Extracorporeal Membrane Oxygenation Therapy Research Articles

Development of Prone Position Ventilation Device and Study on the Application Effect of Combined Life Support Technology in Critically Ill Patients.

This study aims to evaluate a novel prone position ventilation device designed to enhance patient safety, improve comfort, and reduce adverse events, facilitating prolonged tolerance in critically ill patients. A randomized controlled trial was conducted on 60 critically ill patients from January 2020 to June 2023. Of which, one self-discharged during treatment and another was terminated due to decreased oxygenation, leaving an effective sample of 58 patients. Patients were allocated to either a control group receiving traditional prone positioning aids (ordinary sponge pads and pillows) or an intervention group using a newly developed adjustable prone positioning device. A subset of patients in each group also received life support technologies such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). We assessed prone position ventilation tolerance, oxygen saturation increments postintervention, duration of prone positioning, CRRT filter lifespan, and the incidence of adverse events. The intervention group exhibited significantly longer average tolerance to prone positioning (16.6 hours vs. 8.3 hours, P < 0.001 with a difference of 8.3 (4.4, 12.2) hours), higher increases in oxygen saturation postventilation (9% vs. 6%, P < 0.001 with a difference of 3.0 (1.5, 4.5)), and reduced time required for medical staff to position patients (11.7 min vs. 21.8 min, P < 0.001 with a difference of -10.1 (-11.9, -8.3)). Adverse events, including catheter displacement or blockage, facial edema, pressure injuries, and vomiting or aspiration, were markedly lower in the intervention group, with statistical significance (P < 0.05). In patients receiving combined life support, the intervention group demonstrated improved catheter blood drainage and extended CRRT filter longevity. The newly developed adjustable prone ventilation device significantly improves tolerance to prone positioning, enhances oxygenation, and minimizes adverse events in critically ill patients, thereby also facilitating the effective application of life support technologies.

Hypoxia-Induced Piglet Model of Cardiac Arrest with Assisted Resuscitation by Extracorporeal Membrane Oxygenation.

The mortality rate of newborns with severe congenital heart disease (CHD) has significantly decreased over the past few decades. However, many of these children experience neurological impairments, particularly following a hypoxic cardiac arrest. The use of extracorporeal membrane oxygenation (ECMO) has been considered an effective treatment for severe hypoxia in CHD cases. Various clinical studies have examined the use of ECMO for resuscitation after hypoxic cardiac arrest, but the results have been contradictory, showing a significant incidence of both mortality and morbidity in some studies while others report good outcome. In order to investigate the mechanisms behind brain injury associated with extracorporeal circulation, we have developed a neonatal porcine model of hypoxia-induced cardiac arrest followed by veno-arterial ECMO therapy.

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis.

The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with other curative therapies. We aimed to characterise the mortality of adults with HRPE treated with ECMO, identify factors associated with mortality, and compare different adjunct curative therapies. We conducted a systematic review and meta-analysis, searching four international databases from their inception until 25 June 2023 for studies reporting on more than five patients receiving ECMO for HRPE. Random-effects meta-analyses were conducted. The primary outcome was in-hospital mortality. A subgroup analysis investigating the outcomes with curative treatment for HRPE was also performed. The intra-study risk of bias and the certainty of evidence were also assessed. This study was registered with PROSPERO (CRD42022297518). A total of 39 observational studies involving 6409 patients receiving ECMO for HRPE were included in the meta-analysis. The pooled mortality was 42.8% (95% confidence interval [CI]: 37.2% to 48.7%, moderate certainty). Patients treated with ECMO and catheter-directed therapy (28.6%) had significantly lower mortality (p < 0.0001) compared to those treated with ECMO and systemic thrombolysis (57.0%). Cardiac arrest prior to ECMO initiation (regression coefficient [B]: 1.77, 95%-CI: 0.29 to 3.25, p = 0.018) and pre-ECMO heart rate (B: -0.076, 95%-CI: -0.12 to 0.035, p = 0.0003) were significantly associated with mortality. The pooled risk ratio when comparing mortality between patients on ECMO and those not on ECMO was 1.51 (95%-CI: 1.07 to 2.14, p < 0.01) in favour of ECMO. The pooled mortality was 55.2% (95%-CI: 47.7% to 62.6%), using trim-and-fill analysis to account for the significant publication bias. More than 50% of patients receiving ECMO for HRPE survive. While outcomes may vary based on the curative therapy used, early ECMO should be considered as a stabilising measure when treating patients with HRPE. Patients treated concurrently with systemic thrombolysis have higher mortality than those receiving ECMO alone or with other curative therapies, particularly catheter-directed therapies. Further studies are required to explore ECMO vs. non-ECMO therapies in view of currently heterogenous datasets.

