Extracorporeal Life Support Organization Research Articles

Abstract 270: Eligibility Of Out-of-hospital Cardiac Arrest Patients For Extracorporeal Cardiopulmonary Resuscitation In The United States: A Geographic Information System Model

Introduction: Recent evidence suggest that ECPR may improve survival rates for nontraumatic out-of-hospital cardiac arrest (OHCA). Eligibility criteria for ECPR are often based on patient age, clinical variables, and facility capabilities. Expanding access to ECPR across the U.S. requires a better understanding of how these factors interact with transport time to ECPR centers. Methods: We constructed a Geographic Information System (GIS) model to estimate the number of ECPR candidates in the U.S. We utilized a Resuscitation Outcome Consortium (ROC) database to model time-dependent rates of ECPR eligibility and the Cardiac Arrest Registry to Enhance Survival (CARES) registry to determine the total number of OHCA patients who meet pre-specified ECPR criteria within designated transportation times. Potential ECPR centers were categorized as Extracorporeal Membrane Oxygenation (ECMO)-ready, ECMO-capable, or percutaneous coronary intervention (PCI)-capable centers using data from the Extracorporeal Life Support Organization and the American Hospital Directory. The combined model was used to estimate the total ECPR candidates and the effects of patient and hospital factors on ECPR eligibility. Results: There were 588,203 OHCA patients in the CARES registry from 2013 to 2020. After applying clinical eligibility criteria, 22,104 (3.76%) OHCA patients were eligible for ECPR. The rate of ROSC increased with longer resuscitation time, which resulted in fewer ECPR candidates. The proportion of OHCA patients eligible for ECPR increased with older age cutoffs. Only 1.68% (9,889/588,203) of OHCA patients in the U.S. were eligible for ECPR based on a 45-minute transportation time to an ECMO-ready center model, representing the current state of ECPR in the U.S. The proportion of OHCA patients eligible for ECPR ranged from 0.68% (4,027 patients in the 15-minute transportation time to ECMO-ready center model) to 2.81% (16,558 patients in the 45-minute transportation time to PCI-capable center model). Conclusions: Less than 2% of OHCA patients are eligible for ECPR in the U.S. GIS models can identify the impact of clinical criteria, transportation time, and hospital capabilities on ECPR eligibility to inform future implementation strategies.

Abstract 12769: Association of Lung Protective Ventilation and Outcomes in Patients With Cardiogenic Shock on ECLS

Background: In Acute Respiratory Distress Syndrome, lung protective ventilation (LPV) improves patient outcomes by minimizing the risk of ventilator-associated lung injury. For patients with cardiogenic shock (CS) requiring VA-ECLS, the extracorporeal heart-lung circuit provides a unique opportunity to provide LPV. At present, there are limited data regarding optimal ventilator strategies for patients in CS on VA-ECLS. We hypothesized that CS patients on VA-ECLS who require ventilator support will have better outcomes with LPV. Methods: We queried Extracorporeal Life Support Organization (ELSO) registry for hospital admissions between 2009 and 2019 for CS patients on VA-ECLS and mechanical ventilation. Patients with multiple ECLS runs, congenital heart disease, pre-ECLS cardiac arrest, and durable mechanical circulatory support were excluded. We defined LPV as peak inspiratory pressure (PIP24)<30 cm H 2 O at 24 hours on ECLS. ELSO registry does not report tidal volume, hence, PIP24 was used as surrogate for plateau pressure. PIP24 and driving pressure (PIP24 minus PEEP24) at 24 hours (DP24) were also studied as continuous variables. Our primary outcome was survival to discharge. Multivariable analysis adjusted for baseline SAVE score, age, race, BMI, etiology of CS, intubation hours prior to ECMO and history of chronic lung disease. Results: A total of 2,226 CS patients on VA-ECLS were included of which 1904 received LPV. LPV patients had a significantly lower BMI (median 28.28 vs 31.14, p<0.001), and were less sick, as assessed by their baseline SAVE score (-1.79 vs -2.79, p=0.002). The primary outcome of survival to discharge was significantly greater in LPV cohort (47.4% vs 32.6%, p<0.001). Median PIP24 (22 vs 24, p<0.001) as well as DP24 (14.5 vs 16, p<0.001) were significantly lower in those surviving to discharge. Adjusted OR for primary outcome with LPV was 1.69 (p=0.0023). Adjusted OR for primary outcome with incremental rise in PIP24 (0.78, p=0.0003) and DP24 (0.75, p<0.0001) were also statistically significant. Conclusions: In VA-ECLS patients requiring mechanical ventilation, LPV and lower PIP and DP at 24 hours is associated with improved survival to discharge.

