Abstract
ObjectivesTechnical complications are a known hazard in veno-venous extracorporeal membrane oxygenation (vvECMO). Identifying these complications and predictive factors indicating a developing system-exchange was the goal of the study.MethodsRetrospective study on prospectively collected data of technical complications including 265 adult patients (Regensburg ECMO Registry, 2009-2013) with acute respiratory failure treated with vvECMO. Alterations in blood flow resistance, gas transfer capability, hemolysis, coagulation and hemostasis parameters were evaluated in conjunction with a system-exchange in all patients with at least one exchange (n = 83).ResultsValues presented as median (interquartile range). Patient age was 50(36–60) years, the SOFA score 11(8–14.3) and the Murray lung injury Score 3.33(3.3–3.7). Cumulative ECMO support time 3411 days, 9(6–15) days per patient. Mechanical failure of the blood pump (n = 5), MO (n = 2) or cannula (n = 1) accounted for 10% of the exchanges. Acute clot formation within the pump head (visible clots, increase in plasma free hemoglobin (frHb), serum lactate dehydrogenase (LDH), n = 13) and MO (increase in pressure drop across the MO, n = 16) required an urgent system-exchange, of which nearly 50% could be foreseen by measuring the parameters mentioned below. Reasons for an elective system-exchange were worsening of gas transfer capability (n = 10) and device-related coagulation disorders (n = 32), either local fibrinolysis in the MO due to clot formation (increased D-dimers [DD]), decreased platelet count; n = 24), or device-induced hyperfibrinolysis (increased DD, decreased fibrinogen [FG], decreased platelet count, diffuse bleeding tendency; n = 8), which could be reversed after system-exchange. Four MOs were exchanged due to suspicion of infection.ConclusionsThe majority of ECMO system-exchanges could be predicted by regular inspection of the complete ECMO circuit, evaluation of gas exchange, pressure drop across the MO and laboratory parameters (DD, FG, platelets, LDH, frHb). These parameters should be monitored in the daily routine to reduce the risk of unexpected ECMO failure.
Highlights
Over the last 40 years, extracorporeal membrane oxygenation (ECMO) has been used to support adult patients with respiratory or cardiac failure who are unlikely to survive conventional mechanical ventilation [1]
The most common technical complication with ECMO is clot formation [20]. This retrospective review detailing technical reasons for an ECMO systemexchange in 83/265 patients showed that life-threatening acute mechanical ECMO failure occurred in 10%, and an acute thrombosis of the oxygenator or blood pump in 35%, of which more than half of the cases showed preceeding alterations in gas exchange, laboratory values or an increased resistance of the MO. 55% of the system-exchanges could be done electively due to worsening of gas transfer or device-related coagulation disorders
This study showed that monitoring of gas transfer data, the pressure drop across the MO and of DD might facilitate early identification of respective diffusion barriers
Summary
Over the last 40 years, extracorporeal membrane oxygenation (ECMO) has been used to support adult patients with respiratory or cardiac failure who are unlikely to survive conventional mechanical ventilation [1]. None of the recently published systematic reviews and pooled analyses of retrospective studies focused on the development of technical complications while on ECMO [9]. This is the first experience report by a single ECMO center to evaluate early technical complications on ECMO, which might be relevant for a systemexchange
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