Elevated Renal-Resistive Index as an Indicator of Acute Kidney Injury Associated With Neonatal Extracorporeal Membrane Oxygenation

ObjectiveThis study aims to assess the relationship between elevated renal resistive index (RRI) and acute kidney injury (AKI) related to extracorporeal membrane oxygenation (ECMO) in neonatal patients. DesignThis was a retrospective study. SettingThe study was performed in a teaching hospital. ParticipantsSixteen neonates treated with ECMO in our hospital between June 2021 and December 2022 were included in this study. InterventionsDemographic and clinical data of patients were collected from the computer database. The RRI of patients before and during ECMO treatment was measured by bedside ultrasound. A receiver operating characteristic curve (ROC curve) was constructed to evaluate the diagnostic value of elevation of RRI as an evidence of neonatal ECMO-related AKI. Logistic regression analysis was utilized to calculate the odds ratio (OR) with a 95% confidence interval. Measurements and Main ResultsA total of 16 patients met the inclusion criteria. For the primary outcome, we observed that the RRI during ECMO therapy was significantly elevated in patients with AKI compared to those without AKI. As for the secondary outcome, Receiver Operating Characteristic (ROC) curve analysis revealed an optimal RRI cutoff of 0.797, with an area under the curve (AUC) of 0.855 (95% CI, 0.664-1, p=0.027). The sensitivity and specificity of RRI values greater than 0.797 for diagnosing AKI were 72.7% and 80%, respectively. Univariate logistic regression analysis indicated an odds ratio (OR) of 1.433 (95% CI 1.192-1.873, p < 0.05) for RRI values above 0.797. This association remained statistically significant even after adjusting for serum cystatin C and SOFA score, with an adjusted OR of 1.352 (95% CI 1.108-1.612, p < 0.05). ConclusionThe elevation of the RRI demonstrates a strong correlation with the onset of neonatal ECMO-related AKI, which may offer valuable support for diagnosing neonatal ECMO-related AKI.

Early Blood Clot Detection Using Forward Scattering Light Measurements Is Not Superior to Delta Pressure Measurements.

The occurrence of thrombus formation within an extracorporeal membrane oxygenator is a common complication during extracorporeal membrane oxygenation therapy and can rapidly result in a life-threatening situation due to arterial thromboembolism, causing stroke, pulmonary embolism, and limb ischemia in the patient. The standard clinical practice is to monitor the pressure at the inlet and outlet of oxygenators, indicating fulminant, obstructive clot formation indicated by an increasing pressure difference (ΔP). However, smaller blood clots at early stages are not detectable. Therefore, there is an unmet need for sensors that can detect blood clots at an early stage to minimize the associated thromboembolic risks for patients. This study aimed to evaluate if forward scattered light (FSL) measurements can be used for early blood clot detection and if it is superior to the current clinical gold standard (pressure measurements). A miniaturized in vitro test circuit, including a custom-made test chamber, was used. Heparinized human whole blood was circulated through the test circuit until clot formation occurred. Four LEDs and four photodiodes were placed along the sidewall of the test chamber in different positions for FSL measurements. The pressure monitor was connected to the inlet and the outlet to detect changes in ΔP across the test chamber. Despite several modifications in the LED positions on the test chamber, the FSL measurements could not reliably detect a blood clot within the in vitro test circuit, although the pressure measurements used as the current clinical gold standard detected fulminant clot formation in 11 independent experiments.

