Use Of ECMO Research Articles

The low-dose colchicine in patients after non-CABG cardiac surgery: a randomized controlled trial

BackgroundRecent high-quality trials have shown that the anti-inflammatory effects of colchicine reduce the risk of cardiovascular events in patients suffering post-myocardial infarction and chronic coronary disease. The effect of colchicine in patients undergoing non-coronary artery bypass grafting (non-CABG) with cardiopulmonary bypass remains unclear. We aim to evaluate the effect of colchicine on myocardial protection in patients who underwent non-CABG cardiac surgery.MethodPatients were randomly assigned to colchicine or placebo groups starting 72 h before scheduled cardiac surgery and for 5 days thereafter (0.5 mg daily).The primary outcome was the level of cardiac troponin T (cTnT) at postoperative 48 h. The secondary outcomes included troponin I (cTnI) and creatine kinase-MB (CK-MB), inflammatory biomarkers (procalcitonin and interleukin-6, etc.), and adverse events (30-day mortality, stroke, ECMO and IABP use, etc.).ResultsA total of 132 patients underwent non-CAGB cardiac surgery, 11were excluded because of diarrhea (n = 6) and long aortic cross-clamp time > 2 h (n = 5), 59 were assigned to the colchicine group and 62 to the placebo group. Compared with the placebo group, cTnT (median: 0.3 μg/L, IQR 0.2–0.4 μg/L vs. median: 0.4 μg/L, IQR 0.3–0.6 μg/L, P < 0.01), cardiac troponin I (median: 0.9 ng/ml, IQR 0.4–1.7 ng/ml vs. median: 1.3 ng/ml, IQR 0.6–2.3 ng/ml, P = 0.02), CK-MB (median: 1.9 ng/ml, IQR 0.7–3.2 ng/ml vs. median: 4.4 ng/ml, IQR 1.5–8.2 ng/ml, P < 0.01), and interleukin-6 (median: 73.5 pg/ml, IQR 49.6–125.8 pg/ml vs. median: 101 pg/ml, IQR 57.5–164.7 pg/ml, P = 0.048) were significantly reduced in colchicine group at postoperative 48 h. For safety evaluation, the colchicine (n = 65) significantly decreased post-pericardiotomy syndrome (3.08% vs. 17.7%, P < 0.01) and increased the rate of diarrhea (9.23% vs. 0, P = 0.01) compared with the placebo group (n = 62). No significant difference was observed in other adverse events between the two groups.ConclusionA short perioperative course of low-dose colchicine was effective to attenuate the postoperative biomarkers of myocardial injury and inflammation, and to decrease the postoperative syndrome compared with the placebo.Trial registration ChiCTR2000040129. Registered 22nd Nov. 2020. This trial was registered before the first participant was enrolled. http://www.chictr.org.cn/showproj.aspx?proj=64370.

Social and ethical-moral considerations in cardiopulmonary death donation

The sociocultural perception of Cardiopulmonary Death Donation by the population is an important issue, especially at this time when this type of donation is growing. However, the data that are currently available are insufficient to draw definitive conclusions on public reactions. Controlled organ donation after cardiocirculatory determination of death has generated an ethical and social debate since its implementation. The objective is to analyze the most relevant ethical-moral and social issues that involve this type of donation.We were selected the 30 articles about this area with the PRISMA methodology. 72.2% of the articles that analyze the ethical conflicts on the withdrawal of life support treatment state that the staff that carries it out must be separate from the donation staff. 38.9% believe that it should be done in the ICM and 44.4% that it should be done by the ICM staff themselves. Regarding who should suggest controlled organ donation after cardiocirculatory determination of death, they all agree that it should be totally unrelated to ICM staff. 71.4% of the articles that analyze the use of premortem procedures justify their use based on scientific evidence and declare that they do not harm the potential donor. 42.1% accept the use of permanent circulatory cessation in determining death and 78.9% believe that a consensus should be reached on the waiting time in asystole. Despite some detractors, the use of ECMO is fully justified. Christian and Jewish culture are in favor of non-heart beating donation, but religious and economic objections continue to be raised in the Middle East. 80% of the articles that mention euthanasia classify it as a subject completely unrelated to controlled organ donation after cardiocirculatory determination of deathIn conclusion, Organ donation after cardiocirculatory determination of death has experienced a boom in recent years and continues to lead to ethical-moral and social debate.

