Days Of Extracorporeal Membrane Oxygenation Support Research Articles

Azerbaijan's first successful ECMO patient management – 4 year survival

We present the first successful Extracorporeal Membrane Oxygenation (ECMO) case in our Azerbaijan. After 5 days of ECMO support, the patient have been weaned from ECMO. Following that period, the application of ECMO support has remained an ongoing practice within our clinic. Consequently, we have undertaken the deliberate initiative of presenting an extensive follow-up of 4 years for our pioneering ECMO patient.

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.

Characteristics and outcomes in extracorporeal membrane oxygenation support in COVID-19 patients: A nationwide cohort-study in Argentina

IntroductionOne of the great challenges during the COVID-19 pandemic was the management of ventilatory support. Extracorporeal membrane oxygenation (ECMO) was the main strategy for the management of refractory acute respiratory distress syndrome. ObjectiveRetrospective, multicentre cohort study of adult patients who required extracorporeal membrane oxygenation (ECMO) in participating centers. Clinical and paraclinical characteristics were recorded. A comparison was made between surviving and non-surviving patients. In addition, time from symptom onset to ECMO placement, time from mechanical ventilation, and cannulation were analyzed. Material and methodsRetrospective, multicentre cohort study of adult patients who required extracorporeal membrane oxygenation (ECMO) in participating centers. Clinical and paraclinical characteristics were recorded. A comparison was made between surviving and non-surviving patients. In addition, time from symptom onset to ECMO placement, time from mechanical ventilation, and cannulation were analyzed. ResultsTwenty-six patients were included in the analysis. Mortality during ECMO was 42.3% (n=11) and overall hospital mortality was 65.3% (n=17). The patient cohort did not differ in terms of sociodemographic characteristics and predictors of mortality at ICU admission between survivors and non-survivors. Mobile ECMO was performed in 10 patients, while 16 were cannulated in situ at the participating centers. The median time from symptom onset to ECMO was 14.5 days (IQR 10.7–21.5), 11 days (IQR 9.5–15.5) in the survivor group, and 17 days (IQR 12.5–27) in non-survivors. The median IMV time was 28.5 (IQR 13–38.25) days. Driving pressure (12 vs 10cmH2O; p<.01), compliance (37.2 vs 21.4ml/cmH2O; p<.01), and mechanical power (17.4 vs 11.3J/min; p=.051) of the respiratory system showed statistically significant differences when comparing survivors and non-survivors, during the 3rd day of ECMO support. ConclusionIn our cohort, mortality after ECMO and after 30 days of hospital stay, was 42.3%, similar to that stated on the extracorporeal life support organization (ELSO) COVID-19 registry dashboard. Information about patients with COVID-19 who required ECMO during the first wave in Argentina was provided in this analysis.

Use of High Dose Corticosteroids Reversed COVID-19 Associated ARDS in a Patient Listed for Lung Transplantation

IntroductionIn acute respiratory distress syndrome (ARDS) patients with irreversible lung damage, lung transplantation from a ventilator and/or extracorporeal membrane oxygenation support (ECMO) is feasible. Recently, selection criteria for lung transplant candidates with a COVID-19 associated ARDS have been published. Here, we report the efficacy of high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation.Case ReportA 50-year-old female with a medical history of Multiple Sclerosis (relapsing-remitting type under treatment with anti-alpha4 -integrin therapy), was tested positive for COVID-19. She deteriorated and was admitted to the hospital. High flow oxygen and dexamethasone (six milligram daily), were started but unfortunately, she developed a severe ARDS with need for mechanical ventilation and ECMO support. Corticosteroids according to the Meduri scheme and ciprofloxacin were started. Weaning trials were initiated but failed and CT-thorax showed consolidation and presumed fibrosis. After 37 days on ECMO, she was evaluated and listed for bilateral lung transplantation. A corticosteroid pulse therapy of 1000 mg of methylprednisolone IV for three days during antibiotic coverage with piperacillin/tazobactam was started and within three days the clinical condition of the patient improved and she could be weaned from ECMO (51 days of ECMO) and delisted from the lung transplantation waiting list. Nowadays, patient does not require oxygen, is at home and revalidating.SummaryHere, we report the efficacy of a regimen with high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation. Corticosteroids are beneficial for immunomodulation and may reduce hyperinflammation. Our trial with administration of high dose corticosteroids pulse therapy in COVID-19 ARDS patients refractory to corticosteroids according to “classical schemes” has been successful and is informative. Further studies, will hopefully further elucidate responders and non-responders to high dose corticosteroid pulse therapy and preferably answer the question if prophylactic use of antibiotics and antifungals (in view of possible complications such as pulmonary aspergillosis and mucormycosis) is prudent in this vulnerable group.

