Complications Of Extracorporeal Membrane Oxygenation Research Articles

Plasmapheresis for extracorporeal membrane oxygenation (ECMO)-induced hemolysis in infants

Background: Intravascular hemolysis is a known complication of extracorporeal membrane oxygenation (ECMO). Characterized by elevated plasma-free hemoglobin (PFH), intravascular hemolysis is associated with cytotoxic effects leading to renal replacement therapy (RRT), longer ECMO runs and mortality. Therapeutic plasma exchange (TPE) in tandem with ECMO was described as a therapy for various pathologic conditions, but there are no ELSO guidelines for the treatment of ECMO-induced hemolysis. We describe the use of TPE in the management of severe ECMO-induced hemolysis. Methods: Two term neonates receiving veno-arterial (VA) ECMO developed severe PFH, with peak values over 500 mg/dL. TPE was performed in tandem with the ECMO circuit. Packed red cells were used to prime the TPE circuit, and citrate anticoagulation was added to establish the interface, which could not be achieved with existing heparin in the ECMO circuit. Therapy was completed with saline solution as a decoy for citrate, to avoid hypocalcemia and intracranial bleeding. Plasma volume was replaced by fresh frozen plasma (FFP). Results: In one patient PFH fell to 120 mg/dL, but rebounded to close to 500 mg/dL, only to stabilize between 210 and 300 mg/dL after the second TPE. He was liberated from ECMO, but could not survive a respiratory decompensation. The other patient’s PFH improved to 360 mg/dL after one TPE and continued to decline to 120 mg/dL over the ensuing days. Despite that improvement, care was withdrawn. Conclusion: TPE is effective in decreasing the burden of PFH, is well tolerated in tandem with ECMO, and a database of infants with ECMO-induced hemolysis needs to be created to assess the current practice, and establish clinical guidelines for its most appropriate therapy.

Emergency laparotomy and endoscopic gastrostomy in patients on extra-corporeal membrane oxygenation (ECMO) support.

An infrequent yet known complication of ECMO is abdominal compartment syndrome requiring emergency laparotomy. Also, the need for prolonged enteral nutrition while on ECMO may require endoscopic gastrostomy to maintain adequate nutritional status. Here we describe our experience with emergency laparotomy and endoscopic gastrostomy in patients on ECMO support. We retrieved patient histories from our clinical archives and performed a retrospective description of all patients taken to an emergency laparotomy or endoscopic gastrostomy while on ECMO support at our cardiovascular referral center from July 2019 through June 2024. During the research period of 5years a total of 401 patients were placed on ECMO support for either cardiogenic shock or respiratory failure. A total of 27 (7%) patients required an abdominal intervention while on ECMO. 14 (3.5%) patients required emergency laparotomy and 13 (3.2%) of patients required endoscopic gastrostomy tube placement. Overall 30-day mortality of all patients requiring a general surgery procedure while on ECMO support was 33%. ECMO support can result in many complications despite its many benefits. Patients who require emergency laparotomy while on ECMO have lower survival-to-discharge and higher mortality at 30days. Endoscopic gastrostomy however, can be safely performed on ECMO with little to no bleeding complications despite anticoagulation.

VV-ECMO in critical COVID-19 obese patients: a cohort study

BackgroundObesity causes significant difficulties in successful extracorporeal membrane oxygenation (ECMO) support and may interfere with patient outcomes. During the COVID-19 pandemic, we experienced an increased number of obese patients supported with ECMO in our intensive care unit due to severe illness in this population.MethodsWe designed a single-center retrospective study to identify prognostic factors for 180-day survival in obese critical COVID-19 patients receiving venovenous ECMO (VV-ECMO). We included adult critical COVID-19 patients on VV-ECMO, who were obese and overweight (according to the World Health Organization) and admitted to a tertiary hospital’s intensive care unit from April 1, 2020, to May 31, 2022. Univariate logistic regression analysis was performed to assess differences in 180-day mortality.ResultsForty-one patients were included. The median age was 55 (IQR 45–60) years, and 70.7% of the patients were male. The median body mass index (BMI) was 36 (IQR 31–42.5) kg/m2; 39% of patients had a BMI ≥ 40 kg/m2. The participants had 3 (IQR 1.5–4) days of mechanical ventilation prior to ECMO, and 63.4% were weaned from VV-ECMO support after a median of 19 (IQR 10–34) days. The median ICU length of stay was 31.9 (IQR 17.5–44.5) days. The duration of mechanical ventilation was 30 (IQR 19–49.5) days. The 180-day mortality rate was 41.5%. Univariate logistic regression analysis revealed that a higher BMI was associated with greater 180-day survival (OR 1.157 [1.038–1.291], p = 0.009). Younger age, female sex, less invasive ventilation time before ECMO, and fewer complications at the time of ECMO cannulation were associated with greater 180-day survival [OR 0.858 (0.774–0.953), p 0.004; OR 0.074 (0.008–0.650), p 0.019; OR 0.612 (0.401–0.933), p 0.022; OR 0.13 (0.03–0.740), p 0.022), respectively].ConclusionIn this retrospective cohort of critical COVID-19 obese adult patients supported by VV-ECMO, a higher BMI, younger age, and female sex were associated with greater 180-day survival. A shorter invasive ventilation time before ECMO and fewer complications at ECMO cannulation were also associated with increased survival.