Meropenem extraction by ex vivo extracorporeal life support circuits.

Meropenem is a broad-spectrum carbapenem-type antibiotic commonly used to treat critically ill patients infected with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. As many of these patients require extracorporeal membrane oxygenation (ECMO) and/or continuous renal replacement therapy (CRRT), it is important to understand how these extracorporeal life support circuits impact meropenem pharmacokinetics. Based on the physicochemical properties of meropenem, it is expected that ECMO circuits will minimally extract meropenem, while CRRT circuits will rapidly clear meropenem. The present study seeks to determine the extraction of meropenem from ex vivo ECMO and CRRT circuits and elucidate the contribution of different ECMO circuit components to extraction. Standard doses of meropenem were administered to three different configurations (n=3 per configuration) of blood-primed ex vivo ECMO circuits and serial sampling was conducted over 24h. Similarly, standard doses of meropenem were administered to CRRT circuits (n=4) and serial sampling was conducted over 4h. Meropenem was administered to separate tubes primed with circuit blood to serve as controls to account for drug degradation. Meropenem concentrations were quantified, and percent recovery was calculated for each sample. Meropenem was cleared at a similar rate in ECMO circuits of different configurations (n=3) and controls (n=6), with mean (standard deviation) recovery at 24h of 15.6% (12.9) in Complete circuits, 37.9% (8.3) in Oxygenator circuits, 47.1% (8.2) in Pump circuits, and 20.6% (20.6) in controls. In CRRT circuits (n=4) meropenem was cleared rapidly compared with controls (n=6) with a mean recovery at 2h of 2.36% (1.44) in circuits and 93.0% (7.1) in controls. Meropenem is rapidly cleared by hemodiafiltration during CRRT. There is minimal adsorption of meropenem to ECMO circuit components; however, meropenem undergoes significant degradation and/or plasma metabolism at physiological conditions. These ex vivo findings will advise pharmacists and physicians on the appropriate dosing of meropenem.

Extracorporeal membrane oxygenation treatment for severe asthma had unexpected adverse effects: a case report

Asthma, a chronic respiratory ailment, affects millions worldwide. Extracorporeal membrane oxygenation (ECMO) has gained traction as a life-saving intervention for patients with severe asthma who are unresponsive to conventional treatments. However, complications associated with ECMO, including electrolyte imbalances and hemorrhage, can have significant clinical implications. This case report highlights a 49 years-old male patient with severe asthma who developed pronounced hypokalemia and hemorrhage following venovenous ECMO (VVECMO) therapy. Despite potassium supplementation, serum potassium levels continued declining before normalizing after 24 h. The patient subsequently experienced gastrointestinal bleeding, cerebral hemorrhage, and extensive cerebral infarction, ultimately resulting in a deep coma. Hypokalemia during ECMO therapy can result from a rapid reduction of carbon dioxide, β-receptor agonist use, corticosteroid use, and diuretic administration. Hemorrhage is another common ECMO complication, often linked to heparin anticoagulation therapy. Clinicians should be aware of potential complications and adopt appropriate prevention and management strategies when using ECMO in patients with severe asthma.

Efficacy and Safety of Antithrombin Supplementation in Neonates and Infants on a Continuous Heparin Infusion

