Extracorporeal Life Support Techniques Research Articles

Neutrophils: a key component in ECMO-related acute organ injury.

Extracorporeal membrane oxygenation (ECMO), as an extracorporeal life support technique, can save the lives of reversible critically ill patients when conventional treatments fail. However, ECMO-related acute organ injury is a common complication that increases the risk of death in critically ill patients, including acute kidney injury, acute brain injury, acute lung injury, and so on. In ECMO supported patients, an increasing number of studies have shown that activation of the inflammatory response plays an important role in the development of acute organ injury. Cross-cascade activation of the complement system, the contact system, and the coagulation system, as well as the mechanical forces of the circuitry are very important pathophysiological mechanisms, likely leading to neutrophil activation and the production of neutrophil extracellular traps (NETs). NETs may have the potential to cause organ damage, generating interest in their study as potential therapeutic targets for ECMO-related acute organ injury. Therefore, this article comprehensively summarized the mechanism of neutrophils activation and NETs formation following ECMO treatment and their actions on acute organ injury.

Veno-Venous Extracorporeal Membrane Oxygenation in COVID-19-Where Are We Now?

The recent development in extracorporeal life support (ECLS) has created new therapeutic opportunities for critically ill patients. An interest in extracorporeal membrane oxygenation (ECMO), the pinnacle of ECLS techniques, has recently increased, as for the last decade, we have observed improvements in the survival of patients suffering from severe acute respiratory distress syndrome (ARDS) while on ECMO. Although there is a paucity of conclusive data from clinical research regarding extracorporeal oxygenation in COVID-19 patients, the pathophysiology of the disease makes veno-venous ECMO a promising option.

Extracorporeal Life Support in Adult Patients: A Global Perspective of the Last Decade.

Extracorporeal life support (ECLS) is an external medical device to treat critically ill patients with cardiovascular and respiratory failure. In a nutshell, ECLS is only a "bridging" mechanism that provides life support while the heart and/or the lungs is recovering either by therapeutic medical interventions, transplantation, or spontaneously. Extracorporeal life support has been developed since 1950s, and many studies were conducted to improve ECLS techniques, but unfortunately, the survival rate was not improved. Because of Dr Bartlett's success in using ECLS to treat neonates with severe respiratory distress in 1975, ECLS is made as a standard lifesaving therapy for neonates with severe respiratory distress. However, its use for adult patients remains debatable. The objectives of this study are to outline and provide a general overview of the use of ECLS especially for adult patients for the past 10 years and to elaborate on the challenges encountered by each stakeholder involved in ECLS. The data used for this study were extracted from the ELSO Registry Report of January 2018. Results of this study revealed that the number of ECLS centers and the use of ECLS are increasing over the year for the past decade. There was also a shift of the patient's age category from neonatal to adult patients. However, the survival rates for adult patients are relatively low especially for cardiac and extracorporeal cardiopulmonary resuscitation cases. To date, the complications are still the major challenge of ECLS. Other challenges encountered by the stakeholders in ECLS are the limited amount of well-trained and experienced ECLS teams and centers, the limited government expenditure on health, and the lack of improvement and development of ECLS techniques and devices. Further studies are needed to evaluate the value of ECLS for adult patients.

Indications and outcomes of extracorporeal life support in trauma patients.