Arterial oxygen and carbon dioxide tension and acute brain injury in extracorporeal cardiopulmonary resuscitation patients: Analysis of the extracorporeal life support organization registry

Acute brain injury (ABI) remains common after extracorporeal cardiopulmonary resuscitation (ECPR). Using a large international multicenter cohort, we investigated the impact of peri-cannulation arterial oxygen (PaO2) and carbon dioxide (PaCO2) on ABI occurrence. We retrospectively analyzed adult (≥18 years old) ECPR patients in the Extracorporeal Life Support Organization registry from 1/2009 through 12/2020. Composite ABI included ischemic stroke, intracranial hemorrhage (ICH), seizures, and brain death. The registry collects 2 blood gas data pre- (6 hours) and post- (24 hours) cannulation. Blood gas parameters were classified as: hypoxia (<60mm Hg), normoxia (60-119mm Hg), and mild (120-199mm Hg), moderate (200-299mm Hg), and severe hyperoxia (≥300mm Hg); hypocarbia (<35mm Hg), normocarbia (35-44mm Hg), mild (45-54mm Hg) and severe hypercarbia (≥55mm Hg). Missing values were handled using multiple imputation. Multivariable logistic regression analysis was used to assess the relationship of PaO2 and PaCO2 with ABI. Of 3,125 patients with ECPR intervention (median age=58, 69% male), 488 (16%) experienced ABI (7% ischemic stroke; 3% ICH). In multivariable analysis, on-ECMO moderate (aOR=1.42, 95%CI: 1.02-1.97) and severe hyperoxia (aOR=1.59, 95%CI: 1.20-2.10) were associated with composite ABI. Additionally, severe hyperoxia was associated with ischemic stroke (aOR=1.63, 95%CI: 1.11-2.40), ICH (aOR=1.92, 95%CI: 1.08-3.40), and in-hospital mortality (aOR=1.58, 95%CI: 1.21-2.06). Mild hypercarbia pre-ECMO was protective of composite ABI (aOR=0.61, 95%CI: 0.44-0.84) and ischemic stroke (aOR=0.56, 95%CI: 0.35-0.89). Early severe hyperoxia (≥300mm Hg) on ECMO was a significant risk factor for ABI and mortality. Careful consideration should be given in early oxygen delivery in ECPR patients who are at risk of reperfusion injury.

Disparities in the treatment of cardiogenic shock: does sex matter?

The use of extracorporeal life support for cardiogenic shock has significantly increased over the past decade. However, there are insufficient data for the presence of sex-associated outcomes differences. Our study assesses differences between male and female patients placed on venoarterial extracorporeal life support (VA-ECLS) for cardiogenic shock from an international database. This is a multicentre, retrospective study on 9888 adult patients on VA-ECLS for cardiogenic shock from the Extracorporeal Life Support Organization registry from 2011 to 2019. The 1:1 nearest neighbour propensity score matching was performed. The primary end point was in-hospital mortality. Secondary end points include bleeding, infection and other complications. There were 6747 (68%) male patients and 3141 (32%) female patients. Male patients were more likely to have history of myocardial infarction, coronary artery disease, diabetes, chronic kidney disease and congestive heart failure. Female patients were more likely to be centrally cannulated. After propensity score matching, there was no difference seen in in-hospital mortality. In regards to complications, female patients were more likely to experience limb ischaemia, whereas males were more likely to receive renal replacement therapy and have longer hospital stays. Multivariable logistic regression confirmed sex was not independently associated with mortality. There was no difference in-hospital mortality between male and female patients receiving VA-ECLS for cardiogenic shock. Female patients were more likely to have limb ischaemia as a complication. Varying cannulation approaches for female patients should be further investigated.