Lung Ultrasound in Pediatric Acute Respiratory Distress Syndrome Received Extracorporeal Membrane Oxygenation: A Prospective Cohort Study.

ObjectiveThe aim of this study was to assess the prognostic value of the lung ultrasound (LUS) score in patients with pediatric acute respiratory distress syndrome (pARDS) who received extracorporeal membrane oxygenation (ECMO).MethodsA prospective cohort study was conducted in a pediatric intensive care unit (PICU) of a tertiary hospital from January 2016 to June 2021. The severe pARDS patients who received ECMO were enrolled in this study. LUS score was measured at initiation of ECMO (LUS-0 h), then at 24 h (LUS-24 h), 48 h (LUS-48 h), and 72 h (LUS-72 h) during ECMO, and when weaned from ECMO (LUS-wean). The value of LUS scores at the first 3 days of ECMO as a prognostic predictor was analyzed.ResultsTwenty-nine children with severe pARDS who received ECMO were enrolled with a median age of 26 (IQR 9, 79) months. The median duration of ECMO support was 162 (IQR 86, 273) h and the PICU mortality was 31.0% (9/29). The values of LUS-72 h and LUS-wean were significantly lower in survivors than that in non-survivors (both P < 0.001). Daily fluid balance volume during the first 3 days of ECMO support were strongly correlated with LUS score [1st day: r = 0.460, P = 0.014; 2nd day: r = 0.540, P = 0.003; 3rd day: r = 0.589, P = 0.001]. The AUC of LUS-72 h for predicting PICU mortality in these patients was 1.000, and the cutoff value of LUS-72 h was 24 with a sensitivity of 100.0% and a specificity of 100.0%. Furthermore, patients were stratified in two groups of LUS-72 h ≥ 24 and LUS-72 h < 24. Consistently, PICU mortality, length of PICU stay, ratio of shock, vasoactive index score value, and the need for continuous renal replacement therapy were significantly higher in the group of LUS-72 h ≥ 24 than in the group of LUS-72 h < 24 (all P < 0.05).ConclusionLung ultrasound score is a promising tool for predicting the prognosis in patients with ARDS under ECMO support. Moreover, LUS-72 h ≥ 24 is associated with high risk of PICU mortality in patients with pARDS who received ECMO.

Percutaneous Pulmonary Artery Cannulation to Treat Acute Secondary Right Heart Failure While on Veno-venous Extracorporeal Membrane Oxygenation.

Right heart failure (RHF) is a common, yet difficult to manage, complication of severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO) that is associated with increased mortality. Reports of the use of percutaneous mechanical circulatory support devices for concurrent right heart and respiratory failure are limited. This series describes the percutaneous cannulation of the pulmonary artery for conversion from veno-venous to veno-pulmonary artery return ECMO in 21 patients who developed secondary RHF. All patients cannulated between May 2019 and September 2021 were included. Either a 19 or 21 French venous cannula was placed percutaneously into the pulmonary artery via the internal jugular or subclavian vein, providing a total of 821 days of support (median 23 [4-71] days per patient) with flows up to 6 L/min. Five patients underwent cannulation at the bedside, with the remainder performed in the cardiac catheterization laboratory. Pulmonary artery cannulation occurred after 12 [8.5-23.5] days of ECMO support. Vasoactive infusion requirements decreased significantly within 24 hours of pulmonary artery cannula placement (p = 0.0004). Nonetheless, 75% of these patients expired after a median of 12 [4-63] days of support, with three patients found to have had significant pericardial effusions peri-arrest. This cannulation technique may be an effective alternative to veno-arterial ECMO cannulation or the placement of a dual-lumen cannula for the treatment of RHF.

Tracheostomy Practices and Outcomes in Children During Respiratory Extracorporeal Membrane Oxygenation.

