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Niles E, Haase DJ, Tran Q, Gerding JA, Esposito E, Dahi S, Galvagno SM, Boswell K, Rector R, Pearce R, Abdel-Wahab M, Singh A, Pirzada S, Tabatabai A, Powell EK. Triage of V-V ECMO referrals for COVID-19 respiratory failure. Artif Organs 2024; 48:665-674. [PMID: 38551363 DOI: 10.1111/aor.14723] [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] [Received: 08/30/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND As the pandemic progressed, the use of extracorporeal membrane oxygenation (ECMO) for COVID-19-related acute respiratory distress syndrome increased, and patient triage and transfer to ECMO centers became important to optimize patient outcomes. Our objectives are to identify predictors of patient transfer for veno-venous extracorporeal membrane oxygenation (V-V ECMO) evaluation as well as to describe the outcomes of accepted patients. METHODS This is a single-center, retrospective analysis of V-V ECMO transfer requests for adult patients with known or suspected COVID-19 and respiratory failure from March 2020 until March 2021. Data were collected prospectively during the triage process for transfer requests as part of clinical patient care at our institution. RESULTS Of 341 referred patients, 112 (33%) were accepted for transfer to our facility, whereas 229 (67%) patients were declined for transfer. The Classification and Regression Tree analysis showed that patients' high pressure during airway pressure release ventilation (APRV) and age were the variables most significantly associated with the decision to accept or decline patients for transfer. CONCLUSIONS Our triage process enabled one-third of referred patients to be transferred for evaluation, with nearly 70% of those patients ultimately receiving ECMO support. High ventilator settings on APRV and young age were associated with acceptance for transfer. Accepted patients also had a higher incidence of adjunctive therapies (proning and paralysis) prior to transfer request, less cardiac or renal dysfunction, and a shorter duration of mechanical ventilation. Further research is warranted to investigate the outcomes of nontransferred patients.
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Affiliation(s)
- Erin Niles
- Critical Care Resuscitation Unit, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Daniel J Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Quincy Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - James A Gerding
- Critical Care Resuscitation Unit, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Emily Esposito
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Siamak Dahi
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly Boswell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Raymond Rector
- Perfusion Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Robert Pearce
- University of Maryland Access Center, Linthicum Heights, Maryland, USA
| | - Maie Abdel-Wahab
- University of Maryland School of Medicine, Research Assistant Program, Baltimore, Maryland, USA
| | - Aditi Singh
- University of Maryland School of Medicine, Research Assistant Program, Baltimore, Maryland, USA
| | - Saad Pirzada
- University of Maryland School of Medicine, Research Assistant Program, Baltimore, Maryland, USA
| | - Ali Tabatabai
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth K Powell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Mazuru V, Mang S, Ajouri J, Muellenbach RM, Bals R, Feth M, Zeiner C, Wengenmayer T, Lepper PM, Rixecker TM, Seiler F. External Validation of the PREdiction of Survival on Extracorporeal Membrane Oxygenation Therapy (PRESET) Score: A Single Center Cohort Experience. ASAIO J 2024:00002480-990000000-00480. [PMID: 38728743 DOI: 10.1097/mat.0000000000002226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition affecting >10% of intensive care unit (ICU) patients worldwide with a mortality of up to 59% depending on severity. Extracorporeal membrane oxygenation (ECMO) is a potentially life-saving procedure in severe ARDS but is technically and financially challenging. In recent years, various scoring systems have been proposed to select patients most likely to benefit from ECMO, with the PREdiction of Survival on ECMO Therapy (PRESET) score being one of the most used. We collected data from 283 patients with ARDS of various etiology who underwent veno-venous (V-V) ECMO therapy at a German tertiary care ICU from January 2012 to December 2022. Median age in the cohort was 56 years, and 64.31% were males. The in-hospital mortality rate was 50.88% (n = 144). The median (25%; 75% quartile) severity scores were 38 (31; 49) for Simplified Acute Physiology Score (SAPS) II, 12 (10; 13) for Sequential Organ Failure Assessment (SOFA) and 7 (5; 8) for PRESET. Simplified Acute Physiology Score-II displayed the best prognostic value (area under the receiver operating characteristic [AUROC]: 0.665 [confidence interval (CI): 0.574-0.756; p = 0.046]). Prediction performance was weak in all analyzed scores despite good calibration. Simplified Acute Physiology Score-II had the best discrimination after adjustment of our original cohort. The use of scores explored in this study for patient selection for eligibility for V-V ECMO is not recommendable.