Outcomes of Venovenous Extracorporeal Membrane Oxygenation in Viral Acute Respiratory Distress Syndrome.

Our study assessed the relationship between the duration of venovenous extracorporeal membrane oxygenation (V-V ECMO) and patient outcomes. We studied patients undergoing V-V ECMO support for acute respiratory distress syndrome (ARDS) between 2009 and 2017 who were reported to the Extracorporeal Life Support Organization registry. We evaluated survival, major bleeding, renal failure, pulmonary complications, mechanical complications, neurologic complications, infection, and duration of V-V ECMO support. Multivariable regression modeling assessed risk factors for adverse events. Of the 4,636 patients studied, the mean support duration was 12.2 ± 13.7 days. There was a progressive increase in survival after the initiation of V-VECMO, peaking at a survival rate of 73% at 10 days of support. However, a single-day increase in V-V ECMO duration was associated with increased bleeding events (odds ratio [OR] 1.038; 95% confidence interval [CI]: 1.029-1.047; p < 0.0001), renal failure (OR 1.018; 95% CI: 1.010-1.027; p < 0.0001), mechanical complications (OR 1.065; 95% CI: 1.053-1.076; p < 0.0001), pulmonary complications (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001), and infection (OR 1.04; 95% CI: 1.03-1.05; p < 0.0001). V-V ECMO progressively increases survival for ARDS over the first 10 days of support. Thereafter, rising complications associated with prolonged durations of support result in a progressive decline in survival.

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

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

ECMO During COVID-19: A Society of Thoracic Surgeons/Extracorporeal Life Support Organization Survey

BackgroundThe Society of Thoracic Surgeons Workforce on Critical Care and the Extracorporeal Life Support Organization sought to identify how the coronavirus disease 2019 (COVID-19) pandemic has changed the practice of venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) programs across North America. MethodsA 26-question survey covering 6 categories (ECMO initiation, cannulation, management, anticoagulation, triage/protocols, and credentialing) was emailed to 276 North American Extracorporeal Life Support Organization centers. ECMO practices before and during the COVID-19 pandemic were compared. ResultsResponses were received from 93 (34%) programs. The percentage of high-volume (>20 cases per year) VV ECMO programs increased during the pandemic from 29% to 41% (P < .001), as did institutions requiring multiple clinicians for determining initiation of ECMO (VV ECMO, 25% to 43% [P = .001]; VA ECMO, 20% to 32% [P = .012]). During the pandemic, more institutions developed their own protocols for resource allocation (23% before to 51%; P < .001), and more programs created sharing arrangements to triage patients and equipment with other centers (31% to 57%; P < .001). Direct thrombin inhibitor use increased for both VA ECMO (13% to 18%; P = .025) and VV ECMO (12% to 24%; P = .005). Although cardiothoracic surgeons remained the primary cannulating proceduralists, VV ECMO cannulations performed by pulmonary and critical care physicians increased (13% to 17%; P = .046). ConclusionsThe Society of Thoracic Surgeons/Extracorporeal Life Support Organization collaborative survey indicated that the pandemic has affected ECMO practice. Further research on these ECMO strategies and lessons learned during the COVID-19 pandemic may be useful in future global situations.

Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation.