The use of extracorporeal life support (ECLS) in the trauma population remains controversial and has been reported only in small cohort studies. Recent ECLS technical advances have increased its use as an advanced critical care option in trauma. Given the degree of resource utilization, costs, and expertise required to provide ECLS support in trauma patients, we sought to perform a multi-institutional study to assess the indications and outcomes of ECLS in trauma. A retrospective review of adult (≥16 years) trauma patients receiving ECLS support in the Extracorporeal Life Support Organization (ELSO) registry (1989-2016) was performed. Standardized data from the contributing ELSO centers includes patient demographics, diagnoses, and ECLS technique and procedures. Additionally, baseline characteristics, precannulation and postcannulation physiologic data, complications, and outcomes were recorded. Survival was categorized both by transition off ECLS support and survival to hospital discharge. Two hundred seventy-nine trauma patients were identified (0.92% of 30,273 adult ECLS patients). Extracorporeal life support increased significantly in the last 5 years (173 in 2011-2016, 62%) compared with 106 in the prior 18 years. Trauma patients were predominantly male (78%), with a mean age of 34.8 ± 15.4 years (range, 16-88 years). Thoracic injury was the most common diagnosis; acute respiratory distress syndrome was the most common indication. Extracorporeal life support was venovenous for respiratory failure (89%), VA for cardiac failure (7%), and VA for ECLS-assisted cardiopulmonary resuscitation (CPR) (E-CPR) (4%). Extracorporeal life support duration was 8.8 ± 9.5 days (longest 83 days), and was longer for respiratory support (9.3 ± 9.3 days) vs. cardiac support (4.1 ± 4.5 days) and E-CPR (6.5 ± 16.8 days). Overall survival from ECLS was 70% and survival to hospital discharge was 61% in the total cohort (63% respiratory, 50% cardiac, 25% E-CPR), similar to survival rates in other ELSO registry cohorts. More than 80% of patients had a reported complication during ECLS support. The most common complication was cardiovascular (51%) followed by a bleeding complication (29%). Multiple organ failure was the most common cause of death (15.4%). Data from the largest registry of critically ill trauma patients receiving ECLS support demonstrates reasonable survival. With growing experience and improved safety profile, trauma should not be considered a contraindication for ECLS. Further analysis of the ELSO registry regarding trauma-specific risk factors and ECLS-specific practices may identify best candidates and improve trauma ECLS outcomes. Therapeutic study, level III.

Urgent Lung Transplantation in Severe Acute Respiratory Failure Based on Rapidly Progressive Interstitial Lung Disease: A Case Report

Lung transplantation (LUTX) became a worldwide accepted standard therapy for certain well-defined chronic end-stage lung diseases. Until recently, patients on mechanical ventilation or extracorporeal life support techniques were hardly eligible for LUTX because of the inferior short-term results. However, a paradigm shift has occurred, and now these techniques represent bridging options to LUTX for listed patients. In the current practice, transplantation from the intensive care unit (ICU) is not extraordinary in patients on the waiting list. On the other hand, transplantation of an ICU patient who has previously been healthy without any chronic lung disease is still exceptional. Here we report a unique case of a 37-year-old woman without any relevant medical history who developed acute lung failure based on a cryptogenic organizing pneumonia. Her condition rapidly deteriorated and she required mechanical support, then she was bridged to transplantation on venovenous extracorporeal membrane oxygenation. She was listed for LUTX, and despite elevated panel-reactive antibody values, positive crossmatch LUTX was performed. Induction therapy, alemtuzumab, plasmapheresis, and intravenous immunoglobulin were administered. Her recovery was slow but finally she could be discharged from hospital in stable condition. After 2 months at home, she was readmitted to the hospital with respiratory failure from combined antibody-mediated rejection and infection. Before December 2015, the launch of Hungarian National Lung Transplantation Program, Hungarian patients were transplanted in Vienna. This case presents an exceptional example of national and international teamwork that aimed to save a young woman's life.

Vascular access for extracorporeal life support: tips and tricks.

In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD). Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO2 removal (ECCO2R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine.

Extracorporeal membrane oxygenation as a support for emergency bronchial reconstruction in a traumatic patient with severe hypoxaemia: Figure 1:

Extracorporeal membrane oxygenation (ECMO) is an extracorporeal life support technique to provide cardiac and/or respiratory assistance to patients. ECMO has been demonstrated to be beneficial for the life support of selected traumatic individuals. However, the application of arteriovenous ECMO as an intraoperative support strategy in emergency operations has rarely been described. The presented case involves a 31-year old male who sustained a right bronchial rupture and other multiple injuries in a car accident. His right main bronchus was sewn completely closed during the first operation in a local hospital, and he developed refractory hypoxaemia and haemodynamic instability. Although general anaesthesia was not applicable, arteriovenous ECMO was applied as a support to perform the second operation to reconstruct successfully his right main bronchus. As a result, he recovered from this injury.

