Use Of Extracorporeal Life Support Research Articles

Extracorporeal life support in adult patients with out-of-hospital cardiac arrest.

The use of extracorporeal life support in cardiopulmonary resuscitation (CPR) of adult patients experiencing out-of-hospital cardiac arrest by the application of veno-arterial extracorporeal membrane oxygenation (ECMO) during cardiac arrest has been increasing over the past decade. This can be attributed to the encouraging results of extracorporeal CPR (ECPR) in multiple observational studies. To date, only one randomised controlled trial has compared ECPR to conventional advanced life support measures. Patient selection is crucial for the success of ECPR programmes. A rapid and organised approach is required for resuscitation, i.e. cannula insertion with ECMO pump initiation in combination with other aspects of post-cardiac arrest care such as targeted temperature management and early coronary reperfusion. The provision of an ECPR service can be costly, resource intensive and technically challenging, as limited studies have reported on its cost-effectiveness.

Applications and Outcomes of Extracorporeal Life Support Use in Adult Liver Transplantation: A Case Series and Review of Literature.

The use of extracorporeal life support (ECLS) is increasingly reported in adult liver transplantation (LT). However, neither the role of ECLS in the perioperative setting for LT nor its outcomes has been well defined. We performed a retrospective chart review of all adult LT patients at our institution who received ECLS from 2004 to 2021. We also conducted a comprehensive literature search for adult LT cases that involved perioperative ECLS for respiratory or cardiac failure. Over the study period, 11 LT patients required ECLS at our institution, two for respiratory and nine for cardiac failure. Both patients with respiratory failure received ECLS as a bridge to LT and survived to discharge. Nine patients required ECLS for acute cardiac failure either intraoperatively or postoperatively, and two survived to discharge. In the literature, we identified 35 cases of respiratory failure in LT patients requiring perioperative ECLS. Applications included preoperative bridge to LT (n = 6) and postoperative rescue (n = 29), for which overall survival was 44%. We identified 31 cases of cardiac failure in LT patients requiring either ECLS or cardiopulmonary bypass for cardiac support or rescue for intraoperative or postoperative cardiac failure (n = 30). There is evidence for consideration of ECLS as a bridge to LT in patients with potentially reversible respiratory failure or as rescue therapy for respiratory failure in posttransplant patients. ECLS has a prohibitively high risk of futility in pretransplant patients with cardiac failure but may have a role in LT patients with a functioning graft and potentially reversible cardiac failure.

New Trends, Advantages and Disadvantages in Anticoagulation and Coating Methods Used in Extracorporeal Life Support Devices.

The use of extracorporeal life support (ECLS) devices has significantly increased in the last decades. Despite medical and technological advancements, a main challenge in the ECLS field remains the complex interaction between the human body, blood, and artificial materials. Indeed, blood exposure to artificial surfaces generates an unbalanced activation of the coagulation cascade, leading to hemorrhagic and thrombotic events. Over time, several anticoagulation and coatings methods have been introduced to address this problem. This narrative review summarizes trends, advantages, and disadvantages of anticoagulation and coating methods used in the ECLS field. Evidence was collected through a PubMed search and reference scanning. A group of experts was convened to openly discuss the retrieved references. Clinical practice in ECLS is still based on the large use of unfractionated heparin and, as an alternative in case of contraindications, nafamostat mesilate, bivalirudin, and argatroban. Other anticoagulation methods are under investigation, but none is about to enter the clinical routine. From an engineering point of view, material modifications have focused on commercially available biomimetic and biopassive surfaces and on the development of endothelialized surfaces. Biocompatible and bio-hybrid materials not requiring combined systemic anticoagulation should be the future goal, but intense efforts are still required to fulfill this purpose.

The Use of Extracorporeal Life Support in Children With Immune-Mediated Diseases.