Children receiving prolonged extracorporeal membrane oxygenation (ECMO) support may benefit from tracheostomy during ECMO by facilitating rehabilitation; however, the procedure carries risks, especially hemorrhagic complications. Knowledge of tracheostomy practices and outcomes of ECMO-supported children who undergo tracheostomy on ECMO may inform decision-making. Retrospective cohort study. ECMO centers contributing to the Extracorporeal Life Support Organization registry. Children from birth to 18 years who received ECMO support for greater than or equal to 7 days for respiratory failure from January 1, 2015, to December 31, 2019. None. Three thousand six hundred eighty-five children received at least 7 days of ECMO support for respiratory failure. The median duration of ECMO support was 13.0 days (interquartile range [IQR], 9.3-19.9 d), and inhospital mortality was 38.7% (1,426/3,685). A tracheostomy was placed during ECMO support in 94/3,685 (2.6%). Of those who received a tracheostomy on ECMO, the procedure was performed at a median 13.2 days (IQR, 6.3-25.9 d) after initiation of ECMO. Surgical site bleeding was documented in 26% of children who received a tracheostomy (12% after tracheostomy placement). Among children who received a tracheostomy, the median duration of ECMO support was 24.2 days (IQR, 13.0-58.7 d); inhospital mortality was 30/94 (32%). Those that received a tracheostomy before 14 days on ECMO were older (median age, 15.8 yr [IQR, 4.7-15.5] vs 11.7 yr [IQR, 11.5-17.3 yr]; p =0.002) and more likely to have been supported on venovenous-ECMO (84% vs 52%; p = 0.001). Twenty-two percent (11/50) of those who received a tracheostomy before 14 days died in the hospital, compared with 19/44 (43%) of those who received a tracheostomy at 14 days or later (p = 0.03). Tracheostomies during ECMO were uncommon in children. One in four patients who received a tracheostomy on ECMO had surgical site bleeding. Children who had tracheostomies placed after 14 days were younger and had worse outcomes, potentially representing tracheostomy as a "secondary" strategy for prolonged ECMO support.

The interplay of inflammation and coagulation in COVID-19 Patients receiving extracorporeal membrane oxygenation support.

Bleeding and thrombosis are common complications during Extracorporeal Membrane Oxygenation (ECMO) support for COVID-19 patients. We sought to examine the relationship between inflammatory status, coagulation effects, and observed bleeding and thrombosis in patients receiving venovenous (VV) ECMO for COVID-19 respiratory failure. Cross-sectional cohort study. Quaternary care institution. The study period from April 1, 2020, to January 1, 2021, we included all patients with confirmed COVID-19 who received VV ECMO support. None. Thirty-two patients were supported with VV ECMO during the study period, and 17 patients (53%) survived to hospital discharge. The ECMO nonsurvivors mean lactate dehydrogenase (LDH) levels were markedly elevated in comparison to survivors (1046 u/L [IQR = 509, 1305] vs 489 u/L [385658], p = 0.003). Platelet/fibrinogen dysfunction, as reflected by the low Maximum Amplitude (MA) on viscoelastic testing, was worse in nonsurvivors (65.25mm [60.68, 67.67] vs 74.80mm [73.10, 78.40], p = 0.01). Time-group interaction for the first seven days of ECMO support, showed significantly lower platelet count in the nonsurvivors (140 k/ul [103, 170] vs 189.5 k/ul [ 146, 315], p < 0.001) and higher D-dimer in (21 μg/mL [13, 21] vs 14 μg/mL [3, 21], p < 0.001) in comparison to the survivors. Finally, we found profound statistically significant correlations between the clinical markers of inflammation and markers of coagulation in the nonsurvivors group. The ECMO nonsurvivors experienced higher rate of bleeding (73.3% vs 35.3%, p = 0.03), digital ischemia (46.7% vs 11.8%, p = 0.02), acute renal failure (60% vs 11.8%, p = 0.01) and bloodstream infection (60% vs 23.5%, p = 0.03). The correlation between inflammation and coagulation in the nonsurvivors supported with VV ECMO could indicate dysregulated inflammatory response and worse clinical outcomes.

Association of Fluid Balance and Survival of Pediatric Patients Treated With Extracorporeal Membrane Oxygenation.

