ECMO Care Research Articles

ICU Nurses' Perception of Sensitive Indicators of Quality of Care for ECMO Patients in Guizhou Province, China: A Cross-Sectional Study.

This study aimed to investigate the cognitive evaluation level of ICU nurses in Guizhou Province, China, on the sensitivity indicators of nursing quality for ECMO patients. This was a cross-sectional observational study conducted in Guizhou Province, China, from May to July 2023, 259 ICU nurses were surveyed. Objective sampling method was used to select the participants from 10 hospitals in Guizhou Province that carried out ECMO. Data were collected through questionnaire survey. Two researchers checked and recorded Epidata 3.1. SPSS 25.0 was used for statistical analysis of the data, and frequency, mean and component ratio were used for descriptive statistical analysis. The importance rating was used to reflect the degree of nurses' agreement with the indicators. The results of this study showed that 79.1% of the 253 ICU nurses in Guizhou Province, China, had not participated in training and courses related to indicators of quality of care evaluation for ECMO patients. The main way for ICU nurses to acquire knowledge related to indicators of quality of care sensitivity for ECMO patients was departmental training, which accounted for 87.4%. And the other ways, in descending order, were public, the matic lectures or academic conferences, journals and magazines; their evaluation scores of the importance of most of the quality of care sensitivity indicators for ECMO patients was moderate, with the scores ranging from 73 to 150. Among them, the range of importance evaluation scores for each indicator was 4.01 ~ 4.48. The overall cognitive evaluation of ICU nurses in Guizhou Province, China, on most sensitivity indicators of quality of care for ECMO patients was moderate, and there is a general lack of systematic courses and training on the knowledge related to ECMO care quality sensitive indicators.

Using "board games" to improve the effectiveness of extracorporeal membrane oxygenation care for nurses in intensive care unit

AimThe purpose of this study was to evaluate the effectiveness of ECMO care board games facilitated teaching approach (ECMO care board games) in enhancing ECMO care knowledge, clinical reasoning and learning engagement among intensive care unit (ICU) nurses. BackgroundECMO is a highly complex, relatively low-incidence, high-risk clinical life support device system used in the intensive care unit (ICU). Its usage has increased nearly tenfold over the past 30 years. Traditionally, ECMO education has been delivered through classroom teaching, which has demonstrated limited effectiveness in promoting nurses’ learning engagement, clinical reasoning competency and confidence. The literature suggests that well-designed board games can enhance learning engagement, stimulate higher-level thinking and improve the effectiveness and confidence of nurses' learning. DesignA quasi-experimental study two-group repeated measure design. MethodsA purposive sample of 73 ICU nurses from two campuses of one medical center was recruited (37 in the experimental group and 36 in the control group). The experimental group received ECMO care training through ECMO care board games facilitated teaching approach, whereas the control group completed the training through a traditional teaching approach. Instruments used for data collection include a demographic information sheet, ECMO Care Knowledge Scale, Clinical Reasoning Scale (Huang et al., 2023) and Learning Engagement Scale (Ciou , 2020). Both groups completed a pre-test before the training, a post-test one week after the training and a second post-test three weeks after the training. ResultsPrior to the intervention, there were no significant differences between the two groups in ECMO care knowledge and learning engagement. However, there was a significant difference in clinical reasoning. One week after the intervention, the experimental group demonstrated significantly higher scores in ECMO care knowledge, clinical reasoning and learning engagement than the control group (p <0.01). Three weeks after the intervention, the experimental group showed significantly higher scores in ECMO care knowledge, clinical reasoning and learning engagement (p <0.001). ConclusionsThe content for ECMO care is complex and difficult. Board games can enhance ECMO care knowledge, clinical reasoning and learning engagement. This teaching strategy may be applied to learning challenging subjects in the future to improve learning effectiveness. The clinical reasoning framework is conducive to guiding nurses' learning. In future continuing education, board games designed based on the clinical reasoning framework and tailored to the focus of in-service education can effectively enhance nurses' learning effectiveness.

Cannula associated deep vein thromboses in COVID-19 patients supported with VV ECMO.