Introduction: Antithrombin (AT) is an inhibitor of several coagulation proteins, including FIIa and FXa. Heparins accelerate/potentiate the interaction between AT and these factors through a conformational change in AT. Plasma AT concentrations are low in neonates, lower in sick premature neonates, and reach adult levels by 6 to 12 months of age. The developmental differences in plasma AT levels are an important consideration when treating an infant with heparin, as the activity of heparin depends on the presence of AT as a cofactor. As a result, AT supplementation is often considered in this cohort, particularly in the setting of heparin resistance. Objective: The objective of this study was to describe the use of AT supplementation at Boston Children's Hospital (BCH), a quaternary care, free-standing children's hospital, and investigate the safety and efficacy of AT supplementation in infants on a continuous heparin infusion. Methods: This study was approved by the Institutional Review Board at BCH. Data were abstracted for infants who received AT supplementation while on a therapeutic heparin infusion in the neonatal, cardiac, and medical intensive care units between January 2016 and October 2022. Infants on extracorporeal membrane oxygenation and continuous renal replacement therapy were excluded. The primary outcome was attainment of therapeutic anticoagulation within 48 hours after an AT course, defined as at least one occurrence of a partial thromboplastin time (PTT) level between 60 and 85 seconds and/or anti-factor Xa (anti-FXa) activity between 0.35 and 0.7 units/mL. Clinically relevant bleeding was defined as moderate/clinically relevant non-major bleeding or severe/major bleeding, as determined by either the Neonatal Bleeding Assessment Tool for infants with post-menstrual age (PMA) &amp;lt; 44 weeks or the International Society on Thrombosis and Haemostasis criteria for infants with PMA &amp;gt; 44 weeks, respectively. Data were summarized using descriptive statistics. Results: Over the 7-year period, 50 infants receiving 61 courses of AT supplementation were included. 12 patients received multiple AT doses within a course, resulting in the administration of 75 total AT doses. The median gestational age was 38 weeks (range 28-41 weeks), with a mean birth weight of 3.1 kg (range 0.8-4.5 kg). Median postnatal age at the time of the first AT dose was 19 days (range 3-341 days). The majority of heparin courses were indicated for thrombosis (49%) and post-operative cardiac surgery (40%). Median baseline AT activity was 37% (range 18-61%). The primary outcome was achieved in 90% AT courses. Of these, 73% were therapeutic only by PTT levels, 9% only by anti-FXa activity, and 18% by both. The benefit of AT administration was not sustained, as only 39% PTT levels and anti-FXa activity measured 48 hours after the AT course remained therapeutic. 41 infants had an AT level measured within 6 hours after the dose, and 61% (25/41) achieved a level between 80 and 120% of the calculated target. AT levels decreased over 48 hours, with an estimated half-life of 49 hours. 21% of AT courses had an increase in bleeding severity, with the majority being minor bleeds. Clinically relevant bleeding occurred after AT administration in only 8% (4/50) subjects. The relationship between simultaneously measured PTT levels and anti-FXa activity was investigated in a secondary analysis. Of the 250 paired levels, only one pair was therapeutic for both values ( Figure 1). Other than the single pair, in all other samples with a therapeutic anti-FXa, the simultaneously measured PTT was supratherapeutic. Three of the four patients with clinically relevant bleeding had at least one paired PTT level and anti-FXa activity available on the day of bleeding. Out of the seven paired samples, 86% of moderate bleeding occurred when the PTT level was supratherapeutic and the anti-FXa activity was subtherapeutic. Discussion: AT supplementation in infants may briefly increase the therapeutic efficacy of heparin, dependent on the monitoring parameter used, as PTT levels and anti-FXa activity poorly correlate. Additionally, permitting the PTT to increase over a certain threshold may increase the risk of bleeding. Further studies are needed to provide recommendations on heparin infusion titrations, AT dosing, and the monitoring of PTT levels and/or anti-FXa activity in the neonatal/infant populations on a continuous heparin infusion.

A comparative analysis of the Vasoactive-Inotropic Score, the Vasoactive-Ventilation-Renal Score, and the Oxygenation Index as outcome predictors in infants with a congenital diaphragmatic hernia.