To describe the use and outcomes of extracorporeal membrane oxygenation support among children with immune-mediated conditions. Retrospective cohort study. The Extracorporeal Life Support Organization registry. Patients 1 month to 18 years old with International Classification of Diseases, 9th Edition and International Classification of Diseases, 10th Edition codes for immune-mediated conditions from 1989 to 2018. None. During the study period, 207 patients with an immune-mediated condition received extracorporeal membrane oxygenation, and 50% survived to discharge. Most patients (63%) received extracorporeal membrane oxygenation for respiratory support with 53% survival, 21% received cardiac support (55% survival), and 15% received extracorporeal cardiopulmonary resuscitation (34% survival). The most common diagnosis among nonsurvivors was hemophagocytic lymphohistiocytosis/macrophage activation syndrome with 37% survival. Patients with juvenile idiopathic arthritis (23%) and dermatomyositis (25%) had the lowest survival. Nonsurvivors had a higher frequency of infections, neurologic complications, and renal replacement therapy use. Use of preextracorporeal membrane oxygenation corticosteroids was associated with mortality. Children with immune-mediated conditions can be successfully supported with extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation use has increased over time, and survival varies considerably by diagnosis.

Outcomes of adult patients supported by extracorporeal membrane oxygenation (ECMO) following cardiopulmonary arrest. The Mayo Clinic experience.

To describe our experience in use of extracorporeal life support (ECLS) as a rescue strategy in patients following cardiopulmonary resuscitation. A retrospective analysis was performed for patients (n = 101) who received ECLS after cardiorespiratory arrest between May 2001 and December 2014. The primary outcome was survival to hospital discharge. In this cohort median (IQR) age was 56 (37-67) years, 53 (53%) were male, and 90 (89%) were Caucasian. Ventricular tachycardia or ventricular fibrillations were the initial cardiac rhythm in 49 (48.5%) and asystole/pulseless electrical activity in 37 (36.8%). Median (IQR) time to initiation of extracorporeal support from arrest time was 72 (43-170) min. The median (IQR) duration of support was 100 (47-157) hours. Renal failure (66%) and bleeding (66%) were the two most commonly observed complications during ECLS support. The survival to hospital discharge was seen in 47 (47%) patients, and good neurologic outcome (mRs 0-3) was seen in 29%. Acidosis, lactate and continuous renal replacement therapy were independent predictors of mortality. The median (IQR) intensive care unit stay was 14 (4-28) days and hospital stay was 17 (4-35) days. Our institutional experience with ECLS as a rescue measure following cardiac arrest is associated with improvement in mortality, and favorable neurologic status at hospital discharge.

Use of Extracorporeal Life Support for Heart Transplantation: Key Factors to Improve Outcome.

Although patients receiving extracorporeal life support (ECLS) as a bridge to transplantation have demonstrated worse outcomes than those without ECLS, we investigated the key factors in the improvement of their posttransplant outcome. From December 2003 to December 2018, 257 adult patients who underwent heart transplantation (HTx) at our institution were included. We identified 100 patients (38.9%) who underwent HTx during ECLS (ECLS group). The primary outcome was 30-day mortality after HTx. The median duration of ECLS was 10.0 days. The 30-day mortality rate was 3.9% (9.2% in peripheral ECLS, 2.9% in central ECLS, and 1.9% in non-ECLS). The use of ECLS was not an independent predictor of 30-day and 1-year mortality (p = 0.248 and p = 0.882, respectively). Independent predictors of 30-day mortality were found to be higher ejection fraction (p < 0.001), Sequential Organ Failure Assessment score (p < 0.001), and total bilirubin level (p = 0.005). In a subgroup analysis, cannulation type was not a predictor of 30-day mortality (p = 0.275). Early ECLS application to prevent organ failure and sophisticated management of acute heart failure may be important steps in achieving favorable survival after HTx.

Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support (ECLS) Over the Past Two Decades – ELSO Registry Analysis