The primary objective was to investigate the association between partial pressure of carbon dioxide (PaCO 2 ) change after extracorporeal membrane oxygenation (ECMO) initiation and neurologic outcome in neonates treated for respiratory failure. A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database including newborns supported by ECMO for respiratory indication during 2015-2020. The closest Pre-ECMO (Pre-ECMO PaCO 2 ) and at 24 hours after ECMO initiation (H24 PaCO 2 ) PaCO 2 values allowed to calculate the relative change in PaCO 2 (Rel Δ PaCO 2 = [H24 PaCO 2 - Pre-ECMO PaCO 2 ]/Pre-ECMO PaCO 2 ). The primary outcome was the onset of any acute neurologic event (ANE), defined as cerebral bleeding, ischemic stroke, clinical or electrical seizure, or brain death during ECMO. We included 3,583 newborns (median age 1 day [interquartile range {IQR}, 1-3], median weight 3.2 kg [IQR, 2.8-3.6]) from 198 ELSO centers. The median Rel Δ PaCO 2 value was -29.9% [IQR, -46.2 to -8.5]. Six hundred nine (17%) of them had ANE (405 cerebral bleedings, 111 ischemic strokes, 225 seizures, and 6 brain deaths). Patients with a decrease of PaCO 2 > 50% were more likely to develop ANE than others (odds ratio [OR] 1.78, 95% confidence interval [CI], 1.31-2.42, p < 0.001). This was still observed after adjustment for all clinically relevant confounding factors (adjusted OR 1.94, 95% CI, 1.29-2.92, p = 0.001). A significant decrease in PaCO 2 after ECMO start is associated with ANE among neonates requiring ECMO for respiratory failure. Cautious PaCO 2 decrease should be considered after start of ECMO therapy.

Transfusion practice in patients receiving VV ECMO (PROTECMO): a prospective, multicentre, observational study

In patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) packed red blood cell (PRBC) transfusion thresholds are usually higher than in other patients who are critically ill. Available guidelines suggest a restrictive approach, but do not provide specific recommendations on the topic. The main aim of this study was, in a short timeframe, to describe the actual values of haemoglobin and the rate and the thresholds for transfusion of PRBC during VV ECMO. PROTECMO was a multicentre, prospective, cohort study done in 41 ECMO centres in Europe, North America, Asia, and Australia. Consecutive adult patients with acute respiratory distress syndrome (ARDS) who were receiving VV ECMO were eligible for inclusion. Patients younger than 18 years, those who were not able to provide informed consent when required, and patients with an ECMO stay of less than 24 h were excluded. Our main aim was to monitor the daily haemoglobin concentration and the value at the point of PRBC transfusion, as well as the rate of transfusions. The practice in different centres was stratified by continent location and case volume per year. Adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for baseline and time varying confounding. Between Dec 1, 2018, and Feb 22, 2021, 604 patients were enrolled (431 [71%] men, 173 [29%] women; mean age 50 years [SD 13·6]; and mean haemoglobin concentration at cannulation 10·9 g/dL [2·4]). Over 7944 ECMO days, mean haemoglobin concentration was 9·1 g/dL (1·2), with lower concentrations in North America and high-volume centres. PRBC were transfused on 2432 (31%) of days on ECMO, and 504 (83%) patients received at least one PRBC unit. Overall, mean pretransfusion haemoglobin concentration was 8·1 g/dL (1·1), but varied according to the clinical rationale for transfusion. In a time-dependent Cox model, haemoglobin concentration of less than 7 g/dL was consistently associated with higher risk of death in the intensive care unit compared with other higher haemoglobin concentrations (hazard ratio [HR] 2·99 [95% CI 1·95-4·60]); PRBC transfusion was associated with lower risk of death only when transfused when haemoglobin concentration was less than 7 g/dL (HR 0·15 [0·03-0·74]), although no significant effect in reducing mortality was reported for transfusions for other haemoglobin classes (7·0-7·9 g/dL, 8·0-9·9 g/dL, or higher than 10 g/dL). During VV ECMO, there was no universally accepted threshold for transfusion, but PRBC transfusion was invariably associated with lower mortality only when done with haemoglobin concentration of less than 7 g/dL. Extracorporeal Life Support Organization.