VV ECMO is increasingly used as a rescue strategy for hypercarbic and hypoxic respiratory failure refractory to conventional management, and more than 14,000 patients with COVID-19 related respiratory failure have been supported with VV ECMO to date. One of the known complications of VV ECMO support is the development of cannula-associated deep vein thromboses (CaDVT). The purpose of this study was to identify the incidence of CaDVT in COVID-19 patients supported with VV ECMO as compared to non-COVID-19 patients. We hypothesized that due to the hypercoagulable state and longer duration of VV ECMO support required for patients with COVID-19, a higher incidence of CaDVT would be observed in these patients. This is a single center, retrospective observational study. About 291 non-trauma adult patients who were cannulated for VV ECMO and managed at our institution from January 1, 2014 to January 10, 2022 were included. The primary outcome was the presence of CaDVT 24 h after decannulation in COVID-19 versus non-COVID-19 patients. Our secondary outcome was continued presence of DVT on follow up imaging. CaDVT were defined as venous thrombi detected at prior cannulation sites. Both groups had a high incidence of CaDVT. There was no significant difference in the incidence of CaDVT in COVID-19 patients compared to non-COVID-19 patients (95% vs 88%, p = 0.13). Patients with COVID-19 had an increased incidence of persistent CaDVT on repeat imaging (78% vs 56%, p = 0.03). Given the high number of post-decannulation CaDVT in both groups, routine screening should be a part of post ECMO care in both populations. Repeat venous duplex ultrasound should be performed to assess for the need for ongoing treatment given the high incidence of CaDVT that persisted on repeat duplex scans.

Abstract 316: Reperfusion With Mild versus Moderate Hypothermia in a Swine Model of Extracorporeal Cardiopulmonary Resuscitation

Background: Targeted temperature management (TTM) at lower temperatures has shown variable neuroprotective benefits in clinical trials of cardiac arrest. We hypothesized that moderate hypothermia at the time of VA-ECMO reperfusion followed by early rewarming would reduce brain injury in a swine model of refractory VF, compared to mild hypothermia. Methods: Fourteen female pigs had electrically induced VF and conventional CPR for 30 minutes. Animals were cannulated to VA-ECMO and randomized to TTM to 34°C for 4 hours (mild hypothermia, n=7) or 24°C for 1 hour followed by early rewarming to 34°C over 3 hours (moderate hypothermia, n=7). Cooling was initiated upon ECMO reperfusion by circulating ice water through the oxygenator. Brain temperature and cerebral and systemic hemodynamics were continuously monitored. After four hours of post-arrest and ECMO care, brain tissue was obtained for examination. Groups were compared using paired t- and Wilcoxon rank sum tests. Results: The mean time to target brain temperature was 5 and 35 minutes in the mild and moderate groups, respectively (Panel, A). CPR hemodynamics were similar. Carotid blood flow (CBF) was higher in moderate hypothermia animals (79.0±1.56 vs 60.7±1.86% pre-arrest baseline, P &lt;0.001) throughout the post-arrest period. There were no differences in ECMO flow, mean arterial pressure, vasopressor/fluid requirement, bleeding, or thromboelastography. No significant difference in histologic damage score was observed between groups (10.5 [7, 11.8] vs 13 [9, 20], with 24°C vs 34°C respectively P =0.25; Panel, B). Immunohistochemistry markers for white matter and neuronal injury also did not significantly diverge. Conclusion: In a swine model of refractory cardiac arrest treated with ECPR, moderate hypothermia initiated upon reperfusion followed by early rewarming did not appear to be neuroprotective. Histological brain injury at 4 hours post-resuscitation was not affected by the degree of hypothermia.

Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR Trial): Protocol for a Randomized Controlled Trial