Background: The use of extracorporeal life support (ECLS) has increased worldwide over the last decade including for new emerging indications like extracorporeal cardiopulmonary resuscitation, trauma, and COVID-19. Bleeding complications remain feared and frequent, with high morbidity and increased mortality. Yet, data about trends, and in-hospital outcomes, have been poorly investigated.Methods: The Extracorporeal Life Support Organization (ELSO) Registry database was explored for patients who received veno-venous (V-V) and veno-arterial (V-A) ECLS between the years 2000 and 2020. Trends in bleeding complications and mortality were analyzed. Bleeding complications were classified according to site (gastro-intestinal, cannulation site, surgical site, pulmonary, tamponade and central nervous system) and analyzed separately. Multivariable analysis was performed to identify risk factors for bleeding complications.Results: ELSO database analysis included 53.644 patients with single ECLS runs, mean age 51.4± 15.9 years, 33.859 (64.5%) male. Study cohort included 19.748 patients cannulated for V-V ECLS and 30.696 patients for V-A ECLS. Bleeding complications were reported in 14.786 patients (27.6%) and occurred more often in V-A-modalities compared to V-V modalities (30.0% versus 21.9%, pConclusions: The steady decrease in particular cannulation and surgical site related bleeding complications over the past 20 years suggests advances in equipment development (membrane and tubes surfaces) as well as better understanding of anticoagulation management. However, the high incidence of bleeding and association with hospital mortality reinforces the need for studies to understand bleeding complications more thoroughly during ECLS.Funding Information: No funding.Declaration of Interests: Prof. Dr. Lorusso is a consultant for Medtronic, Getinge and LivaNova and medical advisory board member for EUROSETS, all unrelated to this work; all honoraria to the university for research funding. Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). Dr. Tonna received speaker fees and travel compensation from LivaNova and Philips Healthcare, unrelated to this work. Prof. Ten Cate received research support from Bayer and Pfizer, is a consultant for Alveron and stockholder with Coagulation Profile; all unrelated to this work. Prof Zoe McQuilten is supported by an Australian National Health and Medical Council (NHMRC) Investigator Grant.Other authors have no conflict of interest to declare.Ethics Approval Statement: Each institution participating in ELSO Registry approves data reported to the registry through their local institutional review board. This study involved only analysis of pre-existing de-identified data from an international registry, and as such no ethics approval was required. Similarly, no patient consent was required.

Extracorporeal life support in COVID-19-related acute respiratory distress syndrome: A EuroELSO international survey.

Extracorporeal life support (ECLS) is a means to support patients with acute respiratory failure. Initially, recommendations to treat severe cases of pandemic coronavirus disease 2019 (COVID‐19) with ECLS have been restrained. In the meantime, ECLS has been shown to produce similar outcomes in patients with severe COVID‐19 compared to existing data on ARDS mortality. We performed an international email survey to assess how ECLS providers worldwide have previously used ECLS during the treatment of critically ill patients with COVID‐19. A questionnaire with 45 questions (covering, e.g., indication, technical aspects, benefit, and reasons for treatment discontinuation), mostly multiple choice, was distributed by email to ECLS centers. The survey was approved by the European branch of the Extracorporeal Life Support Organization (ELSO); 276 ECMO professionals from 98 centers in 30 different countries on four continents reported that they employed ECMO for very severe COVID‐19 cases, mostly in veno‐venous configuration (87%). The most common reason to establish ECLS was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno‐arterial cannulation due to heart failure (3%). Time on ECLS varied between less than 2 and more than 4 weeks. The main reason to discontinue ECLS treatment prior to patient’s recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators, were responsible for discontinuation of ECLS support. Most ECLS physicians (51%, IQR 30%) agreed that patients with COVID‐19‐induced ARDS (CARDS) benefitted from ECLS. Overall mortality of COVID‐19 patients on ECLS was estimated to be about 55%. ECLS has been utilized successfully during the COVID‐19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure. Age and multimorbidity limited the use of ECLS. Triage situations were rarely a concern. ECLS providers stated that patients with severe COVID‐19 benefitted from ECLS.