The effect of positive fluid balance (FB) on extracorporeal membrane oxygenation (ECMO) outcomes in pediatric patients remains unknown. We sought to evaluate if positive FB in pediatric intensive care unit (PICU) patients with respiratory and/or cardiac failure necessitating ECMO was associated with increased morbidity or mortality. This was a multicenter retrospective cohort study of data from the deidentified PEDiatric ECMO Outcomes Registry (PEDECOR). Patients entered into the database from 2014 to 2017, who received ECMO support, were included. A total of 168 subjects met the study criteria. Univariate analysis showed no significant difference in total FB on ECMO days 1–5 between survivors and non-survivors [median 90 ml/kg (IQR 18–208.5) for survivors vs. median 139.7 ml/kg (IQR 11.2–300.6) for non-survivors, p = 0.334]. There was also no difference in total FB on ECMO days 1–5 in patients with no change in functional outcome as reflected by the Pediatric Outcome Performance Category (POPC) score vs. those who had worsening in POPC score ≥2 at hospital discharge [median 98 ml/kg (IQR 18–267) vs. median 130 ml/kg (IQR 13–252), p = 0.91]. Subjects that required 50 ml/kg or more of blood products over the initial 5 days of ECMO support had an increased rate of mortality with an odds ratio of 5.8 (95% confidence interval of 2.7–12.3; p = 0.048). Our study showed no association of the noted FB with survival after ECMO cannulation. This FB trend was also not associated with POPC at hospital discharge, MV duration, or ECMO duration. The amount of blood product administered was found to be a significant predictor of mortality.

Circulating miRNAs as Promising Biomarkers to Evaluate ECMO Treatment Responses in ARDS Patients

The use of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) has increased in the last decade. However, mortality remains high, and the complexity of ECMO requires individualized treatment. There are some biomarkers to monitor progression and predict clinical outcomes of ARDS. This project aims to advance the management of ARDS patients treated with ECMO by exploring miRNA expression in whole blood. The analysis was conducted on two groups with different length of ECMO: Group A (longer runs) and group B (shorter runs). We analyzed miRNAs before ECMO cannulation, and at 7 and 14 days of ECMO support. Our results showed that in the group B patients, 11 deregulated miRNAs were identified, and showed an opposite trend of expression compared to the group A patients. In silico analysis revealed that these 11 miRNAs were related to processes involved in the pathogenesis and evolution of ARDS. This scenario could represent homeostatic mechanisms by which, in ECMO responsive patients, pathways activated during ARDS progression are switched-off. Circulating miRNAs could represent promising biomarkers to monitor the evolution of ARDS under ECMO support. Further studies may shed light on this topic to improve a personalized approach in such a complex setting of patients.

Physical Therapy and Sedation While on Extracorporeal Membrane Oxygenation for COVID-19–Associated Acute Respiratory Distress Syndrome

ObjectivesThis study aimed to determine whether patients on extracorporeal membrane oxygenation (ECMO) with coronavirus disease 2019 (COVID-19) achieved lower rates of physical therapy participation and required more sedation than those on ECMO without COVID-19.DesignRetrospective, observational, matched-cohort study.SettingBicenter academic quaternary medical centers.ParticipantsAll adults on ECMO for severe COVID-19-associated acute respiratory distress syndrome (ARDS) during 2020 and matched (matched 1:1 based on age ± 15 years and medical center) adults on ECMO for ARDS not associated with COVID-19.InterventionsObservational only.Measurements and Main ResultsMeasurements were collected retrospectively during the first 20 days of ECMO support and included daily levels of physical therapy activity, number of daily sedation infusions and doses, and level of sedation and agitation (Richmond Agitation and Sedation Score). During the first 20 days of ECMO support, the 22 patients who were on ECMO for COVID-19–associated ARDS achieved a similar proportion of days with active physical therapy participation while on ECMO compared to matched patients on ECMO for non-COVID-19 ARDS (22.5% v 7.5%, respectively; p value 0.43), a similar proportion of days with Richmond Agitation and Sedation Score ≥-2 while on ECMO (47.5% v 27.5%, respectively; p value 0.065), and a similar proportion of days with chemical paralysis while on ECMO (8.4% v 18.0%, respectively; p value 0.35).ConclusionsThe results of this matched cohort study supported that sedation requirements were not dramatically greater and did not significantly limit early physical therapy for patients who had COVID-19–associated ARDS and were on venovenous extracorporeal membrane oxygenation (VV-ECMO) versus those without COVID-19–associated ARDS who were on VV-ECMO.