Cost-Utility of Venovenous Ecmo Associated with Protective Mechanical Ventilation in the Treatment of Patients with Acute Respiratory Distress Syndrome

Introduction: with the emergence of COVID-19 in the world, there was a race against time in the search for studies and scientific information that validated the most appropriate treatment. As a result, when caring for patients with the disease who developed ARDS and progressed to a severe condition with hospitalization in the ICU, the need for scientific evidence to guide care for these patients was even greater. Speculation about the effectiveness of using ECMO for these patients began to emerge, and with it, the need for scientific studies that would show the costs and benefits of acquiring this technology in the SUS. The dissertation that is intended to be defended is whether the use of VV ECMO associated with protective mechanical ventilation in patients with ARDS is more cost-effective compared to exclusive protective mechanical ventilation. General Objective: to analyze the cost-effectiveness of veno-venous ECMO in the treatment of patients with COVID-19 who evolve with severe Acute Respiratory Failure. Specific Objectives: review the scientific literature to summarize the best scientific evidence available on the safety and efficacy of using exclusive mechanical ventilation and venovenous ECMO in patients with acute respiratory failure, and estimate the costs associated with mechanical ventilation and the use of veno-venous ECMO. Method: Rapid systematic review for a complete health economic assessment based on a Markov model to estimate the incremental cost-effectiveness of using venovenous ECMO associated with protective mechanical ventilation in the treatment of patients with ARDS due to COVID-19. Results: Based on the estimated costs in each of the base case scenarios and the probabilities of the clinical effects resulting from the interventions, the study showed that the ECMO + protective IMV intervention offers around 0.295 AAQA compared to 0.2015 AAQA offered by the exclusive protective VMI. The incremental cost of ECMO + protective IMV is BRL 12,519.94 for 0.397 effectiveness compared to 0.215 exclusive protective IMV (incremental effectiveness of 0.182). For each qualityadjusted year of life gained, the amount of R$ 68,902.92 would have to be disbursed. Conclusion: the results showed that both veno-venous ECMO associated with protective mechanical ventilation and exclusive protective mechanical ventilation can be cost-effective alternatives for the treatment of patients with ARDS due to COVID-19 in the SUS, depending on the willingness to pay. However, in terms of effectiveness, ECMO was the most effective alternative, but with the highest cost increase.

Indications for extracorporeal membrane oxygenation in coronavirus disease 2019: is the Berlin definition still adequate to adjust therapeutic interventions? A case report

Indications for extracorporeal membrane oxygenation in coronavirus disease 2019: is the Berlin definition still adequate to adjust therapeutic interventions? A case report

Veno-venous extracorporeal membrane oxygenation, cytokine removal and continuous renal replacement therapy in a severe burn adult patient.

Acute respiratory distress syndrome (ARDS) can develop early in burn patients with inhalation injury in the presence of cytokine storm and the proinflammatory response can be a supplemental factor for ARDS aggravation. We report the case of a 41-years old male with 25% total body surface area deep partial thickness burns to upper body extremity and grade II inhalational injury who developed severe ARDS, nosocomial pneumonia, and septic shock. Veno-venous extracorporeal membrane oxygenation (VV ECMO) and continuous renal replacement therapy (CRRT) with hemoadsorption were successfully used at different moments to overcome critical situations. Although debatable, the use of ECMO in burn patients with severe ARDS could be considered when conventional treatment fails. The use of CRRT combined with hemoadsorption may limit the proinflammatory response sustained by the combination between major burn, ECMO and sepsis.

761: ANTIDEPRESSANT AND ANTIPSYCHOTIC PRESCRIBING FOLLOWING ICU ADMISSION DUE TO COVID-19

Introduction: Patients with post-intensive care syndrome (PICS) suffer from a constellation of cognitive, mental, and physical effects. Previous studies have demonstrated increased antidepressant prescribing in patients with PICS. The purpose of this study was to examine the rates of antidepressant and antipsychotic use in patients with PICS following critical illness due to COVID-19. Methods: This was a retrospective chart review of adult patients (>18 years old) with PICS following critical illness due to COVID-19 who had at least 1 visit to the ICU survivor clinic at IU Health between September 2020 and July 2022. Patients were excluded if they were never admitted to the ICU, were admitted to a non IU Health ICU, or if they had incomplete medical records. The primary endpoint was the rate of combined antidepressant and antipsychotic use before ICU admission compared to their last clinic visit. The chi-square test was used to compare nominal data. Results: A total of 117 patients presented to the survivor clinic during the study time period. 35 patients were included in the analysis. Patients had a mean (+/- SD) age 53 (+/- 17) years and tended to be Caucasian 23 (66%) with low rates of having a college degree 6 (17%). During their ICU stays patients there were high rates of mechanical ventilation 24 (69%). While use of ECMO 9 (26%) and documented delirium 10 (28%) were less frequent. Underlying conditions identified at the initial clinic visit included cognitive impairment 20 (57%), depression 11 (31%), anxiety 8 (23%), and PTSD 4 (11%). Antidepressant and antipsychotic use was higher at the last clinic visit when compared to prior to ICU admission [16 (46%) vs. 5 (14%); p=0.0041]. At the time of the last clinic visit none of the 16 patients were receiving an antipsychotic while all were receiving an antidepressant. Conclusions: Patients with PICS following critical illness due to COVID-19 have an increased rate of antidepressant prescribing use compared to pre-illness. Further research is needed regarding the management and outcomes of these patients following critical illness due to COVID-19.