The Effect of Post Operative Tracheostomy on Outcomes in Lung Transplant Patients

<h3>Purpose</h3> Tracheostomy (trach) placement after lung transplantation (LTx) may be required in patients with prolonged ventilator dependence. However, little research exists on predictors and outcomes for recipients with post-LTx trachs. We examined baseline data and compared short and intermediate term patient outcomes with and without post-LTx trachs. <h3>Methods</h3> Baseline data, short/long term outcomes from patients s/p LTx performed between 1/1/12 and 6/31/19 who required trach during the index hospitalization were evaluated and compared with the trach-free cohort. <h3>Results</h3> Compared to trach-free patients, the trach cohort patients were younger (51.6±13.6 vs. 56.9±10.8, p=0.034) and had a higher mean lung allocation score (LAS) (66.6±22.8 vs. 55.2±20.7, p=0.014). They were more likely to be inpatient at time of LTx (54.2% vs 32.1%, p=0.035), had a bilateral LTx (60.8% vs 35.9%, p=0.001) and require extracorporeal life support (ECLS) pre- (16.7% vs. 1.9%, p=0.0005) and post-LTx (16.7% vs. 0.6%, p=0.001). Trach cohort patients had longer mechanical ventilation (p=0.0001) and hospital length of stay (HLOS) (p=0.0001). More patients in the trach cohort required acute rehab on discharge (p=0.0016). Although index in-hospital mortality of the trach cohort was higher (16.7% vs 2.5%, p=0.013), there was no difference in 1 year mortality (16.7% vs 8.3%, p=0.229) c/w trach-free cohort. There was significantly reduced long-term survival in trach patients (Fig.1) with limited follow up. <h3>Conclusion</h3> LTx recipients requiring post-op trach appear to be sicker, as evidenced by higher LAS and greater ECLS use pre-LTx. Trach cohort had longer duration of mechanical ventilation, post-op HLOS and discharge to acute rehabilitation. In our study, the need for post-LTx trach was associated with increased short term mortality. Although 1 year post-LTx mortality was similar between the groups, long term survival was worse in trach cohort with larger and longer studies needed.

Successful extracorporeal life support in a pediatric trauma patient following angioembolization of pelvic hemorrhage.

Extracorporeal Life Support (ECLS) is rarely used in pediatric trauma patients due to bleeding risk, and the use of ECLS following angioembolization of traumatic hemorrhage has never been reported in a child. We report a case of a 10-year-old boy run over by a parade float resulting in severe thoracic, abdominal, and pelvic trauma, with hemorrhage from pelvic fractures requiring massive transfusion. Due to ongoing blood product requirements and contrast extravasation near the symphysis pubis, angioembolization of the internal iliac arteries was performed. Extreme hypoxemia persisted despite maximal ventilator support due to pulmonary contusions and aspiration pneumonitis. Six hours after angioembolization, venovenous ECLS was initiated. Following an initial heparin bolus, ECLS was run without anticoagulation for 12 h, but development of circuit clot required resumption of low-dose heparin. After four days, his respiratory status improved substantially and ECLS was discontinued. There were no hemorrhagic complications. The patient was discharged home in good health following inpatient rehabilitation. In this case, ECLS was successfully used in the treatment of post-traumatic respiratory failure 6 h following angioembolization of pelvic hemorrhage in a pediatric trauma patient. Further research is needed to determine the safest interval between hemorrhage control and ECLS in severely injured children.

Management of Congenital Diaphragmatic Hernia Treated With Extracorporeal Life Support: Interim Guidelines Consensus Statement From the Extracorporeal Life Support Organization.

The management of infants with congenital diaphragmatic hernia (CDH) receiving extracorporeal life support (ECLS) is complex. Significant variability in both practice and prevalence of ECLS use exists among centers, given the lack of evidence to guide management decisions. The purpose of this report is to review existing evidence and develop management recommendations for CDH patients treated with ECLS. This article was developed by the Extracorporeal Life Support Organization CDH interest group in cooperation with members of the CDH Study Group and the Children's Hospitals Neonatal Consortium.

Utilization of extracorporeal life support for diffuse alveolar damage and diffuse alveolar hemorrhage: A systematic review.