Cytokine adsorption in patients with severe COVID-19 pneumonia requiring extracorporeal membrane oxygenation (CYCOV): a single centre, open-label, randomised, controlled trial

BackgroundWe sought to clarify the benefit of cytokine adsorption in patients with COVID-19 supported with venovenous extracorporeal membrane oxygenation (ECMO).MethodsWe did a single-centre, open-label, randomised, controlled trial to investigate cytokine adsorption in adult patients with severe COVID-19 pneumonia requiring ECMO. Patients with COVID-19 selected for ECMO at the Freiburg University Medical Center (Freiburg, Germany) were randomly assigned (1:1) to receive cytokine adsorption using the CytoSorb device or not. Randomisation was computer-generated, allocation was concealed by opaque, sequentially numbered sealed envelopes. The CytoSorb device was incorporated into the ECMO circuit before connection to the patient circuit, replaced every 24 h, and removed after 72 h. The primary endpoint was serum interleukin-6 (IL-6) concentration 72 h after initiation of ECMO analysed by intention to treat. Secondary endpoints included 30-day survival. The trial is registered with ClinicalTrials.gov (NCT04324528) and the German Clinical Trials Register (DRKS00021300) and is closed.FindingsFrom March 29, 2020, to Dec 29, 2020, of 34 patients assessed for eligibility, 17 (50%) were treated with cytokine adsorption and 17 (50%) without. Median IL-6 decreased from 357·0 pg/mL to 98·6 pg/mL in patients randomly assigned to cytokine adsorption and from 289·0 pg/mL to 112·0 pg/mL in the control group after 72 h. One patient in each group died before 72 h. Adjusted mean log IL-6 concentrations after 72 h were 0·30 higher in the cytokine adsorption group (95% CI −0·70 to 1·30, p=0·54). Survival after 30 days was three (18%) of 17 with cytokine adsorption and 13 (76%) of 17 without cytokine adsorption (p=0·0016).InterpretationEarly initiation of cytokine adsorption in patients with severe COVID-19 and venovenous ECMO did not reduce serum IL-6 and had a negative effect on survival. Cytokine adsorption should not be used during the first days of ECMO support in COVID-19.FundingNone.

Cyclohexanone Exposure in Children on Extracorporeal Membrane Oxygenation Support.

The aim of this study was to determine if plasma cyclohexanone and metabolites are associated with clinical outcomes of children on extracorporeal membrane oxygenation (ECMO) support. We performed a secondary analysis of a prospective observational study of children on ECMO support at two academic centers between July 2010 and June 2015. We measured plasma cyclohexanone and metabolites on the first and last days of ECMO support. Unfavorable outcome was defined as in-hospital death or discharge Pediatric Cerebral Performance Category score > 2 or decline ≥ 1 from baseline. Among 90 children included, 49 (54%) had unfavorable outcome at discharge. Cyclohexanediol, a cyclohexanone metabolite, was detected in all samples and at both time points; concentrations on the first ECMO day were significantly higher in those with unfavorable versus favorable outcome at hospital discharge (median, 5.7 ng/µl; interquartile range [IQR], 3.3-10.6 ng/µl vs. median, 4.2 ng/µl; IQR, 1.7-7.3 ng/µl; p = 0.04). Twofold higher cyclohexanediol concentrations on the first ECMO day were associated with increased risk of unfavorable outcome at hospital discharge (multivariable-adjusted hazard ratio [HR], 1.24 [95% CI, 1.05-1.48]). Higher cyclohexanediol concentrations on the first ECMO day were not significantly associated with new abnormal neuroimaging or 1-year Vineland Adaptive Behavior Scales-II score < 85 or death among survivors.

Outcomes of Adult Patients With Septic Shock Undergoing Extracorporeal Membrane Oxygenation Therapy