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Affiliation(s)
- Vitalie Mazuru
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Sebastian Mang
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Jonas Ajouri
- Department of Anaesthesiology and Critical Care Medicine, Klinikum Kassel, Germany
| | - Ralf M Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Klinikum Kassel, Germany
| | - Robert Bals
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Maximilian Feth
- Department of Anesthesiology, Critical Care, Emergency and Pain Medicine, Military Medical Center Ulm, Ulm, Germany
| | - Carsten Zeiner
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp M Lepper
- Department of Emergency Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Torben M Rixecker
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
| | - Frederik Seiler
- From the Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Medical Center and University of Saarland, Homburg, Germany
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Hayanga JWA, Kakuturu J, Dhamija A, Asad F, McCarthy P, Sappington P, Badhwar V. Cannulate, extubate, ambulate approach for extracorporeal membrane oxygenation for COVID-19. J Thorac Cardiovasc Surg 2023; 166:1132-1142.e33. [PMID: 35396123 PMCID: PMC8915439 DOI: 10.1016/j.jtcvs.2022.02.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/07/2022] [Accepted: 02/23/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We compared outcomes in patients with severe COVID-19 versus non-COVID-19-related acute respiratory distress syndrome (ARDS) managed using a dynamic, goal-driven approach to venovenous extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective, single-center analysis of our institutional ECMO registry using data from 2017 to 2021. We used Kaplan-Meier plots, Cox proportional hazard models, and propensity score analyses to evaluate the association of COVID-19 status (COVID-19-related ARDS vs non-COVID-19 ARDS) and survival to decannulation, discharge, tracheostomy, and extubation. We also conducted subgroup analyses to compare outcomes with the use of extracorporeal cytoreductive techniques (CytoSorb [CytoSorbents Corp] and plasmapheresis). RESULTS The sample comprised 128 patients, 50 with COVID-19 and 78 with non-COVID-19 ARDS. Advancing age was associated with decreased probability of survival to decannulation (P = .04). Compared with the non-COVID-19 ARDS group, patients with COVID-19 had a greater probability of survival to extubation (P < .01) and comparable survival to discharge (P = .14). CONCLUSIONS Patients with COVID-19 managed with ECMO had comparable outcomes as patients with non-COVID ARDS. A strategy of early extubation and ambulation might be a safe and effective strategy to improve outcomes and survival, even for patients with severe COVID-19.
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Affiliation(s)
- J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Fatima Asad
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Paul McCarthy
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Penny Sappington
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
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Shah N, Xue B, Xu Z, Yang H, Marwali E, Dalton H, Payne PPR, Lu C, Said AS. Validation of extracorporeal membrane oxygenation mortality prediction and severity of illness scores in an international COVID-19 cohort. Artif Organs 2023; 47:1490-1502. [PMID: 37032544 DOI: 10.1111/aor.14542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a lifesaving support modality for severe respiratory failure, but its resource-intensive nature led to significant controversy surrounding its use during the COVID-19 pandemic. We report the performance of several ECMO mortality prediction and severity of illness scores at discriminating survival in a large COVID-19 V-V ECMO cohort. METHODS We validated ECMOnet, PRESET (PREdiction of Survival on ECMO Therapy-Score), Roch, SOFA (Sequential Organ Failure Assessment), APACHE II (acute physiology and chronic health evaluation), 4C (Coronavirus Clinical Characterisation Consortium), and CURB-65 (Confusion, Urea nitrogen, Respiratory Rate, Blood Pressure, age >65 years) scores on the ISARIC (International Severe Acute Respiratory and emerging Infection Consortium) database. We report discrimination via Area Under the Receiver Operative Curve (AUROC) and Area under the Precision Recall Curve (AURPC) and calibration via Brier score. RESULTS We included 1147 patients and scores were calculated on patients with sufficient variables. ECMO mortality scores had AUROC (0.58-0.62), AUPRC (0.62-0.74), and Brier score (0.286-0.303). Roch score had the highest accuracy (AUROC 0.62), precision (AUPRC 0.74) yet worst calibration (Brier score of 0.3) despite being calculated on the fewest patients (144). Severity of illness scores had AUROC (0.52-0.57), AURPC (0.59-0.64), and Brier Score (0.265-0.471). APACHE II had the highest accuracy (AUROC 0.58), precision (AUPRC 0.64), and best calibration (Brier score 0.26). CONCLUSION Within a large international multicenter COVID-19 cohort, the evaluated ECMO mortality prediction and severity of illness scores demonstrated inconsistent discrimination and calibration highlighting the need for better clinically applicable decision support tools.