Extracorporeal membrane oxygenation as life-saving bridge for patients with airway obstruction caused by neck and chest tumors to salvage procedure: an in-depth review

Narrowed or stenotic airways are frequently encountered in emergency practice. Neck and chest tumors-caused airway obstruction usually follow a severe clinical course, necessitating urgent ventilation as a bridge to perform emergency operations. In certain cases, traditional ventilation methods may not safely address complicated airway conditions. In such instances, a special cardiopulmonary support becomes necessary to manage both hemodynamics and ventilation for patients. Extracorporeal membrane oxygenation (ECMO) is considered a last-resort treatment for respiratory failure. When dealing with emergency difficult airway situations, ECMO offers certain advantages over conventional ventilation. However, its effectiveness in managing airway obstruction due to solid tumor located in neck or chest is not well-established due to limited clinical practice. Published articles about this topic are still limited, and primarily rely on case series and reports. As a result, they offer insufficient data and illustrations to fully elucidate emergency issues. In the present article, we summarize the existing literature concerning ECMO utility in managing patients with airway obstruction due to solid tumor located in neck or chest based on PubMed, Web of Science, and other medical databases, to conduct an in-depth review. We conducted an analysis of 27 studies, including a total of 54 patients with airway obstruction caused by tumors. All patients underwent surgical relief of airway obstruction with ECMO as ventilatory support. Postoperatively, 87% of the patients (47/54) survived. 7.4% of the patients (4/54) died due to postoperative disease progression, unrelated to ECMO complications. The prognosis of 5.6% of the patients (3/54) could not be obtained. Additionally, we present an interesting case series (n=5) based on a real-world research to demonstrate the different outcomes among airway-obstructed patients due to neck and chest masses. In this series, four patients supported by ECMO successfully discharged postoperatively, while one patient on conventional ventilation died due to respiratory collapse before surgery. Meanwhile, we share novel illustrations and clinical figures to supplement the understanding of this condition. The findings presented in this article provide a basis for further studies and can be used to improve management of the patients.

Usefulness of net retrieval devices for central airway obstruction caused by blood clots during extracorporeal membrane oxygenation: Case series.

Extracorporeal membrane oxygenation (ECMO) is the last trump card for severe respiratory failure. The main complications of ECMO are bleeding and thrombosis, both of which can be life-threatening. Large blood clots can cause central airway obstruction (CAO) during ECMO, and CAO should be removed as soon as possible because of asphyxiation. However, there is no comprehensive reports on its frequency and management. The purpose of this study is to share therapeutic experiences for rare and serious conditions and provide valuable insights. We report 3 patients placed on ECMO for severe respiratory failure. CAO due to large blood clots occurred during ECMO in all 3 patients. Large blood clots were removed using flexible bronchoscopy, grasping forceps, and net retrieval devices in all 3 patients. In all 3 patients, large blood clots were removed multiple times during ECMO. The patients' respiratory conditions improved and they were eventually weaned off the ECMO. CAO due to large blood clots during ECMO is rare. The frequency of CAO requiring bronchoscopic removal was estimated to be approximately 1,5%. When this occurs, clots should be removed as soon as possible. Net retrieval devices are useful tools for the collection of large blood clots.