Pediatric Single‐Lumen Cannula Venovenous Extracorporeal Membrane Oxygenation: A French Center Experience

Single-lumen cannula venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a special extracorporeal life support (ECLS) technique used for neonatal and pediatric refractory hypoxemia. This is an alternative flow rate ECLS that consists of successive clamping on the drainage and the injection lines. Currently, the Armand-Trousseau's pediatric intensive care unit remains the only pediatric ECMO center proposing this partial assistance. This article details a technical note and a retrospective analysis of our experience in refractory hypoxemia. The retrospective study, from 2007 to 2011, included all pediatric and neonatal patients treated by single-lumen cannula VV ECMO. The study was focused on pre-ECMO patient characteristics and complications during ECMO course. During the last 5 years, 67 pediatric patients were assisted by this single-lumen cannula VV ECMO. Sixty-one patients (91%) were newborns. Thirty-nine patients presented with meconium aspiration syndrome (58%), which was the most frequent etiology. Before cannulation, mean oxygenation index (OI) was 32 ± 11, alveolar-arterial oxygen difference was 604 ± 47 mm Hg, and partial pressure arterial oxygen/fraction inspired oxygen ratio was 59.2 ± 35.8. Forty-eight patients (72%) presented pulmonary hypertension, and 66 patients were treated by nitric oxide (98%). Fifty patients (75%) were treated by vasopressors or inotropic drugs. Average duration of ECMO was 13.2 ± 7.8 days. There were forty-six survivors (69%). The worst prognosis was for respiratory syncytial virus pneumonia. Complications like acute renal injury and hematologic and transfusion acts were not so different than those observed in classical ECMO techniques. Nevertheless, 19 patients presented a stroke (28% of the overall population), but this high rate did not seem to be due to the ECLS technique used. Single-lumen cannula VV ECMO is a partial and efficient ECMO support. Our experience shows that this technique is as efficient and less invasive than two cannulas ECMO. The single-lumen cannula VV ECMO is a simple and safe ECLS support used for neonatal or pediatric refractory hypoxemia. Because this is a partial assistance, it is a promising ECLS support.

Extracorporeal life support

Extracorporeal life support (ECLS) denotes the use of prolonged extracorporeal cardiopulmonary bypass in patients with acute, reversible cardiac or respiratory failure. As technology has advanced, organ support functions other than gas exchange, such as liver, renal, and cardiac support, have been provided by ECLS, and others, such as immunologic support, will be developed. The future of ECLS will include improvements in devices accompanied by circuit simplification and auto-regulation. Such enhancements in technology will allow application of ECLS to populations currently excluded from such support; for example, thromboresistant circuits will eliminate the need for systemic anticoagulation and lead to the use of this technique in premature newborns. As the ECLS technique becomes safer and simpler, and as morbidity and mortality are minimized, criteria for application of ECLS will be relaxed. New approaches to ECLS, such as pumpless arteriovenous bypass, the artificial placenta, arteriovenous CO(2) removal (AVCO(2)R), and intravenous oxygenators (IVOX), will become more commonly applied. Such advances in technology will allow broader and more routine application of ECLS for lung and other organ system failure.

Adición de un cortocircuito arterio-venoso durante el soporte vital extracorpóreo veno-arterial de un paciente con síndrome cardiopulmonar por Hantavirus: Caso clínico

A subgroup of patients infected with the Hantavirus develops a pulmonary syndrome (HPS) characterized by severe acute respiratory failure and myocardial depression, that has a high mortality rate. Extracorporeal life support (ECLS) could be a valuable therapeutic tool in such patients. We report a 24 years old male with HPS that was successfully managed when an arterio-venous shunt was added to a conventional veno-arterial ECLS technique. Precise criteria have been developed to predict which patients should be considered for this treatment.