To date, different severity scores and indices are available to predict outcome in infants with a congenital diaphragmatic hernia (CDH). The Oxygenation Index (OI) and the Vasoactive-Inotropic Score (VIS) has already been evaluated in the CDH population. The Vasoactive-Ventilation-Renal (VVR) Score was recently evaluated as new severity score in several studies on infants with need for cardiac surgery. The score was shown to outperform the VIS and OI as outcome predictors in these infants, but no data are available regarding the evaluation of the VVR Score in CDH infants. This was a retrospective single-center analysis at the University Children's Hospital, Bonn, Germany, during the study period from January 2019 until December 2022. Of 108 CDH infants treated at our institution, a final cohort of 100 neonates met the inclusion criteria. diagnosis of CDH (right-sided, left-sided, or bilateral). early mortality (before surgical correction of the diaphragm), palliative care after birth, no available data for OI, VIS, and VVR Score calculation. The OI, the VIS, and the VVR Score were calculated at three selected timepoints: at 48-72 h after birth (T1), before surgery (T2), and after surgery (T3). The primary clinical endpoint (in-hospital mortality) was reached in 21% of the infants. Infants surviving to discharge were allocated to group A, infants with fatal outcome to group B. In the univariate analysis, the OI was significantly higher in infants allocated to group B at T2 (p < .001), and T3 (p < .001). The VIS was significantly higher only at T1 in infants allocated to group B (p = .001). The VVR Score was significantly higher at T1 (p = .017), and at T3 (p = .002) in infants not surviving to discharge. In the multivariate analysis, the OI at T2 + T3 (p < .001), the VIS at T1 (p = .048), and the VVR Score at T1 + T3 (p = .023, and p = .048, respectively) remained significantly associated with in-hospital mortality. The OI presented the highest area under the curve (AUC) at T2 and T3 (T2:0.867, p = .001; T3:0.833, p = .000) regarding the primary endpoint in the overall cohort. In the subgroup of infants without need for extracorporeal membrane oxygenation (ECMO) therapy (n = 60) the VVR Sore presented the best performance with an AUC of 0.942 (p = .000) at T3. The severity scores OI, VIS, and VVR-Score are independent predictors of in-hospital mortality in CDH infants. The OI seems to outperform the VIS and VVR-Score as outcome predictor immediately before and after CDH surgery, whereas the VVR Score presented the best performance in the subgroup of CDH infants without need for ECMO and mild-to-moderate CDH defects.

Should Obesity Be an Exclusion Criterion for Extracorporeal Membrane Oxygenation Support? A Scoping Review.

Obesity is often considered a contraindication to extracorporeal membrane oxygenation (ECMO) candidacy due to technical challenges with vascular access, higher cardiac output requirements, and known associations between obesity and overall increased morbidity and mortality due to chronic health conditions. However, a growing body of literature suggests that ECMO may be as safe and efficacious in both obese and nonobese patients. This scoping review provides a synthesis of the available literature on the outcomes of obese patients supported with (1) venovenous (VV)-ECMO in acute respiratory distress syndrome (ARDS) not due to coronavirus disease 2019 (COVID-19), (2) VV-ECMO in ARDS due to COVID-19, (3) venoarterial (VA)-ECMO for all indications, and (4) studies combining data of patients supported with VA- and VV-ECMO. A librarian-assisted search was performed using 4 primary electronic medical databases (PubMed, Web of Science, Excerpta Medica database [Embase], and Cochrane Library) from January 2003 to March 2023. Articles that reported outcomes of obese patients requiring ECMO support were included. Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. A total of 354 publications were imported for screening on titles and abstracts, and 30 studies were selected for full-text review. A total of 26 publications met the inclusion criteria: 7 on VV-ECMO support in non-COVID-19 ARDS patients, 6 on ECMO in COVID-19 ARDS patients, 8 in patients supported with VA-ECMO, and 5 combining both VA- and VV-ECMO data. Although the included studies are limited to retrospective analyses and display a heterogeneity in definitions of obesity and comparison groups, the currently available literature suggests that outcomes and complications of ECMO therapy are equivalent in obese patients as compared to nonobese patients. Hence, obesity as measured by body mass index alone should not be considered an exclusion criterion in the decision to initiate ECMO.