1267: SUCCESSFUL UTILIZATION OF ECMO AND ELS IN A PEDIATRIC PATIENT WITH HYDROXYCHLOROQUINE INGESTION

Introduction: Hydroxychloroquine ingestion can present with seizures, myocardial depression, vasodilation, QRS and QTc prolongation leading to ventricular arrhythmias and cardiac arrest. Ingestions >5 g and blood concentrations >20 mg/L are associated with mortality. Plasma concentrations peak at 2-6 hours with 800–1400-hour half-life. Therapies including sodium bicarbonate, benzodiazepines, activated charcoal, and lipid infusions offer questionable benefit. Hydroxychloroquine has a large volume of distribution (>50 L/kg) and is 40-70% protein bound, so hemodialysis is not efficient for drug clearance. We describe the first case of extracorporeal liver support (ELS) (albumin dialysis) for hydroxychloroquine clearance, and the use of ECMO and ELS utilized in tandem for hydroxychloroquine ingestion. Description: A 17-year-old female presented after a 20 g intentional ingestion of hydroxychloroquine. She had ventricular tachycardia with a 15-minute cardiac arrest. She received activated charcoal, sodium bicarbonate, benzodiazepines, and lipid infusion. Due to vasodilatory shock refractory to 4 high-dose vasoactive infusions, she was cannulated to femoral-femoral venoarterial (VA) ECMO on hospital day (HD) 2. She weaned from ECMO on HD 5, but developed lower extremity ischemia necessitating a right through-the-knee amputation. To facilitate clearance of protein-bound hydroxychloroquine, ELS was initiated on HD 1. ELS was discontinued on HD 7, but resumed on HD 9 due to recurrence of vasoplegia. Hydroxychloroquine levels peaked at 52 mg/L on HD 1. Her level was 9.7 mg/L prior to discontinuation of ELS, increased to 12 mg/L after discontinuation, and decreased to < 1 mg/L on HD 15 when ELS was discontinued. She had full renal and neurologic recovery and was discharged to inpatient rehabilitation. Discussion: In cases of severe hydroxychloroquine ingestion, VA ECMO can be utilized for refractory circulatory shock and can provide hemodynamic stability to utilize other extracorporeal therapies in tandem. Based on the clinical and pharmacologic evidence in this case, ELS may provide expedited drug clearance in cases of hydroxychloroquine ingestion.

Effect of intraoperative support mode on circulating inflammatory biomarkers after lung transplantation surgery.

Processes that activate the immune system during lung transplantation can lead to primary graft dysfunction (PGD) or allograft rejection. We analyzed cytokine expression profiles after reperfusion and allograft outcomes in a cohort of patients (n=59) who underwent lung transplantation off-pump (n=26), with cardiopulmonary bypass (CPB; n=18), or with extracorporeal membrane oxygenation (ECMO; n=15). Peripheral blood was collected from patients at baseline and at 6 and 72h after reperfusion. To adjust for clinical differences between groups, we utilized a linear mixed model with overlap weighting. PGD3 was present at 48 or 72h after reperfusion in 7.7% (2/26) of off-pump cases, 20.0% (3/15) of ECMO cases, and 38.9% (7/18) of CPB cases (p=0.04). The ECMO and CPB groups had greater reperfusion-induced increases in MIP-1B, IL-6, IL-8, IL-9, IL1-ra, TNF-alpha, RANTES, eotaxin, IP-10, and MCP-1 levels than the off-pump group. Cytokine expression profiles after reperfusion were not significantly different between ECMO and CPB groups. Our data suggest that, compared with an off-pump approach, the intraoperative use of ECMO or CPB during lung transplantation is associated with greater reperfusion-induced cytokine release and graft injury.

