Microcirculatory assessment of patients under VA-ECMO.

Atila Kara,Robert J Van Thiel,Wouter De Wilde,Sakir Akin,Eric A Dubois,Felix Zijlstra,Ard Struijs,Can Ince,Diederik Gommers,Kadir Caliskan,Dinis Dos Reis Miranda

doi:10.1186/s13054-016-1519-7

Abstract

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival.MethodsTwenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48–72 h after initiation of VA-ECMO (T2), 5–6 days after (T3), 9–10 days after (T4), and within 24 h of VA-ECMO removal.ResultsOf the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm2, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772–1.0).ConclusionPVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1519-7) contains supplementary material, which is available to authorized users.

Highlights

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock
All consecutive patients requiring VA-ECMO for Cardiogenic shock (CS) were included in the study with the exception of two patients who died within 24 h for whom it was not possible to measure microcirculation due to continuous resuscitation in an overcrowded intensive care unit (ICU) box and for four patients who did not consent to inclusion in the study
The following data were recorded at ICU admission: age, gender, body mass index, Sequential Organ Failure Assessment (SOFA) score [21], Acute Physiology and Chronic Health Evaluation (APACHE) II score, indications for VA-ECMO, heart rate, mean arterial pressure, lactate, hemoglobin (Hb), hematocrit (Htc), platelet count, lactate dehydrogenase (LDH), free hemoglobin, N-terminal of the prohormone brain natriuretic peptide (NT-proBNP), high sensitive troponin T (HsTnT), creatine kinase (CK), MB fraction of creatine kinase (CK-MB), and echocardiographic parameters

Summary

Introduction

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. Cardiogenic shock (CS) has a high mortality rate and is defined as a state of tissue hypoperfusion induced by cardiac failure [1, 2]. Many conditions, such as acute myocardial infarction [3], end-stage dilated cardiomyopathy [4], myocarditis [5], complications following cardiac surgery [6], and cardiac arrest [7], can cause CS. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective, portable, and rapidly deployable technique for providing

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