Diagnosis of leptospira by metagenomics next-generation sequencing with extracorporeal membrane oxygenation support: a case report

Abstract Background Leptospirosis is an infectious disease caused by pathogenic Leptospira spp., which could result in severe illnesses. Indirect contact with these pathogens is more common. Individuals could contract this disease through contact with contaminated water or during floods. In this case, we present the details of a 40-year-old male pig farmer who suffered from severe pulmonary hemorrhagic leptospirosis and multiple organ failure. The diagnosis of leptospirosis was confirmed through metagenomics next-generation sequencing (mNGS) while the patient received extracorporeal membrane oxygenation (ECMO) support, and antibiotic treatment was adjusted accordingly. The patient underwent comprehensive treatment and rehabilitation in the intensive care unit. Conclusion This case illustrates the importance of early diagnosis and treatment of leptospirosis. While obtaining the epidemiological history, second-generation metagenomics sequencing was utilized to confirm the etiology. The prompt initiation of ECMO therapy provided a crucial window of opportunity for addressing the underlying cause. This case report offers valuable insights for diagnosing patients with similar symptoms.

Abstract 395: Outcomes Of Mechanical Circulatory Support for Cardiogenic Shock in the United States: An Analysis of the 2017-2020 National Inpatient Sample Database

Introduction: Mechanical circulatory support devices, such as Extracorporeal membrane oxygenation(ECMO), Impella, and intra-aortic balloon pump(IABP), play a crucial role in managing patients with cardiogenic shock(CS). This study aimed to compare the outcomes and patient characteristics of different mechanical circulatory support modalities. Methods: We utilized the National Inpatient Sample Database(NIS) data from 2017 to 2020 to identify patients with the diagnosis of CS who received mechanical circulatory support. The study population was categorized into six groups: ECMO, Impella, IABP, ECMO + Impella, and ECMO + IABP. The groups were compared based on patient characteristics, length of stay(LOS), complications, need for a heart transplant, mortality, and total charges. Results: A total of 715,470 patients were identified with CS, 17%(122,100) received mechanical circulatory support, 5,675 had ECMO therapy, 33,360 Impella, 79,540 IABP, 1,890 cases ECMO+Impella, and 1,635 cases ECMO+IABP. Age significantly differed, with ECMO patients being the youngest 54[36-65] years. There were higher proportions of females in the ECMO-only(37.4%) and males in the ECMO+Impella(76.7%). LOS was prolonged in the ECMO group(14 [5-28] days) compared to other groups(p&lt;0.001). Mortality rates were higher in the ECMO group(47.1%), followed by ECMO+Impella(45.8%) and ECMO+IABP (40.1%) (p&lt;0.001). Higher rates of stroke, disseminated intravascular coagulation, and continuous renal replacement therapy requirements were observed in the ECMO group. Bleeding requiring transfusion was more frequent with ECMO+IABP, and limb ischemia was more common in the ECMO+Impella group (p&lt; 0.001). Heart transplant rates were highest after ECMO+IABP therapy. Over the years, ECMO utilization increased, while Impella and IABP utilization remained stable. Notably, the ECMO+IABP had the highest total charges among all the therapy modalities evaluated (p &lt; 0.001). Conclusions: The rising utilization of ECMO and ECMO-IABP therapies indicates a changing treatment landscape. However, these approaches exhibit lower survival rates, potentially due to the severity of CS, heightened complications, and increased costs compared to standalone IABP or Impella therapies.

An adolescent female with intentional ingestion of a large amount of metformin requiring extracorporeal membrane oxygenation and continuous renal replacement therapy

Acute overdose of metformin can show potentially fatal lactic acidosis. Management should be directed towards close monitoring of renal function and hemodynamics. Patients may require dialysis or extracorporeal membrane oxygenation in cases of hemodynamic instability. This case presents an adolescent with massive metformin ingestion estimated at 100 g leading to metformin-associated lactic acidosis and subsequent respiratory failure, cardiovascular collapse, and acute kidney injury. The complications were successfully managed with venoarterial extracorporeal membrane oxygenation, continuous renal replacement therapy, and mechanical ventilation.