Modern extracorporeal life-support (ECLS) technology has been successfully utilized to treat patients with diffuse alveolar damage (DAD) and diffuse alveolar hemorrhage (DAH); however, reports in the literature remain scarce. We sought to pool existing evidence to better characterize ECLS use in these patients. An electronic search was conducted to identify all studies in the English literature reporting the use of ECLS for DAD/DAH. Thirty-two articles consisting of 38 patients were selected, and patient-level data were extracted and pooled for analysis. Median patient age was 36 [IQR: 27, 48] years, and the majority (63.2%) were female. Most common etiological factors included granulomatosis with polyangiitis (8/38, 21.1%), systemic lupus erythematosus (8/38, 21.1%), Goodpasture's syndrome (4/38, 10.5%), and microscopic polyangiitis (4/38, 10.5%). Immunologic markers included anti-neutrophil cytoplasmic antibody (ANCA) in 15/38 (39.5%), anti-nuclear antibody (ANA) in 6/38 (15.8%), and anti-glomerular basement membrane (anti-GBM) antibodies in 4/38 (10.5%). DAH was present in 32/38 (84.2%) of cases and DAD without evidence of DAH was present in 6/38 (15.8%) of cases. ECLS strategies included extracorporeal membrane oxygenation of veno-venous type (VV-ECMO) in 28/38 (73.7%), veno-arterial type (VA-ECMO) in 5/38 (13.2%), and one case of right ventricular assist device with oxygenator (RVAD-ECMO). Heparin was utilized in 18/38 (47.4%) of cases with no difference in use between DAH versus no DAH (P=.46) or VA- versus VV-ECLS (P=1). Median duration of ECLS was 10 [5, 14] days. Pre- versus post-ECLS comparison of blood gases showed improvement in median PaO2 (49 [45, 59] mm Hg vs. 80 [70, 99] mm Hg, P<.001), PaO2:FiO2 ratio (48.2 [41.4, 54.8] vs. 182.0 [149.4, 212.2], P<.01), and pulse oximetry values (76% [72, 80] vs. 96% [94, 97], P=.086). Overall, 94.7% (36/38) of patients survived to decannulation while 30-day mortality was 10.5% (4/38) with no differences between VA- and VV-ECMO (P=1 and P=.94, respectively). DAD/DAH occurs in a younger, predominantly female population, and tends to be associated with systemic autoimmune processes. ECLS, independent of its type, appears to result in favorable short-term survival.

Ambulatory home wearable lung: progress and future directions.

Extracorporeal life support (ECLS) was first implemented as an extension of cardiopulmonary bypass technology. The early use of ECLS in patients with acute respiratory distress syndrome (ARDS) was discouraging, likely due to limitations of technology and understanding of the disease process. However, over the last decade, there has been a rapid expansion in ECLS use. This "rebirth" in 2009 was largely driven by the need for ECLS during the Influenza A subtype H1N1 pandemic and the results of the conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR) trial showing improved outcomes in patients with ARDS on ECLS compared to traditional management. Along with the increase in overall use of ECLS, there has been an increase in the number of patients with lung failure who are on long-term support, either awaiting lung recovery or transplantation. Many of these patients are awake, participating in physical rehabilitation, and even ambulating while supported with ECLS. Given the recent advances in patient care, and improvements in ECLS technology, the movement towards home for stable patients supported with ECLS may be on the horizon. Patients supported with ventricular assist devices (VAD) underwent a similar transition towards home in the 1990s, before which they were hospital bound. The road to an ambulatory home wearable lung will likely mirror that pathway. This review will give a brief overview of the transition of VAD patients out of the hospital, the history of ECLS, the current state of ECLS for lung failure, new and upcoming ECLS technology, and hurdles on the road home for ECLS patients.

Pediatric and neonatal extracorporeal life support: current state and continuing evolution.

The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.

An Easy-to-Use Machine Learning Model to Predict the Prognosis of Patients With COVID-19: Retrospective Cohort Study.

