Extracorporeal Membrane Oxygenation Placement Research Articles

Assessing Right Ventricle Over Time in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: Insights From Serial Echocardiography.

Extracorporeal membrane oxygenation (ECMO) is often used in acute respiratory distress syndrome (ARDS) with refractory hypoxemia. There is limited literature highlighting the development of right ventricular (RV) failure while on ECMO. We conducted a retrospective multicenter observational study including 70 patients who were placed on veno-venous (VV)-ECMO for respiratory failure at Mayo Clinic, Jacksonville, and Mayo Clinic, Rochester, between January 2018 and June 2022 and had at least two post-ECMO transthoracic echoes. The primary outcomes were the incidence and progression of RV dysfunction and dilatation. The secondary outcome was in-patient mortality. Among 70 patients in our cohort, 60.6% had a normal RV function at the time of ECMO placement, whereas only 42% had a normal RV function at the second post-ECMO echo. On multinomial regression, a moderate decrease in RV function was associated with ECMO flow (odds ratio [OR] = 2.32, p = 0.001) and ECMO duration (OR = 1.01, p = 0.01). A moderately dilated RV size was also associated with ECMO flow (OR = 2.62, p < 0.001) and ECMO duration (OR = 1.02, p = 0.02). An increasing degree of RV dysfunction was associated with worse outcomes. Our study showed that the increasing duration and flow of VV-ECMO correlated with progressive RV dilatation and dysfunction, which were associated with poor survival.

Outcomes in patients who received ECMO and/or volatile anesthetics as rescue therapies for status asthmaticus

Background: In the state of Kentucky many status asthmaticus (SA) patients require care in the Pediatric Intensive Care Unit (PICU) and a fraction of these patients may receive “rescue therapies” with inhaled volatile anesthetics (IVA) and/or Extracorporeal Membrane Oxygenation (ECMO). Our objective was to compare the clinical parameters of individual patients who received either or both therapies. Methods: Children between 2-18 years of age admitted to our PICU from January 2014- July 2020 with SA were reviewed categorized as 1) patients who received IVA alone 2) patients who received IVA and then subsequently ECMO and 3) patients on ECMO alone. Results: 1772 children with SA episodes were identified with a mortality of 13 patients. 7 children with SA were identified who received either IVA, ECMO or both. One patient received only IVA, 5 received both IVA and ECMO and one received only ECMO. All received standard asthma therapies of steroids, albuterol, magnesium sulphate and aminophylline prior to escalation. Six out of seven refractory SA received IVA, and five (83%) of those were subsequently escalated to ECMO. pCO2 levels had no improvement after IVA administration but decreased by an average of 20 points after ECMO. Patients peak inspiratory pressures decreased within the 1 st 24 hours of ECMO cannulation from a mean of 30 to 18. There were no other complications related to ECMO placement. Conclusion: While we cannot decisively draw any conclusions from our study due to small sample, it was noted that there was no clear advantage of using IVA prior to ECMO in our patients. Most patients who received IVA were escalated to ECMO indicating that early ECMO cannulation may be beneficial. Given the high cost and potential complications of both, there is a need for the development of well-defined guidelines for severe SA management in the PICU.

Installed strategy and clinical observation of self-made extracorporeal membrane oxygenation system in the treatment of critically ill patients

To summarize the strategy and method for the treatment of critically ill patients with self-made extracorporeal membrane oxygenation (ECMO) system. A observative study was conducted. Fifty-six patients with ECMO assisted support in Fuwai Central China Cardiovascular Disease Hospital from December 2020 to December 2021 were enrolled. According to the clinical situation of the patients and the wishes of the family, conventional ECMO package (conventional group) or self-made ECMO package (self-made group) was chosen. In the conventional group, the disposable ECMO package was used to install the machine, pre charge and exhaust the air. In the self-made group, the disposable consumables commonly used in extracorporeal circulation during cardiac surgery (including centrifugal pump heads, membrane oxygenation, tubes, connectors, etc.) were used to create a self-made ECMO system. Based on the patient's situation, personalized tube model selection and length control were carried out. The preparation time, auxiliary time, auxiliary method, total pre charge volume, free hemoglobin (FHb) levels after 2 hours of ECMO operation and operating costs, as well as changes in hemodynamics, arterial blood gas analysis, and blood indicators within 48 hours after ECMO placement in the two groups were recorded. The occurrence of adverse events related to the ECMO system during ECMO adjuvant therapy in two groups was simultaneously observed. Fifty-six patients were enrolled finally, with 28 cases in the conventional group and 28 cases in the self-made group, and all successfully completed the operation of ECMO. There was no statistically significant difference in ECMO system preparation time, auxiliary time, auxiliary method, and FHb levels after 2 hours of ECMO operation between the conventional group and the self-made group [preparation time (minutes): 13±4 vs. 15±5, auxiliary time (hours): 287±34 vs. 276±42, veno-arterial ECMO (cases): 22 vs. 24, veno-venous ECMO (cases): 6 vs. 4, FHb after 2 hours of ECMO operation (mg/L): 226±67 vs. 253±78, all P > 0.05]. However, the total pre charge volume and operating costs in the self-made group were significantly lower than those in the conventional group [total pre charge volume (mL): 420±25 vs. 650±10, operating costs (ten thousand yuan): 3.8±0.4 vs. 6.7±0.3, both P < 0.01]. The hemodynamics, arterial blood gas analysis, and blood indicators of patients in the two groups were relatively stable within 48 hours after ECMO operation, and most of the indicators between the two groups showed no statistically significant differences. The hemoglobin (Hb) levels at 12, 24, and 48 hours after the machine transfer in the self-made group were significantly higher than those in the conventional group (g/L: 128.5±23.7 vs. 117.5±24.3 at 12 hours, 121.3±31.3 vs. 109.6±33.2 at 24 hours, 118.5±20.1 vs. 105.2±25.7 at 48 hours, all P < 0.05). Both groups of patients did not experience any adverse event related to the ECMO system, such as membrane pulmonary infiltration, joint detachment, and massive hemolysis, during the ECMO assisted treatment process. When implementing ECMO for critically ill patients in clinical practice, a self-made ECMO system with disposable consumables commonly used in extracorporeal circulation during cardiac surgery can be used for cardiopulmonary function assistance support, thereby saving patients medical costs and alleviating their dependence on disposable ECMO package in clinical practice.