A Case of Chlamydia Psittacosis with Severe Pneumonia Combined with Acute Hepatitis B and Literature Review

Chlamydia psittaci infection can lead to severe clinical manifestations in humans, including rapidly progressive severe pneumonia, adult respiratory distress syndrome (ARDS), sepsis, multiple organ dysfunction, and even death. Here, we reported a 47-year-old man who presented with shortness of breath, fever and diarrhea. His chest CT showed right pneumonia with consolidation, and severe psittacosis pneumonia was confirmed by metagenomic sequencing of bronchoalveolar lavage fluid. The condition continued to worsen under ventilator treatment, and ARDS occurred. VV-ECMO was used to support for five days to improve hypoxia. In the middle and late stage of the disease course, the ALT of the patient showed an upward trend, and the HBV DNA and hepatitis B surface antigen were positive. Considering the medical history, it might be acute hepatitis B, and antiviral therapy was given. After three weeks of combined therapy, the patient recovered and was discharged from the hospital. Chlamydia psittacosis pneumonia is prone to misdiagnosis and misdiagnosis when the symptoms are not typical, and high-throughput sequencing is needed for definite diagnosis. Short-term use of ECMO in severe pneumonia of Chlamydia psittaci can help shorten the course of the disease and reverse the disease. The route of viral hepatitis B infection is unknown. If acute hepatitis B co-infection with other pathogens initiates antiviral therapy, it may prevent its transformation to chronic.

ANALYSIS OF ESTONIAN ECMO REGISTRY DATA OF COVID OUTBRAKE 2020 TO 2022

We launched Estonian nationwide ECMO registry in 2021 including data of all patients supported with ECLS in both ECMO centres - Tartu University Hospital and North Estonia Medical Centre. For the completeness of Registry all retrospective data were added back from 2009. Dataset includes patient demographics, diagnoses, ICU-, hospital- and 12 month survival, ECLS details and complications. To date, the registry contains data of 301 patients. Since January 2020, 65 confirmed Covid-19 patients have received ECLS support: VV-ECMO was used 55, ECCO2R 7, VA support 1 and eCPR in 2 instances. The primary outcome in our analysis was in-hospital death. Secondary outcome was to compare in-hospital mortality and length of stay of Covid-confirmed patients to the 54 non-Covid ARDS patients treated with VV-ECMO. <b>Findings:</b> Data for 55 adult patients with Covid-19 who received VV-ECMO support were available and included to this study. Of these 19(34.5%) were discharged home or to rehabilitation centre, 6(10.9%) were still in hospital at a time of analysis and 22(40.0%) died. One patient was bridged to successful lung transplantation. We also supported two pregnant patients with good maternal and neonatal outcomes. Comparing hospital mortality of Covid-confirmed cases to 54 non-Covid adult ARDS patients, hospital mortality was similar between the groups - 44.9% (22/49) and 46.2% (34/52) respectively. For those who were discharged alive, hospital LOS was longer for Covid-confirmed cases compared to non-Covid patients (mean 59 vs 50 days, respectively). <b>Interpretation:</b> In patients with Covid-19 who received ECMO, observed outcome supports existing recommendations to consider use of ECMO in refractory Covid-19 related respiratory failure when performed in experienced centres. Registry can also be used to coordinate ECMO beds, equipment and personnel as resources become constrained. We constantly monitored availability of ECMO beds and agreed on common indications for VV ECMO in covid patients. Further analysis will concentrate on 12 month survival and functional outcome.

MANAGEMENT OF MAJOR AIRWAY HAEMORRHAGE WITH VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN A HEART TRANSPLANT RECIPIENT