ECMO produces very rapid changes in primary hemostasis detected by PFA-200 during lung transplantation: An observational study

BackgroundThe pathology of primary hemostasis is a common complication of extracorporeal membrane oxygenation (ECMO) support. Scientific data describing its changes in patients on short-term ECMO support and the ability and speed of the restoration of its functions are limited. AimsThe aim of this study was to describe the pathology of primary hemostasis induced by short-term ECMO support and its development over time using PFA-200®, ROTEM® platelet and von Willebrand factor (vWF) analyses. MethodsIn patients undergoing lung transplantation surgery using intra-operative veno-arterial ECMO support, blood samples were analyzed using the following tests: PFA-200®, ROTEM® platelet tests, vWF antigen, ristocetin cofactor (RCo) and collagen binding protein (CB) before, during and after ECMO support. ResultsBlood samples from 32 patients were analyzed. All three PFA-200® tests (COL/EPI, COL/ADP and COL/P2Y) showed significant deterioration during ECMO support with rapid restoration after ECMO cessation (p<0.05), suggesting an ECMO-induced primary hemostasis disorder. A significant increase of vWF antigen after ECMO cessation (p<0.05) was found with an increase of ristocetin cofactor and collagen binding protein levels, although it was not significant (p>0.05). ConclusionsShort-term ECMO support induces primary hemostasis pathology. It occurs immediately after initiation but is rapidly restored after ECMO cessation, which is detectable by PFA-200®. Despite there being persistent platelet dysfunction after ECMO cessation as seen with the ROTEM® platelet results, the increased levels of vWF antigen might explain the normal results of primary hemostasis detected by PFA-200®.

Management of Bleeding and Thrombotic Complications During Pediatric Extracorporeal Membrane Oxygenation: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference.

To derive systematic-review informed, modified Delphi consensus regarding the management of bleeding and thrombotic complications during pediatric extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE Consensus Conference. A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. The management of bleeding and thrombotic complications of ECMO. Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Twelve references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Two good practice statements, 5 weak recommendations, and 18 consensus statements are presented. Although bleeding and thrombotic complications during pediatric ECMO remain common, limited definitive data exist to support an evidence-based approach to treating these complications. Research is needed to improve hemostatic management of children supported with ECMO.

Complete thrombosis of a bioprosthetic mitral valve and left atrium in a patient on venoarterial extracorporeal membrane oxygenation with favorable outcome

Intra-cardiac thrombosis is a potentially devastating complication of extracorporeal membrane oxygenation (ECMO) mechanical circulatory support. We present here a patient who suffered complete thrombosis of a fresh mitral prosthesis and left atrium in the setting of ECMO with aortic insufficiency who was treated with repeat valve replacement and thrombectomy. To our knowledge, she is the only patient in the reported literature to have survived this complication.

Extracorporeal Membrane Oxygenation for Acute Lung Injury in Idiopathic Inflammatory Myopathies-A Potential Lifesaving Intervention.

Idiopathic inflammatory myopathies (IIM) can present with acute IIM-related lung injury and respiratory failure, leading to a high mortality risk in intensive care units (ICU). Extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome can be lifesaving. We aimed to report a case series of IIM patients that received ECMO. Patients with IIM from tertiary care centers in Belgium, Canada, Denmark, United States, and Sweden who underwent ECMO were reviewed to describe clinical characteristics, disease outcomes and hospitalization course. Clinical characteristics at admission and during ICU stay including ECMO complications and mortality causes were summarized. The study included 22 patients (50% female, mean±SD age at admission 47 ± 12 years) with anti-MDA5 positive dermatomyositis (68%), anti-synthetase syndrome (14%), polymyositis (9%), overlap myositis (5%) and non-MDA5 dermatomyositis (5%). Patients had low comorbidity scores and 46% had received immunosuppression before their ICU admission. Eight (36%) patients died in the ICU, six (27%) were bridged to recovery and eight (36%) were bridged to transplant. When comparing patients bridged to recovery and those who died in the ICU, those who died were older (p= 0.03) and had higher median Charlson comorbidity index scores (p= 0.05). Both groups had similar frequencies of ECMO-related complications (33% vs 50%, p= 0.94). In the patients exposed to ECMO in this case series, 14 were successfully bridged to recovery or transplant, while 8 died in the ICU. Large studies are needed to collect data on clinical outcomes in patients with IIM-ILD exposed to ECMO to identify the best candidates for the intervention.