Extracorporeal membrane oxygenation (ECMO) has been shown to provide benefits in children, but not adults, with septic shock. This study described the clinical outcomes of adults in septic shock who underwent ECMO. This study retrospectively investigated adults who were supported on venoarterial or venovenous modes of ECMO and who had septic shock at the time of cannulation from January 1, 2009 to December 31, 2016 at a quaternary medical center in the United States. The primary outcomes were rate of survival to hospital discharge and time to survival using Kaplan-Meier survival estimates. This study analyzed survival by mode, previous cardiac arrest, and timing of cannulation (<96 and ≥96 hours after admission to the intensive care unit). Secondary outcomes were complications and days of ECMO support, length of stay in the intensive care unit, and hospitalization days. Of 243 patients supported on ECMO during this 7-year period, 32 met the criteria for septic shock, and the majority had a pulmonary source of infection (72%). The most common mode of support was venovenous ECMO (65%), and median ejection fraction was 51%. Median time on ECMO was 5.8 days (interquartile range, 2.6, 11.3 days). Survival to hospital discharge was 13 of 32 (41%), whereas median survival was 14.5 days (interquartile range, 5.2, 23.7 days). There was no statistically significant difference in survival by subgroup, including ECMO mode. Health care-associated infections were frequent (25%). This cohort of patients undergoing ECMO had equivalent median survival compared with literature-based estimates of other cohorts of patients with septic shock.

Factor XII Deficiency in ECMO Patients

Background: Extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support of critically ill patients is used frequently in the pediatric and adult population. Although a lifesaving modality, it is burdened with high morbidity and mortality as a result of hematologic complications (Dalton, et al. Am J Respir Crit Care Med. 2017). Bleeding and thrombosis are related to contact of blood and its cellular components with the non-biologic surface of the extracorporeal circuit used that results in a massive inflammatory and clotting response. Factor XII deficiency is not associated with bleeding, but results in a significant prolongation of conventional coagulation assays making them unreliable for monitoring. Here we discuss 3 cases of Factor XII deficiency and the implications it has on monitoring anticoagulation in patients on ECMO. Laboratory characteristics for all 3 patients are outlined in Table 1. Case 1: Newborn full-term male with persistent pulmonary hypertension (PPHN) and meconium aspiration syndrome (MAS) with respiratory failure was placed on ECMO support on day of life 1. Patient received several units of cryoprecipitate and fresh frozen plasma (FFP) to correct deficiencies throughout his 31 day ECMO course. Patient did not have any bleeding or thrombotic complications, however he showed no improvement in lung function and decision was made to discontinue ECMO support. Case 2: Newborn full-term male with severe hypoxic ischemic encephalopathy (HIE) and MAS with secondary PPHN required ECMO support on day of life 1. His Factor XII level normalized with replacement by FFP and was decannulated after 11 days of ECMO support. This patient was discharged home with family in stable condition at 5 weeks of age. Case 3: 20-year-old female with history of recurrent astrocytoma, chronic lung disease, hydrocephalus with ventriculoperitoneal (VP) shunt, and tracheostomy presented with multifocal pneumonia and suspected sepsis. Despite fluid resuscitation and ventilatory management patient continued to have hypotension and hypoxia and thus was placed on ECMO. Prior to cannulation, patient was noted to have a coagulopathy. In addition, Factor II was low at 57% and corrected with one unit of FFP; which was thought to be related to consumptive process. On ECMO day 8, she had worsening hypotension despite vasopressor support and fixed and dilated pupils; suspected to have thromboembolic stroke and thus decision was made to withdraw life support. Discussion: Adequate anticoagulation in patients with Factor XII deficiency requiring ECMO support presents a challenging task. Patients with Factor XII deficiency generally do not show symptoms of a bleeding disorder, which may lead to misinterpretation of coagulation assays (Kokoye, et al. Thromb Res 2016). Increased contact activation inside the ECMO cannula causes activation of platelets, consumption of Factor XII, and formation of FXIIa-antithrombin complexes that may contribute to increased risk for thrombus formation (Kokoye, et al. Thromb Res 2016 and Bachler, et al. J Thromb Thrombolysis 2019). All patients had Factor XII levels &lt;40% on initial testing, which is sufficient to cause severe changes to the aPTT. A circulating anticoagulant aPTT was completed to assess for presence of lupus anticoagulants in 2 of the patients, which has been known to falsely elevate the aPTT and was negative (Bachler, et al. J Thromb Thrombolysis 2019). All patients received FFP in an attempt to correct deficiency and facilitate the use of aPTT and ACTs for monitoring. However, this did not prove to be successful in 2/3 patients despite receiving adult plasma. Hepzyme TEGs showed improvement in R-time post-FFP in 2 patients, but in 1 there remained evidence of factor deficiency. It is clear that traditional coagulation assays, including aPTT and ACT, become unreliable and the R-time on TEG becomes difficult to dissect heparin versus coagulation factor effect. We recommend attempting to correct factor deficiency with FFP to potentially decrease risk of thrombotic complications, and choosing an alternative laboratory monitoring assay for heparin, such as Anti-Xa levels, which may more accurately correspond to the anticoagulation status in this population. Currently, we are running a modified thrombin generation assay in these Factor XII deficient patients, pre/post-FFP, to identify if there is a decrease in thrombin generation post-FXII/FFP supplementation. Table 1 Disclosures Chitlur: Bayer: Consultancy, Membership on an entity's Board of Directors or advisory committees; Takeda/Shire: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bioveritiv/Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees; CSL-Behring: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Research Funding; Octapharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novo Nordisk Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees.