<h3>Objective</h3> To report the successful use of venovenous extracorporeal membrane oxygenation in a heart transplant recipient with a catastrophic airway haemorrhage. <h3>Design and methods</h3> Review of hospital records and imaging. <h3>Results</h3> A 56 year-old man with a past medical history of asthma, bronchiectasis and immunoglobulin A deficiency presented with end-stage ischaemic cardiomyopathy and recurrent pulmonary oedema. He was assessed for and underwent a heart transplant. The donor graft was well matched, but a small soft left anterior descending coronary artery plaque was noted at retrieval. In the first 24 hours post-transplant, he had a falling cardiac index followed by dysrhythmias. He was placed on veno-arterial extracorporeal membrane oxygenation (VA ECMO) and underwent PCI to the LAD lesion and started on aspirin and prasugrel. 48 hours later, his oxygenation requirements increased, his chest x-ray showed infiltrates and differential hypoxia (Harlequin Syndrome) was diagnosed. VAV ECMO was established. Overnight following VAV ECMO, fresh blood and clots were suctioned from the endotracheal tube, with falling tidal volumes to the point he was effectively unventilated. A CT scan showed extensive bronchial casts. A rigid bronchoscopy removed the clot. No specific bleeding point was identified, but general ooze from both bronchi was observed. Antiplatelet agents and systemic heparin were stopped, whilst distal limb perfusion catheter heparin was continued. Serial bronchoscopies were performed daily, removing small quantities of clot and applying topical therapies to various bleeding points in the right upper lobe. Tidal volumes remained under 100ml. Disseminated intravascular coagulation was diagnosed and product replacement guided by laboratory results and thromboelastography was undertaken. With improving cardiac function, arterial decannulation was achieved, leaving the patient on VV ECMO. This was continued for a further week with repeated flexible bronchoscopy and clot retrieval. Bleeding resolved after several days with conservative therapy, avoiding surgical or interventional radiological procedures. Improvements in tidal volumes were observed and eventually VV ECMO was successfully weaned. Aspirin was restarted as single antiplatelet therapy. He subsequently made a good recovery. <h3>Discussion</h3> VV ECMO is well established as a treatment in respiratory failure and pulmonary haemorrhage. However, use of VAV and VV ECMO for a major airway bleed in a heart transplant patient has not, to our knowledge, been previously described. The risks of running circuits without anticoagulation in patients totally dependent on them are high and managing this risk, alongside the new stent in a crucial coronary artery, were challenging. This case highlights the importance of balancing thrombosis and bleeding risk, especially in the context of new coronary stents, and has prompted consideration whether short-acting agents such as tirofiban may have a role in these especially high-risk cases.

Utilization and Outcomes of Extracorporeal Membrane Oxygenation Following Traumatic Brain Injury in the United States.

Objectives: Describe contemporary ECMO utilization patterns among patients with traumatic brain injury (TBI) and examine clinical outcomes among TBI patients requiring ECMO. Design: Retrospective cohort study. Setting: Premier Healthcare Database (PHD) between January 2016 to June 2020. Subjects: Adult patients with TBI who were mechanically ventilated and stratified by exposure to ECMO. Results: Among patients exposed to ECMO, we examined the following clinical outcomes: hospital LOS, ICU LOS, duration of mechanical ventilation, and hospital mortality. Of our initial cohort (n = 59,612), 118 patients (0.2%) were placed on ECMO during hospitalization. Most patients were placed on ECMO within the first 2 days of admission (54.3%). Factors associated with ECMO utilization included younger age (OR 0.96, 95% CI (0.95-0.97)), higher injury severity score (ISS) (OR 1.03, 95% CI (1.01-1.04)), vasopressor utilization (2.92, 95% CI (1.90-4.48)), tranexamic acid utilization (OR 1.84, 95% CI (1.12-3.04)), baseline comorbidities (OR 1.06, 95% CI (1.03-1.09)), and care in a teaching hospital (OR 3.04, 95% CI 1.31-7.05). A moderate degree (ICC = 19.5%) of variation in ECMO use was explained at the individual hospital level. Patients exposed to ECMO had longer median (IQR) hospital and ICU length of stay (LOS) [26 days (11-36) versus 9 days (4-8) and 19.5 days (8-32) versus 5 days (2-11), respectively] and a longer median (IQR) duration of mechanical ventilation [18 days (8-31) versus 3 days (2-8)]. Patients exposed to ECMO experienced a hospital mortality rate of 33.9%, compared to 21.2% of TBI patients unexposed to ECMO. Conclusions: ECMO utilization in mechanically ventilated patients with TBI is rare, with significant variation across hospitals. The impact of ECMO on healthcare utilization and hospital mortality following TBI is comparable to non-TBI conditions requiring ECMO. Further research is necessary to better understand the role of ECMO following TBI and identify patients who may benefit from this therapy.

Safety of Bedside Portable Low-Field Brain MRI in ECMO Patients Supported on Intra-Aortic Balloon Pump.