Extracorporeal membrane oxygenation (ECMO) provides support for the pulmonary or cardiovascular function of children in whom the predicted mortality risk remains very high. The inevitable host inflammatory response and activation of the coagulation cascade due to the extracorporeal circuit contribute to additional morbidity and mortality in these patients. Mixing nitric oxide (NO) into the sweep gas of ECMO circuits may reduce the inflammatory and coagulation cascade activation during ECMO support. The purpose of this study is to test the feasibility and safety of mixing NO into the sweep gas of ECMO systems and assess its effect on inflammation and coagulation system activation through a pilot randomized controlled trial. The Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR) trial is an open-label, parallel-group, pilot randomized controlled trial to be conducted at a single center. Fifty patients who require ECMO support will be randomly assigned to receive either NO mixed into the sweep gas of the ECMO system at 20 ppm for the duration of ECMO or standard care (no NO) in a 1:1 ratio, with stratification by support type (veno-venous vs veno-arterial ECMO). Outcome measures will focus on feasibility (recruitment rate and consent rate, and successful inflammatory marker measurements), the safety of the intervention (oxygenation and carbon dioxide control within defined parameters and methemoglobin levels), and proxy markers of efficacy (assessment of cytokines, chemokines, and coagulation factors to assess the impact of NO on host inflammation and coagulation cascade activation, clotting of ECMO components, including computer tomography scanning of oxygenators for clot assessments), bleeding complications, as well as total blood product use. Survival without ECMO and the length of stay in the pediatric intensive care unit (PICU) are clinically relevant efficacy outcomes. Long-term outcomes include neurodevelopmental assessments (Ages and Stages Questionnaire, Strength and Difficulties Questionnaire, and others) and quality of life (Pediatric Quality of Life Inventory and others) measured at 6 and 12 months post ECMO cannulation. Analyses will be conducted on an intention-to-treat basis. The NECTAR study investigates the safety and feasibility of NO as a drug intervention during extracorporeal life support and explores its efficacy. The study will investigate whether morbidity and mortality in patients treated with ECMO can be improved with NO. The intervention targets adverse outcomes in patients who are supported by ECMO and who have high expected mortality and morbidity. The study will be one of the largest randomized controlled trials performed among pediatric patients supported by ECMO. Australian New Zealand Clinical Trials Registry ACTRN12619001518156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376869. DERR1-10.2196/43760.

Comparison of the predictive ability of lactate and central venous blood gas in pediatric venoarterial mode extracorporeal membrane oxygenation outcome.

This study aims to compare lactate and central venous blood gas in the prediction of outcome in pediatric venoarterial mode extracorporeal membrane oxygenation (V-A ECMO). This was a retrospective observational study conducted on patients undergoing V-A ECMO care in the pediatric intensive care unit of a tertiary medical center in Taiwan. Patients under 18 years of age undergoing V-A ECMO from January 2009 to April 2019 were included in this study. This study consisted of 47 children who received V-A ECMO with an overall weaning rate of 66.0%. The mean age was 5.5 years and mean ECMO duration was 11.6 days. Successful weaning group had significantly lower lactate levels at initial (58.7±47.0 mg/dL vs. 108.0±55.3 mg/dL, p = 0.003), 0-12 h (37.8±29.0 mg/dL vs. 83.5±60.0 mg/dL, p Z 0.001), and 12-24 h (29.4±26.9 mg/dL vs. 69.1±59.1 mg/dL, p = 0.003) after ECMO initiation; however, the central venous blood gas including pH, HCO3, CO2, base excess (BE), and O2 saturation showed no significant difference. The favorable outcome group had significantly lower lactate levels at 0-12 h (32.8±26.3 mg/dL vs. 71.3±53.3 mg/dL, p = 0.005), and 12-24h (20.7±10.2 mg/dL vs. 61.9±53.5 mg/dL, p = 0.002); however, the HCO3 levels (26.2±4.5 mmol/L vs. 22.9±6.8 mmol/L, p = 0.042) and BE (2.2±5.4 vs. 2.2±8.5, p = 0.047) were significantly higher at 12-24 h. In multivariate logistic regression, 12-24 h lactate value was an independent factor for unfavorable outcomes (p = 0.015, odds ratio [OR] = 1.1) with the best cut-off value of 48.6 mg/dL (sensitivity 48%, specificity 100%). Lactate has better outcome prediction than central venous blood gas in pediatric V-A ECMO. The lactate value 12-24 h after ECMO initiation was an independent factor for unfavorable outcomes.

Patient-centered weaning from venoarterial extracorporeal membrane oxygenation: "A practice-oriented narrative review of literature".