BackgroundPrioritizing patients in need of intensive care is necessary to reduce the mortality rate during the COVID-19 pandemic. Although several scoring methods have been introduced, many require laboratory or radiographic findings that are not always easily available.ObjectiveThe purpose of this study was to develop a machine learning model that predicts the need for intensive care for patients with COVID-19 using easily obtainable characteristics—baseline demographics, comorbidities, and symptoms.MethodsA retrospective study was performed using a nationwide cohort in South Korea. Patients admitted to 100 hospitals from January 25, 2020, to June 3, 2020, were included. Patient information was collected retrospectively by the attending physicians in each hospital and uploaded to an online case report form. Variables that could be easily provided were extracted. The variables were age, sex, smoking history, body temperature, comorbidities, activities of daily living, and symptoms. The primary outcome was the need for intensive care, defined as admission to the intensive care unit, use of extracorporeal life support, mechanical ventilation, vasopressors, or death within 30 days of hospitalization. Patients admitted until March 20, 2020, were included in the derivation group to develop prediction models using an automated machine learning technique. The models were externally validated in patients admitted after March 21, 2020. The machine learning model with the best discrimination performance was selected and compared against the CURB-65 (confusion, urea, respiratory rate, blood pressure, and 65 years of age or older) score using the area under the receiver operating characteristic curve (AUC).ResultsA total of 4787 patients were included in the analysis, of which 3294 were assigned to the derivation group and 1493 to the validation group. Among the 4787 patients, 460 (9.6%) patients needed intensive care. Of the 55 machine learning models developed, the XGBoost model revealed the highest discrimination performance. The AUC of the XGBoost model was 0.897 (95% CI 0.877-0.917) for the derivation group and 0.885 (95% CI 0.855-0.915) for the validation group. Both the AUCs were superior to those of CURB-65, which were 0.836 (95% CI 0.825-0.847) and 0.843 (95% CI 0.829-0.857), respectively.ConclusionsWe developed a machine learning model comprising simple patient-provided characteristics, which can efficiently predict the need for intensive care among patients with COVID-19.

Survival Benefit Associated With the Use of Extracorporeal Life Support for Neonates With Congenital Diaphragmatic Hernia.

To measure the survival among comparable neonates with CDH supported with and without ECLS. Despite widespread use in the management of newborns with CDH, ECLS has not been consistently associated with improved survival. A retrospective cohort study was performed using ECLS-eligible CDH Study Group registry patients born between 2007 and 2019. The primary outcome was in-hospital mortality. Neonates who did and did not receive ECLS were matched based on variables affecting risk for the primary outcome. Iterative propensity score-matched, survival (Cox regression and Kaplan-Meier), and center effects analyses were performed to examine the association of ECLS use and mortality. Of 5855 ECLS-eligible CDH patients, 1701 (29.1%) received ECLS. "High-risk" patients were best defined as those with a lowest achievable first-day arterial partial pressure of CO2 of ≥60 mm Hg. After propensity score matching, mortality was higher with ECLS (47.8% vs 21.8%, odds ratio 3.3, 95% confidence interval 2.7-4.0, hazard ratio 2.3, P < 0.0001). For the subgroup of high-risk patients, there was lower mortality observed with ECLS (64.2% vs 84.4%, odds ratio 0.33, 95% confidence interval 0.17-0.65, hazard ratio 0.33, P = 0.001). This survival advantage was persistent using multiple matching approaches. However, this ECLS survival advantage was found to occur primarily at high CDH volume centers that offer frequent ECLS for the high-risk subgroup. Use of ECLS is associated with excess mortality for low- and intermediate-risk neonates with CDH. It is associated with a significant survival advantage among high-risk infants, and this advantage is strongly influenced by center CDH volume and ECLS experience.

Extracorporeal Life Support (ECLS): A Review and Focus on Considerations for COVID-19

Extracorporeal life support (ECLS) is a support modality for patients with severe acute respiratory distress syndrome (ARDS) who have failed conventional treatments including low tidal volume ventilation, prone positioning, and neuromuscular blockade. In addition, ECLS can be used for hemodynamic support for patients with cardiogenic shock or following cardiac arrest. Injured patients may also require ECLS support for ARDS and other indications. We review the use of ECLS for ARDS patients, trauma patients, cardiogenic shock patients, and post-cardiac arrest patients. We then describe how these principles are applied in the management of the novel coronavirus disease 2019 pandemic. Indications, predictors, procedural considerations, and post-cannulation management strategies are discussed.