(1) Background: Fifty percent of patients supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are concurrently supported with an intra-aortic balloon pump (IABP). Acute brain injury (ABI) is a devastating complication related to ECMO and IABP use. The standard of care for ABI diagnosis requires transport to a head CT (HCT) scanner. Recent data suggest that point-of-care (POC) magnetic resonance imaging (MRI) is safe and may be effective in diagnosing ABI in ECMO patients; however, no data exist in patients supported on ECMO with an IABP. We report pre-clinical safety data and a case series to evaluate the safety and feasibility of POC brain MRI in ECMO patients supported with IABP. (2) Methods: Prior to patient use, ex vivo testing with an IABP catheter within the Swoop® Portable MRI (0.064 T) System™ was conducted. After IRB approval, clinical testing was performed for the safety and feasibility of early ABI detection. (3) Results: No deflection force was measured with a 7.5 French Maquet Linear IABP within the 0.064 T field. Three adult ECMO patients (average age: 40 years; 67% female) supported with IABP completed four POC brain MRI exams (median exam time: 30 min). Multiple signal abnormalities were detected on the POC brain MRI, corresponding to HCT results. (4) Conclusions: Our preliminary results suggest that adult VA-ECMO patients with IABP support can be safely imaged with low-field POC brain MRI in the intensive care unit, allowing for the early and bedside imaging of patients.

Abstract 13298: Racial and Ethnic Variation in ECMO Use, Failure to Rescue, &amp; Mortality in Pediatric Cardiac ICU Patients: A Multicenter Cohort Study From the Pediatric Cardiac Critical Care Consortium Registry

Introduction: Previous studies have reported racial disparities in ECMO use. Using a clinical registry, we sought to determine if there was racial &amp; ethnic variation in ECMO use &amp;, if so, whether outcomes were mediated by differences in ECMO use. Methods: Multicenter, retrospective cohort study of the Pediatric Cardiac Critical Care Consortium (PC 4 ) clinical registry. Racial/ethnic categories included White, Black, Hispanic, Asian, &amp; other race (Native American, Pacific Islander, &amp; mixed race). Analyses were stratified by hospitalization type (medical vs. surgical). Multivariable logistic regression models adjusted for measurable confounders &amp; evaluated the association between race/ethnicity with ECMO use, failure to rescue (FTR), &amp; mortality. Analyses of outcomes were adjusted for ECMO use. Secondary analyses explored interactions between race/ethnicity, insurance, &amp; socioeconomic status with ECMO use &amp; outcomes. Results: From 8/1/14-1/31/19, 50,552 hospitalizations from 34 hospitals were studied. Across all hospitalizations, 2.9% (n=1467) included ECMO. In both surgical &amp; medical hospitalizations, Black race &amp; Hispanic ethnicity were associated with severity of illness proxies. In medical hospitalizations, race &amp; ethnicity were not associated with the likelihood of ECMO use. In medical hospitalizations, other race had higher adjusted odds of FTR (aOR 1.69 95% CI 1.06-2.70 p=0.03) &amp; higher adjusted odds of mortality (aOR 1.61 95% CI 1.22-2.12 p=0.001). For surgical hospitalizations, Black (aOR 1.24 95% CI 1.02-1.50 p=0.03) &amp; other race (aOR 1.50 95% CI 1.17-1.93 p=0.001) were associated with higher adjusted odds of ECMO use compared to Whites. No significant differences were found in FTR for surgical hospitalizations but hospitalizations of Hispanics had higher adjusted odds of mortality (aOR 1.31 95% CI 1.03-1.68 p=0.03). No significant interactions were demonstrated between race/ethnicity &amp; indicators of SES with ECMO use or outcomes. Conclusions: Black &amp; other race were associated with increased likelihood of ECMO during surgical hospitalizations. There were racial/ethnic disparities in outcomes not explained by differences in ECMO use. Efforts to mitigate these important disparities should include other aspects of care.

Impact of occurrence of cardiac arrest in the donor on long-term outcomes of pediatric heart transplantation.

The impact of cardiac arrest in the donor on long-term outcomes of pediatric heart transplantation has not been studied. The UNOS database was queried for primary pediatric heart transplantation (1999-2020). The cohort was divided into recipients who received a cardiac allograft from a donor who had a cardiac arrest (CA) versus a donor who did not (NCA). Univariable and multivariable analysis was done to compare recipient outcomes, followed by survival analysis using the Kaplan-Meier method. A total of 7300 patients underwent heart transplantation, of which 579 (7.9%) patients belonged to the CA group. The CA group was younger (median 3 vs. 5 years, p < .001), male (51% vs. 47%, p = .03), and smaller in weight (13 vs. 17 kg, p < .001) and height (101 vs. 109 cm, p < .001) than the NCA group. The groups were similar in recipient heart failure diagnosis and blood type. The CA donors were younger (3 vs. 6 years, p < .001) versus nonwhite (48% vs. 45%, p = .003) and died from drowning and asphyxiation compared to blunt injury and intracranial hemorrhage in the NCA group. The left-ventricular ejection fraction was similar between the groups. There was no difference in VAD and ECMO use before the transplant. The listing status, waitlist days, and allograft ischemic times were similar. Posttransplant morbidity such as stroke, dialysis, pacemaker implantation, and treated rejection were similar. Donor cardiac arrest (hazard ratio = 0.93, p = .5) was not an independent predictor of mortality on multivariable analysis. There was no survival difference even beyond 20 years of follow-up between the groups (p = .88). The occurrence of donor cardiac arrest has no impact on long-term survival in pediatric heart transplant recipients.