Percutaneous access for venovenous extracorporeal life support in neonates

Background: Although percutaneous cannulation has been previously described in adult and pediatric patients older than 3 years, its use in neonates for venovenous extracorporeal life support (ECLS) has not been previously described. Methods: Twenty neonates of weight 3.4 ± 0.6 kg (range, 2.3 to 4.9 kg.) with severe respiratory failure (meconium aspiration syndrome, persistent pulmonary hypertension of the newborn, sepsis) were managed with double-lumen venovenous ECLS. Percutaneous access via the right internal jugular (RIJ) vein with a 12F (n = 13) or 15F (n = 7) double-lumen ECLS cannula was obtained via a modified Seldinger technique. RIJ access was specifically obtained 2 to 3 cm above the clavicle with a 21-gauge needle and a 0.018-in guide wire followed by a technique that allowed insertion of the larger cannula guide wire. Decannulation simply involved removal of the cannula with hemostasis obtained by direct pressure. Results: Percutaneous cannulation was performed without difficulty in 11 infants. Conversion to an open technique for cannula placement was required in four patients early in our experience because percutaneous access to the RIJ with the 0.018-inch guide wire could not be achieved, and in one neonate because the 15F cannula could not be advanced into the RIJ and resulted in laceration of the vein. Inability to achieve RIJ access also led to use of an “exposure-assisted” percutaneous procedure in four patients later in our experience. Complications included a pneumothorax identified on chest radiograph 18 hours after cannulation in one infant and partial thrombotic occlusion of the cannula requiring a change over a guide wire in another. There were no problems associated with decannulation. Conclusions: This is the first description of percutaneous cannulation in neonates for venovenous ECLS. In the authors' early experience, percutaneous access using a 12F double lumen venovenous cannula may be efficiently performed especially in patients >3.0 kg in weight and has the potential for simplifying and reducing the cost of the ECLS technique.

Adaptation of an ECMO team in the era of successful alternative therapies for neonatal pulmonary failure

Neonates with persistent pulmonary hypertension show severe hypoxemia that requires a variety of therapeutic modalities. When patients do not respond to conventional medical management that includes hyperventilation, inotropic support, and vasodilating agents, treatment with extracorporeal membrane oxygenation (ECMO) may be used. More recently, high-frequency oscillatory ventilation and nitric oxide inhalation have been used in these infants and have impacted the need for ECMO. In light of these changes in therapy, the authors reviewed the 6-year clinical experience of an ECMO team to assess trends in patient population and outcome and document adaptation of the medical professionals to a new treatment era. Between 1988 and 1993, 88 neonates who met the institutional criteria were placed on venoarterial ECMO. Oscillatory ventilation was locally introduced in 1991 and nitric oxide treatment in 1992. Patient outcomes for the 1988 to 1990 period were compared with those for 1991 to 1993. Analyses included indication for ECMO therapy, length and complexity of the run, length of hospital stay, and cost of patient care. During the first 3 years, 65 patients were placed on ECMO, compared with 23 patients during the 3 years after introduction of oscillatory ventilation and nitric oxide therapy ( P < .001). The length of ECMO therapy increased from a mean of 128 hours to 190 hours ( P = .005), and the average hospital stay, likewise, increased from 27 days to 42 days. The total cost of care increased by approximately $40,000 per patient. During the 1991 to 1993 period, hyaline membrane disease and primary persistent pulmonary hypertension of the newborn became less of an indication for ECMO and were replaced by an increase in incidence of patients with sepsis and congenital diaphragmatic hernia. Fifty-five of the 65 (85%) patients during the first period survived, compared with 16 of the 23 (70%) patients during the second. With the advent of alternative therapies for severe neonatal pulmonary failure, the need for ECMO decreased in this pediatric tertiary care center. To maintain expertise, the ECMO team was integrated into a hospital-wide critical cardiopulmonary support team. Extracorporeal life support techniques became relevant only within a broader clinical setting created by the new therapeutic environment.