Nosocomial Infections in Adult Patients Supported by Extracorporeal Membrane Oxygenation in a Cardiac Intensive Care Unit

Frequency, characteristics, and outcome of adult patients with multiple consecutive health care-associated infections undergoing extracorporeal membrane oxygenation: A retrospective analysis

BACKGROUND

Data on multiple consecutive health care-associated infections (HAIs) in patients undergoing extracorporeal membrane oxygenation (ECMO) are limited. We aim to identify the characteristics and outcomes of multiple, consecutive HAIs.

METHODS

This retrospective study included adult patients who underwent ECMO in a single cardiac ICU in China from May 2015 to December 2022. The incidence, clinical characteristics, risk factors, and impact on in-hospital mortality among patients with non-HAI, single HAI, and multiple HAIs were analyzed. Pathogens and infection sites for each new episode were compared.

RESULTS

Of 192 patients, 92 (47.92%) developed 141 separate infections, with 41 (21.35%) experiencing multiple infections during a single ECMO period. Respiratory tract infections (RTIs) constituted the majority (75.89%), and gram-negative bacteria were the predominant pathogens (71.63%). RTIs decreased from 86.9% in the first infection to 14.3% in the third (P < .001), while bloodstream infections increased from 10.9 % to 57.1% (P < .001). The proportion of gram-positive bacteria increased from 9.8% to 42.9% (P = .032). Prolonged ECMO duration was the only independent risk factor for multiple consecutive HAIs (odds ratio (OR)=1.220, P < .001).

CONCLUSIONS

Multiple consecutive HAIs during ECMO were frequent, with distinct microbiological changes between initial and subsequent HAIs.

Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis

BACKGROUND

An increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-analysis aim to assess the incidence and risk factors of NIs in adult.

METHODS

We searched PubMed, Scopus, Web of Science, and ProQuest databases up to 2022. The primary endpoint was incidence of NI. Secondary endpoints included time to infection, source of infection, ECMO duration, Intensive care and hospital length of stay (LOS), ECMO survival and overall survival. Incidence of NI was reported as pooled proportions and 95% confidence intervals (CIs), while dichotomous outcomes were presented as risk ratios (RR) as the effective index and 95% CIs using a random-effects model.

RESULTS

Among the 4,733 adult patients who received ECMO support in the 30 included studies, 1,249 ECMO-related NIs per 1000 ECMO-days was observed. The pooled incidence of NIs across 18 studies involving 3424 patients was 26% (95% CI 14-38%).Ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) were the most common NI sources. Infected patients had lower ECMO survival and overall survival rates compared to non-infected patients, with risk ratio values of 0.84 (95% CI 0.74-0.96, P = 0.01) and 0.80 (95% CI 0.71-0.90, P < 0.001), respectively.

CONCLUSION

Results showed that 16% and 20% lower of ECMO survival and overall survival in patients with NI than patients without NI, respectively. However, NI increased the risk of in-hospital mortality by 37% in infected patients compared with non-infected patients. In addition, this study identified the significant positive correlation between ECMO duration and ECMO-related NI.

Infection in ECMO patients: Changes in epidemiology, diagnosis and prevention

Patients with prolonged duration of extracorporeal membrane oxygenation support (ECMO) are a vulnerable population for sepsis, particularly ventilator-associated pneumonia and bloodstream infections. Rates differ between venous-arterial and venous-venous ECMO patients and according to the cannulation technique used. The presence of particular organisms depends on local epidemiology, antibiotic exposure, and the duration of the intervention; patients undergoing ECMO for more than three weeks present a high risk of persistent candidemia. Recognizing predisposing factors, and establishing the best preventive interventions and therapeutic choices are critical to optimizing the management of these complications. Infection control practices, including shortening the period of the indwelling devices, and reducing antibiotic exposure, must be followed meticulously. Innovations in oxygenator membranes require an updated approach. Hand hygiene and avoiding breaking the circuit-oxygenator sterility are cornerstones. ECMO management would benefit from clearer definitions, optimization of infection control strategies, and updated infectious clinical practice guidelines.

Effectiveness of a Game-Based Mobile App for Educating Intensive Critical Care Specialist Nurses in Extracorporeal Membrane Oxygenation Pipeline Preflushing: Quasi-Experimental Trial

Background

In the context of training specialist nurses and nursing education, a game-based mobile app was used as a simulation to teach intensive critical care specialist nurses the knowledge and skills of extracorporeal membrane oxygenation (ECMO) pipeline preflushing.

Objective

This study aimed to evaluate the impact of a game-based mobile app on improving ECMO pipeline preflushing skills in intensive critical care specialist nurses.

Methods

A total of 86 intensive critical care specialist nurses who were learning ECMO for the first time were included in this study. The nurses were divided into 2 groups: a control group (n=43) and an experimental group (n=43). Participants in the experimental group used a game-based mobile app for simulation exercises; the control group received no additional intervention. All participants took a theoretical test and a skill operation test at the beginning of the study and 1 week later. The differences in scores between the 2 groups were compared, and the learning curve of the experimental group was observed.

Results

The final theoretical test scores (88.44 and 85.02) and skill operation test scores (89.42 and 86.33) of the experimental group and control group, respectively, were significantly higher than those of the initial tests (theoretical test scores: 75.88 and 74.42; skill operation test scores: 75.44 and 75.93; all P<.001). The scores of the final theoretical test (88.44) and the final skill operation test (89.42) in the experimental group were higher than the scores of the control group (85.02; P<.001 and 86.33; P<.001, respectively). Learning curve analysis showed that the experimental group needed an average of 17 operations to master the skill.

Conclusions

This study suggests that a game-based mobile app may be more effective for intensive critical care specialist nurses in ECMO pipeline preflushing education than traditional Chinese lecture-practice education.