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is increasingly used in cardiogenic shock for rapid stabilization and bridging towards recovery, long-term mechanical circulatory support or transplant. Although technological advances have instigated its widespread use, the complex, long-lasting ECMO care creates a significant strain on hospital staff and resources. Therefore, optimal clinical management including timely decisions on ECMO removal and further therapy are pivotal, yet require a well-structured weaning approach. Although dedicated guidelines are lacking, a variety of weaning protocols have distillated echocardiographic and hemodynamic predictors for successful weaning. Nevertheless, a strikingly high mortality up to 70% after initial successful weaning raises concerns about the validity of current weaning strategies. Here, we plead for a patient-tailored approach including a bailout strategy when weaning fails. This should account not only for left- but also right ventricular function and interdependence, as well as the temporal course of cardiac recovery in function of extracorporeal support. Patients with a high risk of weaning failure should be identified early, enabling timely transportation to an advanced heart failure center. This review summarizes predictors of successful weaning and discusses all relevant elements for a structured weaning approach with a central role for patient-specific clinical considerations and echocardiography.

Risk factors for bleeding complications during venovenous extracorporeal membrane oxygenation as a bridge to recovery.

BackgroundBleeding complications during venovenous extracorporeal membrane oxygenation (V‐V ECMO) can be critical. However, there is limited information on the associated risk factors. This study investigated the risk factors for bleeding complications during V‐V ECMO as a bridge to recovery.MethodsThis single‐center retrospective study enrolled 59 patients (bleeding and non‐bleeding groups) who received V‐V ECMO from 2012 to 2020, to evaluate whether peak activated partial thromboplastin time (APTT) value, lowest platelet count, and mobilization to sitting on the edge of the bed during V‐V ECMO were risk factors for bleeding complications, defined according to the Extracorporeal Life Support Organization guidelines. Age, sex, body mass index, Sequential Organ Failure Assessment score, and ECMO duration before bleeding complications were covariates in the multivariate logistic regression analysis.ResultsThirty‐one (53%) participants experienced 36 bleeding complications; the ECMO cannulation site, gastrointestinal tract, and nasopharyngeal region were the most common bleeding sites. The use of transfusion products and length of ECMO and intensive care unit stay were significantly and medical costs were non‐significantly increased in the bleeding group. Peak APTT (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01–1.05, p < 0.01) was significantly associated whereas the lowest platelet count (OR 0.96, 95% CI 0.82–1.13, p = 0.66) was unassociated with bleeding complications during ECMO. Achieving mobilization (OR 0.14, 95% CI 0.02–1.17, p = 0.07) decreased the trend of risk for bleeding complications.ConclusionsPeak APTT might be an independent modifiable factor for bleeding complications during V‐V ECMO. The protective effect of mobilization during V‐V ECMO requires further investigation.

Ethical factors determining ECMO allocation during the COVID-19 pandemic

BackgroundECMO is a particularly scarce resource during the COVID-19 pandemic. Its allocation involves ethical considerations that may be different to usual times. There is limited pre-pandemic literature on the ethical factors that ECMO physicians consider during ECMO allocation. During the pandemic, there has been relatively little professional guidance specifically relating to ethics and ECMO allocation; although there has been active ethical debate about allocation of other critical care resources. We report the results of a small international exploratory survey of ECMO clinicians’ views on different patient factors in ECMO decision-making prior to and during the COVID-19 pandemic. We then outline current ethical decision procedures and recommendations for rationing life-sustaining treatment during the COVID-19 pandemic, and examine the extent to which current guidelines for ECMO allocation (and reported practice) adhere to these ethical guidelines and recommendations.MethodsAn online survey was performed with responses recorded between mid May and mid August 2020. Participants (n = 48) were sourced from the ECMOCard study group—an international group of experts (n = 120) taking part in a prospective international study of ECMO and intensive care for patients during the COVID-19 pandemic. The survey compared the extent to which certain ethical factors involved in ECMO resource allocation were considered prior to and during the pandemic.ResultsWhen initiating ECMO during the pandemic, compared to usual times, participants reported giving more ethical weight to the benefit of ECMO to other patients not yet admitted as opposed to those already receiving ECMO, (p < 0.001). If a full unit were referred a good candidate for ECMO, participants were more likely during the pandemic to consider discontinuing ECMO from a current patient with low chance of survival (53% during pandemic vs. 33% prior p = 0.002). If the clinical team recommends that ECMO should cease, but family do not agree, the majority of participants indicated that they would continue treatment, both in usual circumstances (67%) and during the pandemic (56%).ConclusionsWe found differences during the COVID-19 pandemic in prioritisation of several ethical factors in the context of ECMO allocation. The ethical principles prioritised by survey participants were largely consistent with ECMO allocation guidelines, current ethical decision procedures and recommendations for allocation of life-sustaining treatment during the COVID-19 pandemic.