Extracorporeal Membrane Oxygenation Support for Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: An ELSO Registry Analysis.

Extracorporeal Membrane Oxygenation Support for Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: An ELSO Registry Analysis.

Prognostic factors associated with mortality among patients receiving venovenous extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

Venovenous extracorporeal membrane oxygenation (ECMO) can be considered for patients with COVID-19-associated acute respiratory distress syndrome (ARDS) who continue to deteriorate despite evidence-based therapies and lung-protective ventilation. The Extracorporeal Life Support Organization has emphasised the importance of patient selection; however, to better inform these decisions, a comprehensive and evidence-based understanding of the risk factors associated with poor outcomes is necessary. We aimed to summarise the association between pre-cannulation prognostic factors and risk of mortality in adult patients requiring venovenous ECMO for the treatment of COVID-19. In this systematic review and meta-analysis, we searched MEDLINE and Embase from Dec 1, 2019, to April 14, 2022, for randomised controlled trials and observational studies involving adult patients who required ECMO for COVID-19-associated ARDS and for whom pre-cannulation prognostic factors associated with in-hospital mortality were evaluated. We conducted separate meta-analyses of unadjusted and adjusted odds ratios (uORs), adjusted hazard ratios (aHRs), and mean differences, and excluded studies if these data could not be extracted. We assessed the risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. Our protocol was registered with the Open Science Framework registry, osf.io/6gcy2. Our search identified 2888 studies, of which 42 observational cohort studies involving 17 449 patients were included. Factors that had moderate or high certainty of association with increased mortality included patient factors, such as older age (adjusted hazard ratio [aHR] 2·27 [95% CI 1·63-3·16]), male sex (unadjusted odds ratio [uOR] 1·34 [1·20-1·49]), and chronic lung disease (aHR 1·55 [1·20-2·00]); pre-cannulation disease factors, such as longer duration of symptoms (mean difference 1·51 days [95% CI 0·36-2·65]), longer duration of invasive mechanical ventilation (uOR 1·94 [1·40-2·67]), higher partial pressure of arterial carbon dioxide (mean difference 4·04 mm Hg [1·64-6·44]), and higher driving pressure (aHR 2·36 [1·40-3·97]); and centre factors, such as less previous experience with ECMO (aOR 2·27 [1·28-4·05]. The prognostic factors identified highlight the importance of patient selection, the effect of injurious lung ventilation, and the potential opportunity for greater centralisation and collaboration in the use of ECMO for the treatment of COVID-19-associated ARDS. These factors should be carefully considered as part of a risk stratification framework when evaluating a patient for potential treatment with venovenous ECMO. None.

Respiratory support before venovenous ECMO for COVID-19: what is the price?

The COVID-19 pandemic was an unprecedented challenge for the extracorporeal membrane oxygenation (ECMO) community. The demand for extracorporeal gas exchange markedly increased to face the surge in life-threatening respiratory failures; however, as highlighted in the Extracorporeal Life Support Organization COVID-19 guidelines,1 the limited availability of ECMO resources (eg, consoles and circuits) and the heavy workload of health-care personnel forced a strict selection of patients for ECMO. In this context, identifying the predictors of poorer outcomes becomes essential to enable the provision of ECMO support to patients who are most likely to benefit.

Associations of cephalad drainage in neonatal veno-venous ECMO – A mixed-effects, propensity score adjusted retrospective analysis of 20 years of ELSO data

