Adult Extracorporeal Membrane Oxygenation Support Research Articles

193: PROGRAM-WIDE TRANSITION FROM HEPARIN TO BIVALIRUDIN ANTICOAGULATION IN ADULT ECMO: A COST ANALYSIS

Introduction: Bivalirudin is becoming an increasingly popular alternative to heparin for extracorporeal membrane oxygenation (ECMO) anticoagulation due to its short half-life, organ-independent metabolism, thrombin inhibition without the need for a co-factor, and its ability to bind clot-bound and freely circulating thrombin. The objective of this study was to compare the cost implications of bivalirudin and heparin during adult ECMO support. Methods: A retrospective analysis of adults supported on ECMO who received heparin or bivalirudin for anticoagulation between January 2014 and January 2022 at Mayo Clinic was performed. In November 2017, the Mayo Clinic ECMO program transitioned from heparin to bivalirudin as the primary anticoagulant of choice, which separated the pre- and post-transition groups. Cost data were estimated using Wholesale Acquisition Costs and laboratory reimbursement schedules. Cost data were normalized to duration of ECMO support, compared between the pre- and post-transition groups, and were summarized in United States Dollar ($). Results: A total of 126 patients (123 heparin, 3 bivalirudin) in the pre-transition period and 275 patients (82 heparin, 193 bivalirudin) in the post-transition period were included. Antithrombin administration was more frequent in the pre-transition group (31% vs. 12%, p < 0.0001), as were number of coagulation assays per ECMO day (6.1 vs. 5.4, p = 0.0004). The post-transition group had significantly less costs from antithrombin assessments ($1.03 vs. $11.78, p < 0.0001) and antithrombin supplementation ($0 [IQR $0, $0] vs. $0 [IQR $0, $312.82], p < 0.0001) per day of ECMO support. The aggregate costs per patient were similar in the heparin ($333 vs. $248, p = 0.5690) and bivalirudin ($2723 vs $1720, p = 0.4659) groups pre- and post-transition, respectively. Survival at 28-days was greater in the post-transition group (75% vs. 64%, p = 0.0286). Conclusions: Antithrombin assessment and supplementation comprised a majority of anticoagulant-related costs in heparin-based ECMO patients, which was significantly reduced following transition to bivalirudin-based anticoagulation. When considering laboratory and drug costs in aggregate, there is a favorable association between bivalirudin and heparin anticoagulation in adult ECMO patients.

Liver Dysfunction Associated With In-Hospital Mortality in Adult Extracorporeal Membrane Oxygenation Support.

OBJECTIVES:Extracorporeal membrane oxygenator support is a powerful clinical tool that is currently enjoying a resurgence in popularity. Wider use of extracorporeal membrane oxygenator support is limited by its significant risk profile and extreme consumption of resources. This study examines the role of markers of liver dysfunction in predicting outcomes of adult patients requiring extracorporeal membrane oxygenator support.DESIGN:Retrospective review.SETTING:Large extracorporeal membrane oxygenator center, Chicago, IL.PATIENTS:This study reports a single institution experience examining all adult patients for whom extracorporeal membrane oxygenator support was used over an 8-year period. Data were collected regarding patient demographics, details of extracorporeal membrane oxygenator support provided, laboratory data, and outcomes. Trends in liver function were examined for their ability to predict survival.INTERVENTION:Extracorporeal membrane oxygenator support, critical care.MEASUREMENTS AND MAIN RESULTS:Mean age was 50 years (range, 19–82 yr). There were 86 male patients (56.6%) and 66 female patients (43.4%). Indications for initiation of extracorporeal membrane oxygenator support included cardiac 76 patients (50.0%), respiratory 48 patients (31.6%), extracorporeal cardiopulmonary resuscitation 21 patients (13.3%), and combined cardiac/respiratory seven patients (4.6%). Mean duration of extracorporeal membrane oxygenator support was 17 days (range 1–223 d) or median 8 days (interquartile range, 4–17 d). Overall, in-hospital mortality was 56% (86/152). Forty-five percent of adult patients (68/152) surpassed at least one of the following established liver dysfunction thresholds: total bilirubin greater than 15 mg/dL, aspartate aminotransferase greater than 20× upper limit of normal, and alanine aminotransferase greater than 20× upper limit of normal. The multivariable logistic analysis yielded three significant findings associated with in-hospital mortality: highest total bilirubin greater than 15 (adjusted odds ratio = 4.40; 95% CI, 1.19–21.87; p = 0.04), age (adjusted odds ratio = 1.03; 95% CI, 1.00–1.05; p = 0.04), and highest lactate (adjusted odds ratio = 1.15; 95% CI, 1.06–1.26; p = 0.002).CONCLUSIONS:Increases in age, highest total bilirubin, and lactate all correlated with in-hospital mortality in multivariable analysis of patients requiring extracorporeal membrane oxygenator support.

Impact of massive blood transfusion during adult extracorporeal membrane oxygenation support on long-term outcomes: a nationwide cohort study in Taiwan.