Left ventricular unloading and the role of ECpella.

The main reason for the emergency implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is the restoration of adequate systemic perfusion, while protecting the failing heart and promoting myocardial recovery are equally important goals. Following initial haemodynamic stabilization and often the urgent revascularization of the culprit lesion, the clinical focus is then directed towards the most efficient strategy for cardioprotection. Frequent echocardiography measurements may help to estimate the degree of unwanted left ventricular (LV) overloading during VA-ECMO. Additionally, the estimation of high LV filling pressures by Doppler echocardiography or their (in-)direct measurement using a dedicated surgical left atrial pressure line and conventional pulmonary artery catheter in a wedge position or a pigtail catheter in the left ventricle can be performed. Mechanical overload of the left ventricle is the major adverse effect and an obvious mechanistic and prognostic challenge of contemporary ECMO care. Many efforts are under way to overcome this phenomenon by LV unloading, which was effectively achieved by the current combined approach using an axial decompression device, while novel technical developments and approaches are tested and urgently anticipated. The aim of this report is to introduce in depth pathophysiological background, current concepts, and future perspectives in LV unloading strategies.

Rapid ECMO Training for Nurses in Response to the COVID-19 Pandemic

PurposeFrom March 17th to April 29th, our ECMO Program placed 30 adult patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) for management of coronavirus disease 2019 (COVID-19). This acute increase in volume placed a strain on our available ECMO-competent nursing staff. Although perfusionists function as our ECMO specialists, our critical care nurses provide continuous circuit monitoring and respond to emergencies. Because of the need to increase the number of ECMO-competent nurses, on March 27th a focused, two-hour COVID-ECMO training course was implemented.MethodsWe retrospectively reviewed the number of ECMO care hours provided by our nursing staff and separated the nursing staff into two cohorts. Group A consisted of nurses who had undergone ECMO training prior to the pandemic (n=126). Group B consisted of nurses whose initial ECMO training occurred during the pandemic (N=145). We then compared the number of nursing hours provided by each cohort before and after training.ResultsFrom March 27th to May 4th, 145 nurses completed training, increasing our total number of ECMO-competent nurses from 126 to 271 (115% increase). From March 17th to June 30th, 20,677 ECMO care hours were provided. Pre-training, all 634 care hours were 100% provided by Group A nurses. Post-training, 20,043 care hours were provided, consisting of 39% Group A nursing coverage and 61% Group B nursing coverage. There were no differences in nursing related ECMO-emergencies between the two groups. At the conclusion of the surge, 28 out of 30 (93%) patients survived ECMO and 26 out of 29 patients (90%) survived to hospital discharge. One patient has a pending hospital disposition.ConclusionRapid implementation of an abbreviated ECMO education program for nurses is feasible. It met the time-sensitive needs of the COVID-19 pandemic and provided safe nursing coverage to patients requiring ECMO.

Value of cardiac troponin T in predicting the prognosis of patients with cardiogenic shock receiving veno-arterial extracorporeal membrane oxygenation treatment: a consecutive 5-year retrospective study