Morbidity in children after fetoscopic endoluminal tracheal occlusion for severe congenital diaphragmatic hernia: Results from a multidisciplinary clinic

BackgroundAlthough fetoscopic endoluminal tracheal occlusion (FETO) was recently shown to improve survival in a multicenter, randomized trial of severe congenital diaphragmatic hernia (CDH), morbidity outcomes remain essentially unknown. The purpose of this study was to assess long-term outcomes in children with severe CDH who underwent FETO. MethodsWe conducted a prospective study of severe CDH patients undergoing FETO at an experienced North American center from 2015-2021 (NCT02710968). This group was compared to a cohort of non-FETO CDH patients with severe disease as defined by liver herniation, large defect size, and/or ECMO use. Clinical data were collected through a multidisciplinary CDH clinic. Statistics were performed with t-tests and Chi-squared analyses (p≤0.05). ResultsThere were 18 FETO and 17 non-FETO patients. ECMO utilization was 56% in the FETO cohort. Despite significantly lower median observed/expected lung-to-head ratio (O/E LHR) in the FETO group, [FETO: 23% (IQR:18-25) vs. non-FETO: 36% (IQR: 28-41), p<0.001], there were comparable survival rates at discharge (FETO: 78% vs. non-FETO: 59%, p = 0.23) and at 5-years (FETO: 67% vs. non-FETO: 59%, p = 0.53) between the two cohorts. At a median follow up of 5.8 years, metrics of pulmonary hypertension, pulmonary morbidity, and gastroesophageal reflux disease improved among patients after FETO. However, most FETO patients remained on bronchodilators/inhaled corticosteroids (58%) and were feeding tube dependent (67%). ConclusionsThese North American data show that prenatal tracheal occlusion, in conjunction with a long-term multidisciplinary CDH clinic, is associated with acceptable long-term survival and morbidity in children after FETO. Level of EvidenceLevel III

Performance assessment of unfractionated heparin protocol in pediatric patients supported on extracorporeal membrane oxygenation

Abstract Background Using extracorporeal membrane oxygenation in critical care setting is evolving. Unfractionated heparin is the most commonly used anticoagulant and a well-designed protocol is needed. However, there is no consensus from any organization regarding standard protocol. We developed UFH protocol taking into consideration best available evidence and anecdotal ECMO data. This study aims to assess ability of current protocol to achieve anti-Xa assay therapeutic target. Methods Prospective cohort, single-arm study conducted in Pediatric Cardiac Surgery Intensive Care Unit. Twenty patients were required. Anti-Xa assay therapeutic range is 0.1–0.3 U/mL for bleeding and 0.3–0.7 U/mL for non-bleeding patients. The protocol was developed after comprehensive literature review and continuous strict review process by a multidisciplinary ECMO team. It identifies initial UFH infusion dosing and subsequent adjustment, frequency of monitoring Anti-Xa assay, and other laboratory parameters. To ensure protocol adherence, teaching sessions were provided. Finally, we explored survival to discharge rate. The study was approved by the Office of Research Affairs with verbal consent. Results Twenty patients were included, half of them were female. Mean age of 35 months ± SD 52.5 and mean weight of 5.7 kg ± SD 3.8–14.1. Mean estimated glomerular filtration rate using schwartz equation was 80 mL/min/1.73 m2 ± SD 34.7. Main indications of ECMO use were failure to wean after surgery (45%). Median ECMO duration was 6 days+ (IQR: 4.5–7.5). Baseline Anti-Xa assay before cannulation was 0.1 IU/mL. Another important baseline laboratory value was antithrombin III, the mean was 21.1 ± SD 14.3. Selection of bleeding protocol is based on a set of criteria in the bleeding section (Appendix 1). Pre-canulation heparin bolus of 50–100 units/kg was given if ACT is &amp;lt;300 seconds for 11 patients (55%). Holding unfractionated heparin was required in 8 patients (40). Median time UFH was on-hold 13.5 hours (IQR: 10.5–27.5). Achieving Anti-Xa assay therapeutic target thorough out study period was reported in 70% of patients. Median time to achieve target was 41 hours (IQR: 0–91.5) and maintained for 8 hours (IQR: 0–22). Hemorrhagic complications were reported in 8 patients (40%) while thrombotic complications in 5 patients (25%). Both peripheral cannulation site bleeding and gastrointestinal bleeding occurred in 5%. Surgical exploration was needed in 6 patients (30%). Median time to first replacement was 80.5 hours (IQR: 19.5–228.5). Median hospital length of stay was 37 + IQR: 43–22 with survival rate at discharge of 75%. Conclusion Implemented UFH protocol in pediatric ECMO failed to achieve target in early hours after cannulation. However, the majority of those critically ill patients achieved Anti-Xa assay target and maintained it after the third day until day ten. Thromboembolic, hemorrhagic complications, and survival rates were consistent with the reported data Funding Acknowledgement Type of funding sources: None.