Trends in Mortality and Costs of Pediatric Extracorporeal Life Support

Extracorporeal life support (ECLS) has been used for >30 years as a life-sustaining therapy in critically ill patients for a variety of indications. In the current study, we aimed to examine trends in use, mortality, length of stay (LOS), and costs for pediatric ECLS hospitalizations. We performed a retrospective cohort study of pediatric patients (between the ages of 28 days and <21 years) on ECLS using the 2008-2015 National Inpatient Sample, the largest all-payer inpatient hospitalization database generated from hospital discharges. Nonparametric and Cochran-Armitage tests for trend were used to study in-hospital mortality, LOS, and hospitalization costs. Of the estimated 5847 patients identified and included for analysis, ECLS was required for respiratory failure (36.4%), postcardiotomy syndrome (25.9%), mixed cardiopulmonary failure (21.7%), cardiogenic shock (13.1%), and transplanted graft dysfunction (2.9%). The rate of ECLS hospitalizations increased 329%, from 11 to 46 cases per 100 000 pediatric hospitalizations, from 2008 to 2015 (P < .001). Overall mortality decreased from 50.3% to 34.6% (P < .001). Adjusted hospital costs increased significantly ($214 046 ± 11 822 to 324 841 ± 25 621; P = .002) during the study period despite a stable overall hospital LOS (46 ± 6 to 44 ± 4 days; P = .94). Use of ECLS in pediatric patients has increased with substantially improved ECLS survival rates. Hospital costs have increased significantly despite a stable LOS in this group. Dissemination of this costly yet life-saving technology warrants ongoing analysis of use trends to identify areas for quality improvement.

Indications and contraindications for extracorporeal life support for severe heart or lung failure: a systematic review.

The effectiveness of extracorporeal life support (ECLS) in critically ill patients remains unclear despite a substantial increase in its use. This study critically assesses existing ECLS guidelines, consensus statements, and position papers to systematically review them for agreements and differences regarding indications and contraindications for ECLS. The aims of this review were to identify available indications and contraindications for ECLS and to evaluate the quality of the evidence on which they are based. Documents containing recommendations regarding indications and/or contraindications for ECLS in adults (aged 18+) were identified through Medline, EMBASE, and CENTRAL searches. Additional documents were identified from guideline-specific databases and the internet websites of professional societies. Based on the Appraisal of Guidelines for Research and Evaluation (AGREE II), four independent reviewers assessed the rigor of development and quality of the documents. Eleven documents met the inclusion criteria. Three documents received an average score of ≥50% in all domains. However, the Editorial independence domain only scored <50% in most of the documents. Overall, 13 cardiac and 13 pulmonary ECLS indications, and 23 cardiac and 14 pulmonary contraindications were identified. Indications and contraindications for ECLS use are variable across the documents included and leave considerable room for interpretation. The documents included for review show considerable variability, with little consensus on indications and contraindications. This lack of consensus may reflect a lack of clarity regarding ECLS utility. Additionally, it may reveal the necessity for individualized, patient-dependent criteria supported by the best evidence available.

Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review.

Extracorporeal life support (ECLS) is indicated in refractory acute respiratory or cardiac failure. According to the need for anticoagulation, bleeding conditions (e.g., in trauma, pulmonary bleeding) have been considered a contraindication for the use of ECLS. However, there is increasing evidence for improved outcomes after ECLS support in hemorrhagic patients based on the benefits of hemodynamic support outweighing the increased risk of bleeding. We conducted a systematic literature search according to the PRISMA guidelines and reviewed publications describing ECLS support in hemorrhagic conditions. Seventy-four case reports, four case series, seven retrospective database observational studies, and one preliminary result of an ongoing study were reviewed. In total, 181 patients were identified in total of 86 manuscripts. The reports included patients suffering from bleeding caused by pulmonary hemorrhage (n = 53), trauma (n = 96), postpulmonary endarterectomy (n = 13), tracheal bleeding (n = 1), postpartum or cesarean delivery (n = 11), and intracranial hemorrhage (n = 7). Lower targeted titration of heparin infusion, heparin-free ECLS until coagulation is normalized, clamping of the endotracheal tube, and other ad hoc possibilities represent potential beneficial maneuvers in such conditions. Once the patient is cannulated and circulation restored, bleeding control surgery is performed for stabilization if indicated. The use of ECLS for temporary circulatory or respiratory support in critical patients with refractory hemorrhagic shock appears feasible considering tailored ECMO management strategies. Further investigation is needed to better elucidate the patient selection and ECLS management approaches.