To explore the changing trend of cardiac troponin T (cTnT) in patients with cardiogenic shock (CS) receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and its predictive value. A retrospective study was conducted. The data of patients with CS receiving V-A ECMO admitted to the First Affiliated Hospital of Nanjing Medical University from March 2015 to May 2020 were enrolled. The baseline data, ECMO related parameters, serum cTnT levels at 1, 2, 3 days after ECMO and intensive care unit (ICU) prognosis were recorded. The parameters with clinical significance and significant difference in univariate analysis were analyzed by binary multivariate Logistic regression analysis. Meanwhile, receiver operating characteristic (ROC) curve was drawn, area under ROC curve (AUC) was analyzed, and the threshold, sensitivity and specificity of serum cTnT level and its reduction rate for predicting clinical outcome were evaluated. A total of 72 patients were enrolled, of which 42 survived and 30 died at ICU discharge, and the ICU mortality was 41.7%. Univariate analysis results: compared with the survival group, the patients in the death group had higher acute physiology and chronic health evaluation II (APACHE II) score [32 (30, 34) vs. 29 (25, 30)], and the incidence of cardiac arrest before ECMO (70.0% vs. 31.0%), the ratios of invasive mechanical ventilation and continuous renal replacement therapy during ECMO were higher (96.7% vs. 66.7%, 83.3% vs. 42.9%), and the differences were statistically significant (all P < 0.05). Serum cTnT levels (ng/L) at 2 days and 3 days after ECMO in the death group were significantly higher than those in the survival group [2 days: 6 373.5 (898.3, 15 251.5) vs. 1 760.5 (933.0, 4 257.8), 3 day: 6 202.0 (758.9, 16 554.3) vs. 1 678.0 (623.3, 3 407.8), both P < 0.05], and the decrease rates of cTnT within 2 days and 3 days after ECMO were significantly lower than those in the survival group [2 days: 17.3% (-44.2%, 34.7%) vs. 36.8% (18.1%, 60.6%), 3 days: 32.4% (-30.0%, 55.5%) vs. 53.2% (38.3%, 72.3%), both P < 0.05]. Binary multivariate Logistic regression analysis showed that cardiac arrest before ECMO [odds ratio (OR) = 4.564, 95% confidence interval (95%CI) was 1.212-17.193, P = 0.025] and the decrease rate of cTnT level within 2 days after ECMO (OR = 1.617, 95%CI was 1.144-4.847, P = 0.026) were independent prognostic risk factors for the ICU death of CS patients receiving V-A ECMO. ROC curve analysis showed that the decline rate of cTnT within 2 days after ECMO transfer had a certain predictive value for the ICU death of CS patients receiving V-A ECMO. The AUC was 0.704 (95%CI was 0.584-0.824). The optimal diagnostic threshold was 40.0%, the sensitivity was 86.7%, the specificity was 52.4%, the positive predictive value was 66.9%, and the negative predictive value was 89.1%. The early decline rate of cTnT in CS patients who received V-A ECMO treatment in death group was lower than that of survival patients. The cTnT decline rate 2 days after ECMO was an independent risk factor for the death of such patients.

Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure.

Disclaimer: ECMO has, and will certainly continue, to play a role in the management of COVID-19 patients. It should be emphasized that this initial guidance is based on the current best evidence for ECMO use during this pandemic. Guidance documents addressing additional portions of ECMO care are currently being assembled for rapid publication and distribution to ECMO centers worldwide.

Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study

PurposeThere is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre. Materials and methodsA single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017. ResultsThe prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHE II scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required. ConclusionSurvival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service's collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.

Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) for Acute Respiratory Failure Following Injury: Outcomes in a High-Volume Adult Trauma Center with a Dedicated Unit for VV ECMO.

The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) has increased over the past decade. The purpose of this study was to evaluate outcomes in adult trauma patients requiring VV ECMO. Data were collected on adult trauma patients admitted between January 1, 2015, and November 1, 2016. Demographics, injury-specific data, ECMO data, and survival to discharge were recorded. Medians [interquartile range (IQR)] were reported. A p value ≤0.05 was considered statistically significant. Eighteen patients required VV ECMO during the study period. Median age was 28.5years (IQR 24-43). Median injury severity score (ISS) was 27 (IQR 21-41); median PaO2/FiO2 (P/F) prior to ECMO cannulation was 61 (IQR 50-70). Median time from injury to cannulation was 3 (IQR 0-6) days. Median duration of ECMO was 266 (IQR 177-379) hours. Survival to discharge was 78%. Survivors had a significantly higher ISS (p=0.03), longer intensive care unit length of stay (ICU LOS) (p<0.0004), hospital LOS (p<0.000004), and time on the ventilator (p<0.0003). Median time of injury to cannulation was significantly longer in patients who survived to discharge (p=0.01). There was no difference in P/F ratio prior to cannulation (p=ns). We have demonstrated improved outcome of patients requiring VV ECMO following injury compared to historical data. Although shorter time from injury to cannulation for VV ECMO was associated with death, select patients who meet criteria for VV ECMO early following injury should be referred/transferred to a tertiary care facility that specializes in trauma and ECMO care.