BackgroundNeurologic complications can occur during neonatal Veno-Venous (VV) ECMO. The addition of a cephalad drainage cannula (i.e., VVDL+V) to dual lumen cannulation (i.e., VVDL) has been advocated to reduce such complications, but previous studies have presented mixed results. MethodsData from the ECMO Registry of the Extracorporeal Life Support Organization was used to extract all neonates (≤28 days old) who underwent VV ECMO for respiratory support between 2000 and 2019. Primary outcomes were mortality, conversion to Veno-Arterial (VA) ECMO, pump flows, and complications. A mixed-effects, propensity score adjusted analysis was performed. Results4,275 neonates underwent VV ECMO, 581 (13.6%) via VVDL+V cannulation, and 3,694 (86.4%) via VVDL. On unadjusted analyses, VVDL+V patients had higher rates of mortality (25.5% vs 19.0%, p<0.001), conversion to VA ECMO (14.5% vs 4.1%, p<0.001), and higher pump flows at 4 h from ECMO initiation (112.7 vs 105.5 mL/Kg/min, p<0.001), but lower at 24 h (100.3 vs 104.0 mL/Kg/min, p = 0.004), and a higher proportion of them experienced hemorrhagic (29.3% vs 18.3%, p<0.001), cardiovascular (60.8% vs 45.8%, p<0.001), and mechanical (42.5% vs 32.6%, p<0.001) complications compared to VVDL patients. After adjusting for propensity scores and the multi-level nature of ELSO data, there were no differences in neurologic outcomes, pump flows, or mortality. Rather, VVDL+V cannulation was associated with higher rates of conversion to VA ECMO (adjusted odds ratio [AOR] 43.3, 95% CI 24.3 – 77.4, p<0.001), and increased mechanical (AOR 2.2, 95% CI 1.6 – 3.0, p<0.001) and hemorrhagic (AOR 2.0, 95% CI 1.4 – 3.0, p<0.001) complications. ConclusionsIn this analysis, VVDL+V cannulation was not associated with any improvement in neurologic outcomes, pump flows, or mortality, but was rather associated with higher rates of conversion to Veno-Arterial ECMO, mechanical, and hemorrhagic complications.

Evidence summary of early rehabilitation of adults with veno-venous extracorporeal membrane oxygenation

To evaluate and summarize the best evidence for early rehabilitation of adults with veno-venous extracorporeal membrane oxygenation (VV-ECMO). Evidence on early rehabilitation of adult VV-ECMO patients was searched by computer from 7 English literature databases [PubMed database, cumulative index to nursing and allied health literature (CINAHL), Embase database, Cochrane library database, UpToDate clinical consultant, BMJ best clinical practice, JBI database], 5 Chinese literature databases (China biomedical literature database, China Yimai Tong, China national knowledge infrastructure, Wanfang data, VIP database), 5 guideline networks [National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), National Guideline Clearinghouse (NGC), Guidelines International Network (GIN), China Guide Network] and 2 professional association websites [Extracorporeal Life Support Organization (ELSO), Chinese Association of Rehabilitation Medicine]. The search period is from January 2011 to December 2021. The appraisal of guidelines for research and evaluation II (AGREE ) and JBI 2014 quality assessment tools were used to evaluate the quality of inclusion guidelines, systematic reviews, expert consensus and original studies, respectively, and to extract and summarize the best evidence for early rehabilitation of adults with VV-ECMO. A total of 2 guidelines, 2 expert consensuses, 2 systematic reviews and 8 original studies [including 1 randomized controlled trial (RCT), 1 non-randomized controlled study, 3 cohort studies and 3 case reports] were included. The evidence was summarized from 9 aspects including the necessity of early rehabilitation, rehabilitation initiation time, rehabilitation location, pre-rehabilitation preparation, pre-rehabilitation assessment, rehabilitation method, rehabilitation frequency and duration, rehabilitation process monitoring and effect evaluation,and finally 24 pieces of the best evidence were summarized. Early rehabilitation of adults with VV-ECMO is safe and feasible. The summary of the best evidence can provide evidence-based guidance for clinical medical staff to reasonably carry out early rehabilitation.

Cardiogenic shock severity and mortality in patients receiving venoarterial extracorporeal membrane oxygenator support.