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Affiliation(s)
- Neel Shah
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Bing Xue
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ziqi Xu
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Hanqing Yang
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Eva Marwali
- National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Heidi Dalton
- INOVA Fairfax Hospital, Falls Church, Virginia, USA
| | - Philip P R Payne
- Institute for Informatics, School of Medicine, Washington University in St. Louis, Missouri, St. Louis, USA
| | - Chenyang Lu
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
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Xue B, Shah N, Yang H, Kannampallil T, Payne PRO, Lu C, Said AS. Multi-horizon predictive models for guiding extracorporeal resource allocation in critically ill COVID-19 patients. J Am Med Inform Assoc 2023; 30:656-667. [PMID: 36575995 PMCID: PMC10018267 DOI: 10.1093/jamia/ocac256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/07/2022] [Accepted: 12/27/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) resource allocation tools are currently lacking. We developed machine learning (ML) models for predicting COVID-19 patients at risk of receiving ECMO to guide patient triage and resource allocation. MATERIAL AND METHODS We included COVID-19 patients admitted to intensive care units for >24 h from March 2020 to October 2021, divided into training and testing development and testing-only holdout cohorts. We developed ECMO deployment timely prediction model ForecastECMO using Gradient Boosting Tree (GBT), with pre-ECMO prediction horizons from 0 to 48 h, compared to PaO2/FiO2 ratio, Sequential Organ Failure Assessment score, PREdiction of Survival on ECMO Therapy score, logistic regression, and 30 pre-selected clinical variables GBT Clinical GBT models, with area under the receiver operator curve (AUROC) and precision recall curve (AUPRC) metrics. RESULTS ECMO prevalence was 2.89% and 1.73% in development and holdout cohorts. ForecastECMO had the best performance in both cohorts. At the 18-h prediction horizon, a potentially clinically actionable pre-ECMO window, ForecastECMO, had the highest AUROC (0.94 and 0.95) and AUPRC (0.54 and 0.37) in development and holdout cohorts in identifying ECMO patients without data 18 h prior to ECMO. DISCUSSION AND CONCLUSIONS We developed a multi-horizon model, ForecastECMO, with high performance in identifying patients receiving ECMO at various prediction horizons. This model has potential to be used as early alert tool to guide ECMO resource allocation for COVID-19 patients. Future prospective multicenter validation would provide evidence for generalizability and real-world application of such models to improve patient outcomes.
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Affiliation(s)
- Bing Xue
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Neel Shah
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Hanqing Yang
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University in St. Louis, St. Louis, Missouri, USA
- Institute of Informatics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Philip Richard Orrin Payne
- Institute of Informatics, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Chenyang Lu
- Department of Computer Science & Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ahmed Sameh Said
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
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Predictive models in extracorporeal membrane oxygenation (ECMO): a systematic review. Syst Rev 2023; 12:44. [PMID: 36918967 PMCID: PMC10015918 DOI: 10.1186/s13643-023-02211-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the last years to provide hemodynamic and respiratory support in critically ill patients. In this scenario, prognostic scores remain essential to choose which patients should initiate ECMO. This systematic review aims to assess the current landscape and inform subsequent efforts in the development of risk prediction tools for ECMO. METHODS PubMed, CINAHL, Embase, MEDLINE and Scopus were consulted. Articles between Jan 2011 and Feb 2022, including adults undergoing ECMO reporting a newly developed and validated predictive model for mortality, were included. Studies based on animal models, systematic reviews, case reports and conference abstracts were excluded. Data extraction aimed to capture study characteristics, risk model characteristics and model performance. The risk of bias was evaluated through the prediction model risk-of-bias assessment tool (PROBAST). The protocol has been registered in Open Science Framework ( https://osf.io/fevw5 ). RESULTS Twenty-six prognostic scores for in-hospital mortality were identified, with a study size ranging from 60 to 4557 patients. The most common candidate variables were age, lactate concentration, creatinine concentration, bilirubin concentration and days in mechanical ventilation prior to ECMO. Five out of 16 venous-arterial (VA)-ECMO scores and 3 out of 9 veno-venous (VV)-ECMO scores had been validated externally. Additionally, one score was developed for both VA and VV populations. No score was judged at low risk of bias. CONCLUSION Most models have not been validated externally and apply after ECMO initiation; thus, some uncertainty whether ECMO should be initiated still remains. It has yet to be determined whether and to what extent a new methodological perspective may enhance the performance of predictive models for ECMO, with the ultimate goal to implement a model that positively influences patient outcomes.
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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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Shah N, Said AS. Extracorporeal Support Prognostication-Time to Move the Goal Posts? MEMBRANES 2021; 11:537. [PMID: 34357187 PMCID: PMC8304743 DOI: 10.3390/membranes11070537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 12/21/2022]
Abstract
Advances in extracorporeal membrane oxygenation (ECMO) technology are associated with expanded indications, increased utilization and improved outcome. There is growing interest in developing ECMO prognostication scores to aid in bedside decision making. To date, the majority of available scores have been limited to mostly registry-based data and with mortality as the main outcome of interest. There continues to be a gap in clinically applicable decision support tools to aid in the timing of ECMO cannulation to improve patients' long-term outcomes. We present a brief review of the commonly available adult and pediatric ECMO prognostication tools, their limitations, and future directions.
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Affiliation(s)
- Neel Shah
- Division of Pediatric Critical Care, Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, MO 63130, USA;
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