The small circuit pump, oxygenator, and surface coating

Dr Robert Bartlett is the pioneer surgeon credited for moving extracorporeal life support (ECLS) from the operating room to the intensive care unit (ICU), where the therapy has given hope for survival to thousands of neonates, children, and adults with respiratory and/or cardiac failure. Dr Bartlett describes the ECMO timeline as ECMO 1 (1990–2008) and ECMO 2 (2008–present).1 The first phase of ECMO utilized individual components, designed for other uses, assembled together to provide ECLS at the bedside. Circuit monitoring used equipment engineered for other functions, and hence, the need for clinical personnel to oversee the delivery of this technologically complex therapy was extensive. ECMO 2, the second phase in which we are currently practicing has been revolutionized by low-resistance oxygenators, centrifugal technology, and bicaval catheters that can be placed using the Seldinger technique.2 ECMO systems are now integrated, simplified, self-monitoring, and self-regulating, and have allowed for changes in the bedside model of care. A remaining challenge in providing ECLS is the systemic inflammatory response (SIR) induced by blood exposure to the artificial circuitry. The renal, pulmonary, and neurologic dysfunction seen after cardiopulmonary bypass (CPB) has been attributed to the SIR.3 The development of miniaturized extracorporeal circuits (MECC) with reduced tubing length, smaller oxygenators, biocompatible coatings, and fewer components are hypothesized to reduce the blood–foreign surface contact area, and hence, reduce the SIR. A possible breakthrough in the reduction of a SIR may allow transition into the next era of ECMO care. Published reports have shown laboratory evidence that MECC application in CPB blunts the systemic inflammatory response with decreases in C-reactive protein (CRP), leukocytes, and cytokines (IL-6, IL-8, TNF), SC5b-9 (an inflammation complement complex), and activated neutrophil factors.4 In studies evaluating the clinical outcome of patients who have undergone ECLS with MECC, the benefit remains debatable with respect to 30-day mortality, neurocognitive disturbance, cerebrovascular events, renal failure, and myocardial infarction. In the outcome criteria of ventilation period, hospital stay, and ICU stay, MECC showed benefit.5 In the meta-analysis report by Harling et al., the authors found other clinical benefits with MECC, which included the reduction in blood production transfusions.6 The use of MECC for prolonged ECLS has not been extensively reported in the literature, and may be related to the functional longevity of the oxygenator. A small number of case reports have been published and a conclusion cannot be made from the current level of MECC experience for its use as an alternative equipment option in ECMO. Further research in this area will be necessary before MECC can be clinically adapted for ECMO.

Can simulation improve ECMO care?

© 2017 Alinier, Campbell, Labib, Mehta, Hssain, Almomani, Hassan, licensee HBKU Press. This is an open access article distributed under the terms of the Creative Commons Attribution license CC BY 4.0, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited. Alinier G, Campbell C, Labib A, Mehta T, Hssain AA, Almomani EAH, Hassan IF. 'Qatar welcomes the Extracorporeal Life Support Organisation of the South and West Asia Chapter 2017 Conference', Qatar Medical Journal, 4th Annual ELSO-SWAC Conference Proceedings 2017:1 http://dx.doi.org/10.5339/qmj.2017.swacelso.1

ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12-years

BackgroundUse of Extracorporeal Membrane Oxygenation during cardiopulmonary resuscitation (ECPR) is increasingly being deployed as an adjunct to conventional CPR. It is unknown if this has been associated with improved outcomes. AimsTo describe trends in survival and patient demographics for ECPR patients in the international Extracorporeal Life Support Organisation (ELSO) database over the past 12 years and identify factors associated with changes in survival. MethodsPatients greater than 16 years of age who received ECPR between January 2003 and December 2014 were extracted from the ELSO registry and were divided into three 4-year cohorts (Cohort 1: 2003–2006, Cohort 2: 2007–2010, Cohort 3: 2011–2014). Univariable analysis was performed to compare demographics and outcomes of patients across the three cohorts. Univariable and multivariable analyses were then performed to identify factors independently associated with survival. Results1796 patients treated with ECPR were extracted from the registry, aged 50 (±18.5) years. Annual ECPR episodes increased over 10-fold, from 35 to over 400 per year. Survival to hospital discharge was 29% overall (27% cohort 1, 28% cohort 2, 30% cohort 3 (p=0.71)). Age, body weight and documented comorbidities increased over time. There was a reduction in complications associated with ECMO usage. After adjusting for confounders there was no change in the odds of survival over the time period examined. InterpretationOver the period 2003–2014, survival to hospital discharge was 29% for patients who require ECPR. Despite advances in provision of ECMO care and increasing co-morbidities of patients, there has been no change in risk-adjusted survival over time.