#75 Extracorporeal membrane oxygenation (ECMO) in patients with acute kidney injury (AKI): a prospective, observational, multi-center study

Abstract Background and Aims Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with severe respiratory and/or cardiovascular failure. Acute kidney injury (AKI) is a frequent complication in ECMO, resulting in increased morbidity and mortality. We aim to evaluate impact of ECMO on AKI outcome in Kuwait. Method Demographics, comorbidities, management, and 30-day kidney and patient outcome data for adult inpatients with native kidneys with AKI who received ECMO in seven public hospitals in Kuwait from 1/January to 31/December 2021, were prospectively collected and analyzed. Results Total number of AKI cases during study period was 3744, but only 121 patients received ECMO, or only 3.2%, with mean age of 56.3 years; and mean baseline eGFR of 81.6 ml/min. Males were 62.8% of the cohort, and 91.7% of cases were hospital-acquired AKI. Only 21.5% had pre-existing CKD (mainly diabetic kidney disease), and only 26.5% were older than 65, however, 58.7% were diabetics, and 48% were hypertensive. COVID-19 infection was a cause for AKI in 69% of patients. ECMO was veno-venous in 90% of cases, and AKI developed before ECMO initiation in 62.8% of cases. Dialysis was provided for 92% with continuous kidney replacement therapy (CKRT) accounting for 97%, and 93% of patients were in ICU (all on inotropic support). At 30 days, 86.8% of the whole group died (91% of those died on dialysis), six patients remained alive on dialysis, and only four patients recovered kidney function completely. Conclusion Although ECMO utilization in patients with AKI is limited in our AKI cohort, and despite relatively young age and reasonable baseline eGFR for the cohort, ECMO is associated with high need for ICU admission, high incidence of AKI, high need for dialysis, and high mortality rates.

Echocardiographic and Point-of-Care Ultrasonography (POCUS) Guidance in the Management of the ECMO Patient.

Veno-arterial (V-A) and Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) support is increasingly utilized for acute cardiogenic shock and/or respiratory failure. Echocardiography and point-of-care ultrasonography (POCUS) play a critical role in the selection and management of these critically ill patients, however, there are limited guidelines regarding their application. This comprehensive review describes current and potential application of echocardiography and POCUS for pre-ECMO assessment and patient selection, cannulation guidance with emphasis on dual-lumen configurations, diagnosis of ECMO complications and trouble-shooting of cannula malposition, diagnosis of common cardiac or pulmonary pathologies, and assessment of ECMO weaning appropriateness including identification of the aortic mixing point in V-A ECMO.

Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation.

Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.

Survival of Infants With Severe Congenital Kidney Disease After ECMO and Kidney Support Therapy.

Congenital kidney failure not only affects the homeostatic functions of the kidney, but also affects neonatal respiratory integrity. Until recently, extracorporeal membrane oxygenation (ECMO) support was not used in this population because the need for ECMO clearly established nonviability. Since 2016, 31 neonates have been admitted to the NICU at Children's of Alabama with congenital kidney failure. Five patients were placed on ECMO for severe respiratory distress unresponsive to conventional interventions. We evaluated neonates with congenital kidney failure and pulmonary hypoplasia/hypertension refractory to conventional therapies who received ECMO support within the first 9 postnatal days. We describe the pre and postnatal diagnoses, ECMO course details, dialysis modalities, complications, procedures, and long-term outcomes of these patients. All 5 patients received kidney support therapy by postnatal day 7. Diagnoses included posterior urethral valves, bilateral renal dysplasia, and autosomal recessive polycystic kidney disease. Gestational age ranged from 35.6 to 37.1 weeks. Birth weight ranged from 2740 to 3140 g. Days on ECMO ranged from 4 to 23. Four survived and are living today. Pulmonary hypertension resolved in surviving patients. Three surviving patients require no oxygen support, and 1 patient requires nocturnal oxygen. Three survivors received a kidney transplant, and 1 awaits transplant evaluation. Patients with congenital kidney failure with severe pulmonary hypoplasia/pulmonary hypertension no longer warrant a reflexive assignment of nonviability. Meticulous ECMO, respiratory, nutritional, and kidney support therapies may achieve a favorable long-term outcome. Further investigation of strategies for optimal outcome is needed.