What Should Be Done for Improving the Outcomes of Salvage from Cardiogenic Shock on ECMO Support?

Purpose Background: Survival rates for patients requiring extracorporeal membrane oxygenation (ECMO) support due to cardiogenic shock remain poor because of difficulties in decision making on optical timing of ECMO removal or conversion to ventricular assist devices (VAD). Methods From 2005 to 2018, 37 patients supported with ECMO due to circulatory deterioration were referred to our institution for implantation of VAD. The outcomes were analyzed using multi-variate analysis to assess the risk factors of VAD implantation, and we adopted a decision-tree to improve the outcomes. Results Six patients were withdrawn from VAD therapy due to stroke and infection. ECMO could be removed in 6 patients (6.1 days of ECMO support), but one of them was estimated to need VAD support due to the IABP-dependent circulatory condition. In total, 26 patients needed VAD support after 5.7 days of ECMO support. Four of them reached to heart transplantation, and VAD was explanted in 2 patients. Six patients remain on VAD. Statistically significant risk factors by multi-variate analysis on 2-year mortality were preoperative renal replacement (p=0.006) and T.Bil (p=0.051, Threshold 4.0 mg/dl). Two-year survival of patients without end-organ dysfunction as mentioned above was excellent (83.3%). However, that of patients with end-organ dysfunction was miserable (23.1%). Based on these findings, we applied to a following decision-tree. Step I: end-organ dysfunction; if yes, additional introduction of more effective circulatory support with left ventricular venting. Step II: aortic valve opening: if no, emergent/urgent VAD implantation. If yes, wait for cardiac functional recovery on ECMO. Step III: cardiac function; if no recovery, VAD implantation, and if recovered, ECMO removal. Since this decision-tree was applied, ECMO support was initiated in four patients with end-organ dysfunction before VAD implantation. After T.Bil decreased from 15.9mg/dl to 4.6 mg/dl and the value of Creatinine from 4.0 mg/dl to 1.5mg/dl, those patients underwent VAD implantation and survived. Conclusion Our experiences of salvage from ECMO suggest that preoperative renal replacement and T.Bil less than 4.0 mg/dl was a strong risk factor for mid-term mortality. For those patients, recovery from end-organ dysfunction before VAD implantation is essential.

The first case of Cesarean section in a pregnant woman during extracorporeal membrane oxygenation (ECMO) in Russia

A 22-year-old pregnant woman (34.6 weeks of pregnancy) with A(H1N1) influenza-associated acute respiratory distress syndrome was admitted to the intensive care unit. Results. The patient was connected to femoral-jugular veno-venous extracorporeal membrane oxygenation (ECMO) 2 hours after admission. On the 2nd day of ECMO support, in connection with the beginning of labor activity and a threat to the life of the mother and fetus, the decision was made on the implementation of caesarean section (CS) without the termination of ECMO. CS was performed under general anesthesia, 2 hours after discontinuation of heparin infusion. Were extracted a premature baby girl, weighing 2380 g. Intraoperative period was complicated by atonic uterine bleeding, requiring a hysterectomy. On the 16th day the patient was successfully weaned from ECMO and was discharged after 11 days. The newborn was discharged from the clinic in a satisfactory condition after 24 days with a weight of 2860 g. Conclusion. This is the first case in Russia of successful use of ECMO and emergency cesarean section (CS) during ECMO in a pregnant woman with acute respiratory distress syndrome (ARDS) due to complications of influenza A(H1N1).