Shock severity predicts mortality in patients with cardiogenic shock (CS). We evaluated the association between pre-cannulation Society for Cardiovascular Angiography and Intervention (SCAI) shock classification and mortality among patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support for CS. We included Extracorporeal Life Support Organization (ELSO) Registry patients from 2010 to 2020 who received VA ECMO for CS. SCAI shock stage was assigned based on hemodynamic support requirements prior to ECMO initiation. In-hospital mortality was analyzed using multivariable logistic regression. We included 12 106 unique VA ECMO patient runs with a median age of 57.9 (interquartile range: 46.8, 66.1) years and 31.8% were females; 3472 (28.7%) were post-cardiotomy. The distribution of SCAI shock stages at ECMO initiation was: B, 821 (6.8%); C, 7518 (62.1%); D, 2973 (24.6%); and E, 794 (6.6%). During the index hospitalization, 6681 (55.2%) patients died. In-hospital mortality increased incrementally with SCAI shock stage (adjusted OR: 1.24 per SCAI shock stage, 95% CI: 1.17-1.32, P < 0.001): B, 47.5%; C, 52.8%; D, 60.8%; E, 65.1%. A higher SCAI shock stage was associated with increased in-hospital mortality in key subgroups, although the SCAI shock classification was only predictive of mortality in non-surgical (medical) CS and not in post-cardiotomy CS. The severity of shock prior to cannulation is a strong predictor of in-hospital mortality in patients receiving VA ECMO for CS. Using the pre-cannulation SCAI shock classification as a risk stratification tool can help clinicians refine prognostication for ECMO recipients and guide future investigations to improve outcomes.

Prevalence and Impact of Infection during Extracorporeal Membrane Oxygenation in Oncologic Patients: A Retrospective Analysis of the Extracorporeal Life Support Organization (ELSO) Registry.

Background: Extracorporeal membrane oxygenation (ECMO) is widely utilized for severe cardiopulmonary insufficiency, but its application to the oncologic population has been debated given concern for increased risk of infection. This study aims to analyze the implications of infections acquired during ECMO runs in patients with malignancy. Methods: The Extracorporeal Life Support Organization (ELSO) database was queried for patients with an International Classification of Diseases code of neoplasms over the last two decades (2000-2019). Culture-proven infections during ECMO runs were analyzed and compared to previously reported data for all ECMO runs. Results: Two thousand, seven hundred and fifty-seven patients met inclusion criteria. Infection acquired during ECMO run was found in 687 patients, a significantly greater proportion compared to all ECMO runs (24.9% vs 11.7%; P = .001). Adult patients had a significantly higher rate of infection (27.0%; P < .001) compared to neonatal (11.0%) and pediatric (21.4%) patients. Prevalence of infection was highest in pulmonary ECMO (29.0%), while the infection rate standardized with ECMO duration was highest in extracorporeal cardiopulmonary resuscitation (55.03/1000-day ECMO run). Compared with ECMO for all diagnoses, the prevalence of Candida and Klebsiella infection was significantly higher in adult and pediatric oncologic patients. Regardless of the pathogen, the presence of infection was not associated with lower survival (38.6% vs 40.0%; P = .522). Conclusions: Oncologic patients had a significantly higher infection rate while on ECMO compared with the general ECMO population. However, the prognostic impact of these infections was minimal, thus ECMO should not be withheld in oncologic patients solely with concern for infection.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Nosocomial infections during extracorporeal membrane oxygenation.

The aim of this review is to present the latest evidence regarding the prevention, diagnosis and treatment of nosocomial infections during extracorporeal membrane oxygenation (ECMO) support. New descriptive data from the Extracorporeal Life Support Organisation (ELSO) registry and single centre studies have been published. In parallel, there is an increase in the availability of evidence about the diagnostic accuracy of infection markers, yield of routine cultures, effectivity of antibiotic prophylaxis and other preventive measures. ECMO is a rescue therapy for severe hemodynamic or respiratory failure. Nosocomial infections on ECMO support are frequent (infection rate ranging between 20.5% to more than 50% of ECMO runs) and have impact in survival, with reported increases in the risk of death up to 63% in infected patients. However, diagnosis and treatment are challenging, as the unique relationship between patient and circuit may act as a confounder for infection and exacerbate the variability of antibiotic pharmacokinetics in critical illness. Clinical practice regarding antibiotic treatment and infection prevention is not yet supported by high-quality evidence.