Perfusionists’ Perception of a Blended Training Process in the Management of Extracorporeal Membranes

During the SARS-CoV-2 pandemic, many challenges were faced in the global healthcare system, one of which was the lack of competent professionals to implement therapies such as extracorporeal membrane oxygenation (ECMO), which proved to be lifesaving during the H1N1 virus infection. In response to this need, this project aimed to determine the characteristics of a blended training process to contribute to the development of competencies in the management of ECMO therapy and to understand the perception of participants regarding this training process as a suitable strategy for competency development. A mixed design with a descriptive scope based on design-based research was used. The main results indicated that the designed learning environment was suitable for competency development in ECMO therapy management, as well as the importance of including high-quality simulation scenarios in the development of skills for managing this type of therapy. However, the most significant impact was observed in the development of competencies and skills of the participating healthcare professionals through the process of feedback.

Prevalence of FXII-Deficiency and Its Relevance to Monitoring Anticoagulation in Adults Receiving Extracorporeal Membrane Oxygenation.

During extracorporeal membrane oxygenation (ECMO) blood is exposed to artificial surfaces, resulting in contact activation of the intrinsic coagulation pathway initiated by coagulation factor XII (FXII). Little is known about the prevalence of acquired FXII-deficiency, especially during ECMO. The primary outcome was the prevalence of acquired FXII-deficiency (FXII activity <60%) during ECMO. Secondary outcomes included differences in hemorrhagic/thromboembolic complications, doses of unfractionated heparin administered, and time points of anticoagulation within target ranges between patients with and without FXII-deficiency. Of 193 adults receiving ECMO therapy between 2013 and 2021, FXII testing was performed in 64 (33%) patients. Of these, 89% ( n = 57) had an acquired FXII-deficiency. Median complication-free intervals were not different between patients with and without acquired FXII-deficiency (bleeding: 28 days [6-145] vs. 12 days [11-not available], p = 0.85; thromboembolism: 16 days [8-54] vs. 13 days [3-15], p = 0.053). Patients with acquired FXII-deficiency received less heparin (16,554 IU/day vs. 25,839 IU/day; p = 0.009) and were less likely to be within aPTT-target ranges (23.1% [14.3%-36.4%] vs. 37.8% [33.7%-58.3%], p = 0.005). Acquired FXII-deficiency is common during ECMO and may affect monitoring of anticoagulation. The impact of FXII-activity on complications needs to be determined in future studies.

Complications in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy: distribution and relevance. Results from an international, multicentre cohort study.

Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2). All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor. Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS.

Bleeding Complications in COVID-19 Critically Ill ARDS Patients Receiving VV-ECMO Therapy.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) therapy is rapidly expanding worldwide, yet this therapy has a serious risk of bleeding. Whether coagulation-activating viral infections such as COVID-19 may have an impact on the risk of bleeding is largely unknown. This study conducted a monocentric investigation of severely affected COVID-19 patients receiving VV-ECMO therapy with regard to the occurrence and possible influences of minor and major bleeding and transfusion requirements. Among the 114 included study patients, we were able to assess more than 74,000 h of VV-ECMO therapy. In these, 103 major bleeding events and 2283 minor bleeding events were detected. In total, 1396 red blood concentrates (RBCs) were administered. A statistically significant correlation with the applied anticoagulation or demographic data of the patients was not observed. Contrary to the frequently observed thromboembolic complications among COVID-19 patients, patients with VV-ECMO therapy, even under low-dose anticoagulation, show a distinct bleeding profile, especially of minor bleeding, with a substantial need for blood transfusions. COVID-19 patients show a tendency to have frequent bleeding and require repeated RBC transfusions during VV-ECMO. This fact might not be solely explained by the mechanical alteration of ECMO or anticoagulation.

Neutrophil-to-Lymphocyte Ratio as a Predictor of Mortality for COVID-19-Related Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Extracorporeal Membrane Oxygenation Therapy.