ObjectivesBleeding is a common problem during adult extracorporeal membranes oxygenation (ECMO) support, requiring blood transfusion for correction of volume depletion and coagulopathy. The goal of this study is to investigate the long-term outcomes for adults under support of ECMO with massive blood transfusion (MBT).DesignRetrospective nationwide cohort study.SettingData were provided from Taiwan National Health Insurance Research Database (NHIRD).Participants and interventionsTotally 2757 adult patients were identified to receive MBT (red blood cell ≥10 units) during ECMO support from 2000 to 2013 via Taiwan NHIRD.Main outcome measuresThe outcomes included in-hospital major complications/mortality, all-cause mortality, cardiovascular death, newly onset end-stage renal disease and respiratory failure during the follow-up period.ResultsPatients with MBT had higher in-hospital mortality (65.6% vs 52.1%; OR 1.74; 95% CI 1.53 to 1.98) and all-cause mortality during the follow-up (47.0% vs 35.8%; HR 1.46; 95% CI 1.25 to 1.71) than those without MBT. Not only higher incidences of post ECMO sepsis, respiratory failure and acute kidney injury, but also longer duration of ECMO support, ventilator use and intensive care unit stay were demonstrated in the MBT group. Moreover, a subdistribution hazard model presented higher cumulative of respiratory failure (19.8% vs 16.2%; subdistribution HR 1.36; 95% CI 1.07 to 1.73) for the MBT cohort. Positive dose–dependent relationship was found between the amount of transfused red blood cell product and in-hospital mortality. In the MBT subgroup analysis for the impact of transfused ratio (fresh frozen plasma/packed red blood cell) on in-hospital mortality, ratio ≥1.0 had higher mortality.ConclusionsPatients with MBT during ECMO support had worse long-term outcomes than non-MBT population. The transfused amount of red blood cell had positive dose–dependent effect on in-hospital mortality.

Adult extracorporeal membrane oxygenation: an international survey of transfusion and anticoagulation techniques.

Extracorporeal membrane oxygenation (ECMO) is a method of life support for either isolated cardiac failure or respiratory failure, with or without cardiac failure. When used for hemodynamic support, the ECMO circuit presents a non-endothelialized, artificial surface to blood inciting an inflammatory response which activates haemostatic pathways. Anticoagulation may complicate a pre-existing coagulopathy and/or inadequate surgical hemostasis of varying severity. There is no standardized method to achieve and monitor anticoagulation or guide transfusion therapy during ECMO. We tested the hypothesis that institutions across the world conduct similar management of anticoagulation and transfusion during adult ECMO support. This is a descriptive, self-reporting cross-sectional survey of anticoagulation and transfusion practice for patients age 18 or older on ECMO. This 38 multiple-choice question survey was sent to 166 institutions, internationally, utilizing adult ECMO. About 32·4% (54) of institutions responded. Responses were anonymously collected. Descriptive analyses were calculated. Our findings indicate there appears to be a significant practice variation among institutions regarding anticoagulation and transfusion during adult ECMO support. The lack of standard practices among institutions may reflect a paucity of data regarding optimal anticoagulation and transfusion for patients requiring ECMO. Standardized protocols for anticoagulation and transfusion may help increase quality of care for and reduce morbidity, mortality and cost to patients and healthcare centres. Further study is required for standardized, high quality care.

Accumulation of Multipotent Progenitor Cells on Polymethylpentene Membranes During Extracorporeal Membrane Oxygenation.

Multipotent progenitor cells were mobilized during pediatric extracorporeal membrane oxygenation (ECMO). We hypothesize that these cells also adhered onto polymethylpentene (PMP) fibers within the membrane oxygenator (MO) during adult ECMO support. Mononuclear cells were removed from the surface of explanted PMP-MOs (n = 16). Endothelial-like outgrowth and mesenchymal-like cells were characterized by flow cytometric analysis using different surface markers. Spindle-shaped attaching cells were identified early, but without proliferative activity. After long-term cultivation palisading type or cobblestone-type outgrowth cells with high proliferative activity appeared and were characterized as (i) leukocytoid CD45+/CD31+ (CD133+/VEGFR-II+/CD90+/CD14+/CD146dim/CD105dim); (ii) endothelial-like CD45-/CD31+ (VEGF-RII+/CD146+/CD105+/CD133-/CD14-/CD90-); and (iii) mesenchymal-like cells CD45-/CD31- (CD105+/CD90+/CD133dim/VEGFR-II-/CD146-/CD14-). The distribution of the cell populations depended on the MO and cultivation time. Endothelial-like cells formed capillary-like structures and did uptake Dil-acetylated low-density lipoprotein. Endothelial- and mesenchymal-like cells adhered on the surface of PMP-MOs. Further research is needed to identify the clinical relevance of these cells.

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Introduction: Centrifugal blood pumps are being increasingly used to support adults requiring veno-venous (VV) extracorporeal membrane oxygenation support (ECMO). Hypothesis: Our aim was to determine if survival and ECMO related morbidities between adults undergoing VV ECMO differed by pump type. Methods: Adults > 18 years old who underwent VV ECMO support (n = 1585) during 2005 – 2011 and reported to the ECMO registry of the Extracorporeal Life Support Organization with inclusion of pump identity. Data were limited to VV mode and for those patients who underwent more than 1 run of ECMO, only data from the first run was analyzed (n = 907). Using Greedy 1:1 propensity score matching of pre-ECMO characteristics, we compared ECMO-related outcomes in adults supported with centrifugal versus roller style pumps. Results: A total of 406 patients (203 in per pump type) were included. There were no significant differences in pre-ECMO related variables. Adults supported with centrifugal pumps had increased odds of hemolysis OR=5.4 [95% CI 2.3 – 12.6], however, had a decreased odds of diagnosis of surgical bleeding OR=0.51 [0.28 – 0.93] and diagnosis of pneumothorax OR=0.49 [0.26 – 0.93]. There was no difference in odds of acute renal injury between pump type. Survival did not differ between groups. Conclusions: In a propensity score matched cohort of adult ECMO patients, adults supported with centrifugal pumps had increased odds of hemolysis. However there was no difference in odds of renal injury or survival between pump type.

Adult Extracorporeal Membrane Oxygenation Support in Moribund Sepsis May Improve Outcomes

Adult Extracorporeal Membrane Oxygenation Support in Moribund Sepsis May Improve Outcomes