Early withdrawal of life sustaining therapy in extracorporeal cardiopulmonary resuscitation (ECPR): Results from the Extracorporeal Life Support Organization registry

AimsAlthough extracorporeal cardiopulmonary resuscitation (ECPR) improves survival outcomes in refractory cardiac arrest, morbidity and mortality remain significantly high. Information on causes of death in ECPR is limited; however, some evidence suggests withdrawal of life sustaining therapy (WLST) is a major factor in ECPR-associated mortality. We sought to describe the patients experiencing WLST after ECPR. MethodsThe international Extracorporeal Life Support Organization (ELSO) Registry was retrospectively queried for patients more than 18 years old supported with ECPR who underwent WLST due to family request from 2007 to 2017. These patients were split into groups for descriptive and multivariable analysis: early (WLST < 72 hours from cannulation) and routine WLST. ResultsOverall, 411 ECPR patients experienced WLST (median age 42 years IQR = 28–51; 31.7% female) over the 10-year period. 55.5% (n = 228) underwent early WLST with a median ECPR duration of 24 hours (IQR = 7–48) versus routine WLST (median = 147 hours; IQR = 105–238). In multivariable regression analysis, lower arterial blood gas pH (aOR = −3.1; 95% CI = 2.18–2.8; p = 0.04), arterial oxygen saturation (aOR = 1.12; 95% CI = 1.01–1.23; p = 0.02), and higher peak inspiratory pressure (aOR = 0.84; 95% CI = 0.71–1.00; p = 0.05) were independently associated with early WLST. Early WLST patients experienced higher rates of all ECMO-related complications except for infections. ConclusionsMore than half of ECPR patients experienced early WLST within 72 hours. The patients with early WLST had worse markers of severe critical illness at 24 hours and experienced higher rates of complications. Further research should include an appropriate control group to better adjust confounders for ECPR-associated death and focus on prognostication.

Outcomes of Extracorporeal Life Support in Children with Meningococcal Septicemia: A Retrospective Cohort Study.

Meningococcal disease is associated with high mortality despite aggressive antibiotic therapy and intensive care support. Patients may develop refractory hypotension and acute respiratory distress syndrome in which extracorporeal membrane oxygenation (ECMO) could serve as a life-saving rescue therapy. However, there is limited data regarding the outcomes of ECMO support in the setting of meningococcal disease. This retrospective analysis of prospectively collected data from Extracorporeal Life Support Organization registry (1989-2019) enrolled children (29 days-18 years old) with Neisseria meningitidis infection receiving ECMO for any support type and mode. A total of 122 patients underwent a single course of ECMO support, equating to 122 ECMO runs. The overall survival-to-discharge rate was 46.7%. Patients receiving pulmonary venovenous (VV) ECMO had the highest survival-to-discharge of 85.7%, while those receiving venoarterial (VA) ECMO for pulmonary indications had a survival of 32.4%. Patients receiving VA ECMO support for cardiac indications had a survival-to-discharge rate of 60.9%. Those needing extracorporeal cardiopulmonary resuscitation (ECPR) had a poor survival (14.3%). Hemorrhagic complications were common, occurring in 43.4% of patients, but not found to be associated with mortality (complication was present in 47.7% of deceased and 38.6% of survivors, p = 0.31). Multivariable logistic regression analysis revealed that neurologic complications were associated with increased odds of mortality (odds ratio: 44.11; 95% confidence interval: 4.95-393.08). ECMO can be utilized as rescue therapy in children with refractory cardiopulmonary failure in setting of meningococcemia. Patients who require pulmonary VV or cardiac ECMO have the best ECMO outcomes. However, the use of ECMO in those suffering cardiac arrest (ECPR) should be undertaken with caution.