A Rare Case of Symmetrical Peripheral Gangrene in Central Venoarterial Extracorporeal Membrane Oxygenator in a Pediatric Patient, an Unusual Complication of Extracorporeal Membrane Oxygenation

Symmetrical peripheral gangrene is an unusual complication of extracorporeal membrane oxygenation (ECMO) which can arise due to low cardiac output state, high inotropic support, inadequate anticoagulation, disseminated intravascular coagulation, and sepsis. In symmetrical peripheral gangrene, there is no evidence of large vessel occlusion or vasculitis. It can be due to the absence of pulsatile flow in the peripheral arteries that result in stasis and microthrombi formation which causes occlusion of small arterioles. A 10-month-old male child who underwent anomalous left coronary artery from pulmonary artery repair and required central venoarterial ECMO support post-surgery due to severe myocardial dysfunction developed symmetrical peripheral ischemia with gangrenous changes in the right-hand fingers while on extracorporeal membrane oxygenation (ECMO). The limb ischemic changes improved to normal after the child convalesced from heart failure. We describe these changes and the management here.

Successful implementation of prophylactic veno-venoarterial extracorporeal membrane oxygenation in high-risk trauma surgery: A case report.

Extracorporeal Membrane Oxygenation (ECMO) is increasingly utilized in trauma care, yet its elective use during high-risk surgeries remains unreported. We report a successful instance of prophylactic ECMO support via a Veno-Venoarterial (V-VA) configuration during high-risk surgery in a patient with extensive trauma, including severe thoracic damage and a highly unstable thoracic spine fracture. V-VA ECMO prevented complications such as hemodynamic and respiratory collapse associated with chest compression during the surgical procedure, as the patient should be in a prone position. The potential of ECMO as prophylactic support in high-risk surgery amongst trauma patients underscores a novel application of this technology. Complex configurations must be evaluated to avoid associated ECMO complications. Our case highlights the potential of prophylactic ECMO hybrid modes, indicating their safe application during high-risk procedures in select trauma patients.

Extra corporeal membrane oxygenation therapy in acute respiratory distress syndrome due to Coronavirus-2019 (COVID-19): a retrospective study

Aims: Extra corporeal membrane oxygenation (ECMO) has been used as a supportive treatment in ARDS due to COVID-19. Although different results have been reported in the literature regarding its efficacy, ECMO is recommended as a salvage therapy for severe forms of the disease after standard therapy fails. In our study,we aimed to evaluate the survival outcomes of patients supported with ECMO for COVID-19.&#x0D; Methods: Our study was conducted by scanning the data of consecutive adult patients hospitalized in our intensive care unit due to COVID-19. The ECMO process was planned according to the Extracorporeal Life Support Organization (ELSO) and Berlin criteria.&#x0D; Results: 51 patients hospitalized for acute respiratory failure due to COVID-19 were taken to ECMO. Demographic data of patients; 39 (76.5%) men and 12 (23.5%) women. 46 (90.2%) of the patients died. The mean intubation time before ECMO is 3.9 days, and the mean time for non-invasive mechanical ventilation is 5.8 days. The mean PaO2 value before ECMO was79.09 mmHg, the mean PCO2 value was 63.62 mmHg and the mean PaO2/FiO2 ratio was 82.80.&#x0D; Conclusion: The use of ECMO by considering prognostic factors and guidelines is seen as factors that increase the chance of success.Despite the fact that the patients were admitted to ECMO in accordance with the guidelines in our study, the high mortality rate suggests that there is a need for investigation of other supportive treatments and studies to reduce ECMO complications.

Bridging the gap: safety and outcomes of intensivist-led ECMO retrievals.

Most extracorporeal membrane oxygenation (ECMO) cannulations are performed by cardiothoracic surgeons (CTS). Due to an increase in utilization of ECMO and limited availability of CTS, there is a mismatch between ECMO demand and CTS accessibility for remote cannulations. We report our intensivist-led program's experience in remote ECMO cannulations, retrievals, complications, and outcomes. A prospective, single-center, observational study was performed on patients that required ECMO cannulation at the referring facilities and were transported to our institution between program initiation, on October 1, 2014 to September 30, 2022. Results were presented as mean ± SD, median (min - max) or number (%). Since program commencement, 305 patients were accepted for ECMO retrieval. Three hundred and three patients were placed on ECMO at the 47 referring hospitals among 5 states. In our study, 185 (61%) patients required veno-arterial ECMO and 115 (38%) were placed on veno-venous ECMO. Three patients (1%) were cannulated for veno-arteriovenous ECMO. Twenty patients were cannulated under cardio-pulmonary resuscitation. Most of the patients were transported by ambulance (79%), 14% by helicopter, and 7% by airplane. Six out of the 303 patients did not leave the referring facility. All patients that left the referring hospitals arrived safely to our institution. No major complications occurred in route. Our study's findings indicate that non-CTS physicians can successfully cannulate and retrieve patients with a low complication profile.