The first case of severe avian influenza A (H7N9) in Guangdong Province in 2018 successfully treated with extracorporeal membrane oxygenation

Human infection with avian influenza A (H7N9) is easy to induce severe acute respiratory distress syndrome (ARDS), and traditional mechanical ventilation cannot correct hypoxemia, so patients may die from multiple organ failure (MOF) caused by persistent hypoxia. Extracorporeal membrane oxygenation (ECMO) can provide effective respiratory support and win time for the treatment of severe H7N9. The first case of severe H7N9 in Guangdong Province in 2018 was admitted to Zhongshan Hospital Affiliated to Sun Yat-sen University. The case was insult with severe ARDS caused by H7N9, the traditional mechanical ventilation could not correct hypoxemia, and the lung condition gradually improved with ECMO assistance. After 13 days of ECMO support, the patient was successfully weaned from ECMO and was transferred to a general ward after 55 days. After 102 days of rehabilitation, the patient was discharged from hospital and followed up for 2 months, who was in good health and had a good quality of life. This article states the diagnosis and treatment of severe H7N9 in details, providing experience for the treatment of severe H7N9 in the future.

Duration of extracorporeal membrane oxygenation support and survival in cardiovascular surgery patients

ObjectiveThe overall therapeutic goal of venoarterial extracorporeal membrane oxygenation (ECMO) in patients with postcardiotomy shock is bridging to myocardial recovery. However, in patients with irreversible myocardial damage prolonged ECMO treatment would cause a delay or even withholding of further permanent potentially life-saving therapeutic options. We therefore assessed the prognostic effect of duration of ECMO support on survival in adult patients after cardiovascular surgery. MethodsWe enrolled into our single-center registry a total of 354 patients who underwent venoarterial ECMO support after cardiovascular surgery at a university-affiliated tertiary care center. ResultsThrough a median follow-up period of 45 months (interquartile range, 20-81 months), 245 patients (69%) died. We observed an increase in mortality with increasing duration of ECMO support. The association between increased duration of ECMO support and mortality persisted in patients who survived ECMO support with a crude hazard ratio of 1.96 (95% confidence interval, 1.40-2.74; P < .001) for 2-year mortality compared with the third tertile and the second tertile of ECMO duration. This effect was even more pronounced after multivariate adjustment using a bootstrap-selected confounder model with an adjusted hazard ratio of 2.30 (95% confidence interval, 1.52-3.48; P < .001) for 2-year long-term mortality. ConclusionsProlonged venoarterial ECMO support is associated with poor outcome in adult patients after cardiovascular surgery. Our data suggest reevaluation of therapeutic strategies after 7 days of ECMO support because mortality disproportionally increases afterward.

Dynamic driving pressure associated mortality in acute respiratory distress syndrome with extracorporeal membrane oxygenation

BackgroundThe survival predictors and optimal mechanical ventilator settings in patients with severe acute respiratory distress syndrome (ARDS) undergoing extracorporeal membrane oxygenation (ECMO) are uncertain. This study was designed to investigate the influences of clinical variables and mechanical ventilation settings on the outcomes for severe ARDS patients receiving ECMO.MethodsWe reviewed severe ARDS patients who received ECMO due to refractory hypoxemia from May 2006 to October 2015. Serial mechanical ventilator settings before and after ECMO and factors associated with survival were analyzed.ResultsA total of 158 severe ARDS patients received ECMO were finally analyzed. Overall intensive care unit (ICU) mortality was 55.1%. After ECMO initiation, tidal volume, peak inspiratory pressure and dynamic driving pressure were decreased, while positive end-expiratory pressure levels were relative maintained. After ECMO initiation, nonsurvivors had significantly higher dynamic driving pressure until day 7 than survivors. Cox proportional hazards regression model revealed that immunocompromised [hazard ratio 1.957; 95% confidence interval (CI) 1.216–3.147; p = 0.006], Acute Physiology and Chronic Health Evaluation (APACHE) II score (hazard ratio 1.039; 95% CI 1.005–1.073; p = 0.023), ARDS duration before ECMO (hazard ratio 1.002; 95% CI 1.000–1.003; p = 0.029) and mean dynamic driving pressure from day 1 to 3 on ECMO (hazard ratio 1.070; 95% CI 1.026–1.116; p = 0.002) were independently associated with ICU mortality.ConclusionsFor severe ARDS patients receiving ECMO, immunocompromised status, APACHE II score and the duration of ARDS before ECMO initiation were significantly associated with ICU survival. Higher dynamic driving pressure during first 3 days of ECMO support was also independently associated with increased ICU mortality.