high index of suspicion for ICH.
Collapse
|
7
|
Yusoff R, Preuss J, Weightman W, Wilke M, Hodder R, Jansen S, Hockley J, Proctor J. The Use of Extracorporeal Circulation to Facilitate the Resection of a Large Retroperitoneal Sarcoma With Major Vessel Involvement: A Single-Center Review of 20 Cases. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00174-X. [PMID: 37045737 DOI: 10.1053/j.jvca.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE To describe the introduction of extracorporeal corporeal oxygenation (ECMO) to facilitate the surgical resection of large retroperitoneal sarcomas involving major vessels and to report preliminary outcomes. DESIGN A case series. SETTING At a tertiary university hospital and state sarcoma center. PARTICIPANTS Patients undergoing retroperitoneal sarcoma resection requiring inferior vena cava (IVC) reconstruction between June 2018 and March 2022. INTERVENTION ECMO for retroperitoneal tumor resection requiring IVC reconstruction. MEASUREMENTS AND MAIN RESULTS A total of 20 patients underwent ECMO-assisted retroperitoneal sarcoma resection and IVC reconstruction. The median age was 60.5 years (IQR 48-69); 15 women and 5 men. The median procedure and ECMO durations were 10.8 hours (IQR 8.5-12.4 hours) and 2.2 hours (IQR 62-218 minutes), respectively. The median intensive care unit and hospital lengths of stay were 4 days (IQR 3-5 days) and 21 days (IQR 14-31 days), respectively. All 20 patients received packed cell transfusions (median 8 per patient [IQR 4-14]); 11 patients required fresh frozen plasma, 6 required platelets, and 11 required fibrinogen supplementation. One patient required recombinant activated factor VII. Sixteen patients experienced acute kidney injury, with 12 patients progressing to chronic kidney disease. Three patients were required to return to the operating room within 7 days, with no returns within the first 24 hours. There was no in-hospital or 30-day mortality. Survival at 3 years was 84%. CONCLUSIONS ECMO for resecting large retroperitoneal tumor resection was introduced successfully and facilitated satisfactory outcomes for many patients who might otherwise have been considered too high risk.
Collapse
Affiliation(s)
- Reza Yusoff
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - James Preuss
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - William Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Milena Wilke
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Rupert Hodder
- Department of General Surgery, State Sarcoma Centre, Nedlands, Western Australia, Australia
| | - Shirley Jansen
- Curtain Medical School, Curtain University, Perth, Western Australia, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia; Heart and Vascular Research Institute, Harry Perkins Medical Research Institute, Perth, Western Australia, Australia; The University of Western Australia, Nedlands, Western Australia, Australia
| | - Joseph Hockley
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Justine Proctor
- Department of Cardiothoracic Surgery and Perfusion, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| |
Collapse
|
8
|
Case Report of a Successful Pediatric Central Venovenous Extracorporeal Life Support via Right Atrium-Pulmonary Artery Cannulation for Severe Chest Trauma and Hemorrhagic Shock. ASAIO J 2023; 69:e106-e108. [PMID: 35471261 DOI: 10.1097/mat.0000000000001755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Hypoxemic arrests due to severe traumatic pulmonary injury may not respond to usual medical support. Extracorporeal life support (ECLS) can be life-saving; adequate flows are needed in this setting along with a careful choice of anticoagulation strategies to minimize bleeding. A 44 month old child, who presented with severe blunt chest trauma after being run over by a truck was resuscitated with active compressions and code medications seven times before arrival to the intensive care unit. Failure to adequately oxygenate led to an unconventional approach with cannulations of the right atrium (RA) and pulmonary artery (PA) via sternotomy. Anticoagulation regimen started after bleeding had slowed down with active transfusion of blood products and consisted of low-dose heparin and alprostadil infusions for the initial 48 hours. Heparin was adjusted per institutional guidelines thereafter. Physiologically veno-venous central approach enabled fast stabilization due to full oxygenation without recirculation. Additionally, the dual anticoagulation regimen was safe for circuit maintenance. The described method can be considered in small children with similar risks and conditions.
Collapse
|
9
|
Helms J, Frere C, Thiele T, Tanaka KA, Neal MD, Steiner ME, Connors JM, Levy JH. Anticoagulation in adult patients supported with extracorporeal membrane oxygenation: guidance from the Scientific and Standardization Committees on Perioperative and Critical Care Haemostasis and Thrombosis of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2023; 21:373-396. [PMID: 36700496 DOI: 10.1016/j.jtha.2022.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 01/26/2023]
Abstract
Anticoagulation of patients supported by extracorporeal membrane oxygenation is challenging because of a high risk of both bleeding and thrombotic complications, and often empirical. Practice in anticoagulation management is therefore highly variable. The scope of this guidance document is to provide clinicians with practical advice on the choice of an anticoagulant agent, dosing, and the optimal anticoagulant monitoring strategy during extracorporeal membrane oxygenation support in adult patients.
Collapse
Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA), Strasbourg University Hospital, Medical Intensive Care Unit - NHC, INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Corinne Frere
- Sorbonne Université, UMRS 1166, AP-HP. Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Thomas Thiele
- Institut für Transfusionsmedizin, Universitätsmedizin Rostock, Schillingallee 36, Rostock, Germany
| | - Kenichi A Tanaka
- Department of Anesthesiology, Universit of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Matthew D Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie E Steiner
- Division of Hematology/Oncology and Division of Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
10
|
Kowiwattanakarn S, Bhurayanontachai R. Duplicated inferior vena cava, the uncommon cause of decreasing extracorporeal membrane oxygenation blood flow: A case report and review. Perfusion 2022:2676591221090669. [PMID: 35575311 DOI: 10.1177/02676591221090669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Duplicated inferior vena cava (DIVC) is a rare anomaly of the venous system, which is mostly found accidentally during intra-abdominal surgery and radiographic study. This anomaly is asymptomatic but may be related to venous thromboembolism in some patients. We present a case of a patient who had inadequate drainage for extracorporeal membrane oxygenation, which was found to be related to duplicated inferior vena cava.
Collapse
Affiliation(s)
- Siriporn Kowiwattanakarn
- Critical Care Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Rungsun Bhurayanontachai
- Critical Care Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| |
Collapse
|
11
|
De Paulis S, Cavaliere F. Anticoagulation Management in High Bleeding-Risk ECMO in Adults. Front Cardiovasc Med 2022; 9:884063. [PMID: 35463781 PMCID: PMC9020579 DOI: 10.3389/fcvm.2022.884063] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stefano De Paulis
- Department of Cardiovascular Sciences, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - Franco Cavaliere
- Department of Cardiovascular Sciences, Fondazione Policlinico Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|