Pediatric venoarterial and venovenous ECMO

Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure. To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology. This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques. Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation. Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.

Risk factors associated with in-hospital mortality in patients requiring extracorporeal membrane oxygenation in the perioperative period of heart transplantation

Objective: To explore risk factors associated with in-hospital mortality in patients requiring extracorporeal membrane oxygenation (ECMO) in the perioperative period of heart transplantation. Methods: The data of ECMO cases in the perioperative period of heart transplantation from the Chinese Society of Extracorporeal Life Support (CSECLS) between January 2017 and December 2021 were retrospectively analyzed. These patients were divided into the survival group and non-survival group according to their outcomes at discharge. The demographics, indications and complications of ECMO between the two groups were compared, and the related risk factors of poor prognosis were analyzed. Results: A total of 77 patients were included in the study, including 67 males and 10 females, with a median age [M(Q1, Q3)] of 48 (36, 59) years. Sixty-three patients (81.8%) were successfully withdrawn from the ECMO and 46 patients (59.7%) survived to discharge. The median ECMO time was 139 (92, 253) hours. Compared with the survival group, the non-survival group (n=31) had more patients with chronic kidney disease before surgery [22.6% (7/31) vs 4.3% (2/46), P=0.034], and a higher proportion of continuous renal replacement therapy (CRRT) during ECMO [74.2% (23/31) vs 50.0% (23/46), P=0.034]. Moreover, the non-survival group had longer duration of extracorporeal circulation [262 (195, 312) vs 201 (155, 261) min, P=0.056] and higher lactate value in the first 24 hours of ECMO support [2.7 (2.1, 4.7) vs 2.3 (1.4, 3.8) mmol/L, P=0.060], but the differences were not statistically significant. Multivariate logistic regression analysis showed that perioperative application of CRRT was an independent risk factor for poor prognosis in ECMO patients during heart transplantation (OR=19.345, 95%CI: 1.209-309.440, P=0.036). Conclusion: CRRT treatment during ECMO is a risk factor for in-hospital mortality in patients undergoing heart transplantation.

The Etiological and Drug Resistance Characteristics of Multidrug-Resistant Pathogens in Patients Requiring Extracorporeal Membrane Oxygenation: A Retrospective Cohort Study.

Infections induced by multidrug-resistant (MDR) pathogens are one of the most common and serious complications in extracorporeal membrane oxygenation (ECMO) patients. However, there is currently little research about "ECMO and MDR bacteria". The purpose of our study was to clarify the epidemiological characteristics of MDR bacteria and provide references for empiric antibiotic treatments according to the drug susceptibility tests for ECMO patients. There were 104 patients admitted to our department and receiving ECMO treatments between January 2014 and December 2022. Altogether, 61 veno-arterial ECMO (VA-ECMO) and 29 veno-venous ECMO (VV-ECMO) patients enrolled. The data on other intensive care unit (ICU) patients in our department in the same period are summarized. A total of 82 MDR bacteria were detected from ECMO patients, and most of these were MDR Gram-negative bacteria (MDR-GNB). There were also 5559 MDR-GNB collected from other patients in our department in the same period. We found that the distribution of MDR-GNB in ECMO patients was different from other critical patients. The proportion of Klebsiella pneumoniae (MDR-KP) in VV-ECMO patients was higher than other critical patients (35.1% and 21.3%, respectively). Moreover, the proportions of MDR Acinetobacter baumannii (MDR-AB) of VA-ECMO and VV-ECMO were higher than other critical patients (54.6%, 43.2% and 30.5%, respectively). In addition, MDR-AB and MDR-KP in ECMO patients exhibited higher percentages of drug resistance to possibly appropriate antibiotics for other critical patients, but showed better sensitivity to colistin. Infections induced by MDR-GNB in ECMO patients were serious and exhibited higher degrees of drug resistance compared with other ICU patients. Colistin might be an option to consider if there is no medical contraindication. However, widespread use of broad spectrum antibiotics is something that should be discouraged, and alternative options are being explored.