Clinical outcomes of left ventricular unloading with microaxial flow pump Impella during venoarterial extracorporeal membrane oxygenation (VA-ECMO): a systematic review and updated meta-analysis

Abstract Background Whether the addition of percutaneous microaxial flow pump Impella to venoarterial extracorporeal membrane oxygenation (VA-ECMO) as left ventricle unloading strategy is effective in improving outcomes compared to VA-ECMO alone is still to be proved. Purpose Aim of this systematic review and meta-analysis was to assess whether patients with refractory cardiogenic shock treated with IMPELLA in addition to VA-ECMO (ECMELLA) versus ECMO alone may benefit a reduction in early mortality and to assess whether this strategy may result in an increased rate of complications. Methods For this systematic review and meta-analysis, from Dec 2021 to Jan 2022, we searched Scopus, MEDLINE (with PubMed interface) and the Cochrane Central Register of Controlled Trials for randomised controlled trials and observational studies published in any language comparing the use of ECMELLA versus ECMO alone in patients with acute refractory CS (with or without cardiac arrest). Two independent investigators screened titles and abstracts for eligibility, extracted the data, and assessed risk of bias. Risk ratios (RRs) and 95% CIs were calculated with random-effects or fixed-effect models according to the estimated heterogeneity among studies assessed by the I2 index. Primary efficacy endpoint was trial-defined early mortality (in hospital or 30-day mortality). Safety endpoints were major bleeding, the need for renal replacement therapy, hemolysis, severe infections/sepsis and limb ischemia. This study is registered with PROSPERO (CRD42022292517). Results 2061 potentially relevant articles were screened. Our analysis included six retrospective studies with data for 1457 patients. Compared with ECMO alone, ECMELLA was associated with a non-significant reduction in early mortality (RR 0.87, 95% CI 0.72–1.06, p=0.17; Figure 1) and in a significant increase of major bleeding (RR 1.45, 95% CI 1.10–1.91, p=0.009), need for renal replacement therapy (RR 1.70, 95% CI 1.16–2.48, p=0.0008), hemolysis (RR 2.22, 95% CI 1.39–3.56, p=0.005) and limb ischemia (RR 1.61, 95% CI 1.20–2.16, p=0.001). No significant differences were observed in the incidence of severe infections/sepsis between the two groups (RR 1.23, 95% CI 0.97–1.58, p=0.09). (Figure 2) Conclusions The results of this meta-analysis showed that ECMELLA compared to ECMO alone did not significantly reduce early mortality and that, conversely, it resulted in a significantly increased risk of several complication (major bleeding, hemolysis, limb ischemia and renal replacement therapy). This study highlights that, if the benefit of left ventricle unloading with Impella during ECMO in CS shock is uncertain and probably limited to only selected patients, it surely increases the risk of some complications, therefore caution is needed in choosing such a strategy. Funding Acknowledgement Type of funding sources: None.

RAPIDLY PROGRESSING DERMATOMYOSITIS-ASSOCIATED RESPIRATORY FAILURE SUCCESSFULLY STABILIZED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

RAPIDLY PROGRESSING DERMATOMYOSITIS-ASSOCIATED RESPIRATORY FAILURE SUCCESSFULLY STABILIZED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

Anesthesiologists Drive Expanded Use of ECMO

Anesthesiologists Drive Expanded Use of ECMO