The neutrophil-to-lymphocyte ratio (NLR) has been studied as an indicator of systemic inflammation and as a prognostic tool in multiple areas of medicine. Previous research has suggested that higher NLR and rapid increase to peak NLR are associated with poorer outcomes in patients with coronavirus disease 2019 (COVID-19), particularly in those experiencing acute respiratory distress syndrome (ARDS). Within vascular surgery, there is data to suggest a positive correlation between elevated pre-extracorporeal membrane oxygenation (ECMO) NLR and higher rates of mortality following major procedures. This study explores the prognostic value of peri-ECMO NLR in patients requiring veno-venous ECMO (VV-ECMO) therapy for COVID-19-related ARDS. The objective of this study was to explore the utility of pre-ECMO NLR as an easily accessible prognostic factor for patients suffering from COVID-19-associated ARDS that require VV-ECMO. This was a retrospective cohort study within a tertiary care hospital conducted between April 2020 and January 2021. Patients requiring VV-ECMO therapy for COVID-19-associated ARDS were included. Peri-ECMO NLR values, length of stay (LOS), duration on VV-ECMO, and discharge status were recorded. Receiver operating characteristic (ROC) curve analysis and Youden's J statistics were performed to calculate a cut-off value of 11.005 for pre-ECMO NLR and 17.616 for on-ECMO NLR. Pre-ECMO and on-ECMO Kaplan-Meyer curves were generated for two groups of patients, those above and below NLR cutoff thresholds.Two-sample T-test was performed to test for significant differences in LOS and duration on VV-ECMO. Twenty-six patients were included in the study for final analyses. There was an overall mortalityof 39% (n = 10). ROC curve analysis and Youden's J statistic revealed an optimal cut-off value of pre-ECMO NLR = 11.005 and on-ECMO NLR = 17.616. Results showed that the patient group placed on VV-ECMO with a pre-ECMO NLR less than 11.005 experienced no mortality (n = 7) and a median LOS of 28 days (IQR = 14.5-64.5 days). The patient group on VV-ECMO with a pre-ECMO NLR greater than 11.005 (n = 19) included all mortality (n = 10) and had a median LOS of 49 days (IQR = 25.5-63.5 days). The patient group with on-ECMO NLR less than 17.616 also conferred a survival advantage. There was no significant difference in LOS or duration on VV-ECMO between the two groups, pre-ECMO or on-ECMO. A pre-ECMO NLR cutoff was identified and offered statistically significant prognostic value in predicting mortality. A lower on-ECMO NLR value also indicated a survival advantage. Future studies should include NLR within multivariate models to better discern the effect of NLR and elucidate how it can be factored into clinical decision-making. Importantly, this data can be expanded to assess the predictive value of NLR pertaining to the COVID-19-induced ARDS population and matched cohorts.

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

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

Predicting Survival for Veno-Arterial ECMO Using Conditional Inference Trees-A Multicenter Study.

Despite increasing use and understanding of the process, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy is still associated with considerable mortality. Personalized and quick survival predictions using machine learning methods can assist in clinical decision making before ECMO insertion. This is a multicenter study to develop and validate an easy-to-use prognostic model to predict in-hospital mortality of VA-ECMO therapy, using unbiased recursive partitioning with conditional inference trees. We compared two sets with different numbers of variables (small and comprehensive), all of which were available just before ECMO initiation. The area under the curve (AUC), the cross-validated Brier score, and the error rate were applied to assess model performance. Data were collected retrospectively between 2007 and 2019. 837 patients were eligible for this study; 679 patients in the derivation cohort (median (IQR) age 60 (49 to 69) years; 187 (28%) female patients) and a total of 158 patients in two external validation cohorts (median (IQR) age 57 (49 to 65) and 70 (63 to 76) years). For the small data set, the model showed a cross-validated error rate of 35.79% and an AUC of 0.70 (95% confidence interval from 0.66 to 0.74). In the comprehensive data set, the error rate was the same with a value of 35.35%, with an AUC of 0.71 (95% confidence interval from 0.67 to 0.75). The mean Brier scores of the two models were 0.210 (small data set) and 0.211 (comprehensive data set). External validation showed an error rate of 43% and AUC of 0.60 (95% confidence interval from 0.52 to 0.69) using the small tree and an error rate of 35% with an AUC of 0.63 (95% confidence interval from 0.54 to 0.72) using the comprehensive tree. There were large differences between the two validation sets. Conditional inference trees are able to augment prognostic clinical decision making for patients undergoing ECMO treatment. They may provide a degree of accuracy in mortality prediction and prognostic stratification using readily available variables.