Right ventricular dissection after arterial switch operation.

Herein we present the right ventricular dissection and describe its successful management after arterial switch operation in a full-term male neonate. There are no evidence-based recommendations for the management of this rare complication. Our management included veno-arterial extracorporeal membrane oxygenation placement and delayed surgical evacuation of the dissecting haematoma with beneficial outcomes.

Lactate Dehydrogenase and Hemorrhagic Stroke During Extracorporeal Membrane Oxygenation for COVID-19.

Hemorrhagic stroke (HS) is a devastating complication during extracorporeal membrane oxygenation (ECMO) but markers of risk stratification during COVID-19 are unknown. Lactate dehydrogenase (LDH) is a readily available biomarker of cell injury and permeability. We sought to determine whether an elevated LDH before ECMO placement is related to the occurrence of HS during ECMO for COVID-19. Adult patients with COVID-19 requiring ECMO between March 2020 and February 2022 were included. LDH values prior to ECMO placement were captured.Patientswere categorized into high (> 750 U/L) or low (≤ 750 U/L) LDH groups. Multivariable regression modeling was used to determine the association between LDH and HS during ECMO. There were 520patientsthat underwent ECMO placement in 17 centers and 384 had an available LDH. Of whom, 122 (32%) had a high LDH. The overall incidence of HS was 10.9%, and patients with high LDH had a higher incidence of HS than those with low LDH level (17% vs 8%, p = 0.007). At 100days, theprobabilityof a HS was 40% in the high LDH group and 23% in those with a low LDH, p = 0.002. Afteradjustmentfor clinical covariates, high LDH remained associated with subsequent HS (aHR: 2.64, 95% CI 1.39-4.92). Findings weresimilarwhen restricting topatientssupported byvenovenous ECMOonly. Elevated LDH prior to ECMO cannulation is associated with a higher incidence of HS duringdevicesupport. LDH canriskstratify cases for impending cerebralbleedingduring ECMO.

Improve the Completion Rate of ECMO Placement Assistance for Nurses in the NICU

The extracorporeal membrane oxygenation (ECMO) system can provide cardiopulmonary support to and reduce the mortality rate in severely ill newborns. According to our investigation, completion rate of the care process among staff nurses was only 63.5% in our ward. We assumed that the reasons for the above problems included: lack of care awareness, unfamiliarity with the ECMO operation process, inadequate instruments preparation, improper ECMO pipeline fixation, lack of designated space in the unit for placing ECMO supplies, lack of specialty care guidelines, lack of a regular inspection system, and lack of regular on-the-job education. Improve awareness related to assisting ECMO placement among nurses in the neonatal intensive care unit and the completeness of care. 1. Create a care process guidebook describing the procedures for ECMO system placement in newborns to help nurse accomplish proper placement. 2. Establish the ECMO system consumables checklist and install an ECMO system-specialized toolbox to reduce the preparation time and smooth the process. 3. Regularly organize comprehensive nurse training and develop performance indicators to enhance ECMO system placement awareness and skills. The cognitive accuracy rate for the assisted placement of ECMO among nurses in the neonatal intensive care unit increased from 51.9% before improvement to 89.9% afterward. Also, the complete care rate of ECMO placement increased from 63.5% before improvement to 100% afterward. This project effectively improved the accuracy rate of nurses involved in assisting with ECMO placement, made the ECMO system placement process easier to implement, improved the care process completion rate, and improved newborn care quality.

Outcomes with use of extra-corporeal membrane oxygenation in high-risk pulmonary embolism: a national database perspective.

High-risk pulmonary embolism (PE) patients can be managed with systemic lysis, catheter-based therapies, or surgical embolectomy. Despite the advent of newer therapies, patients with high-risk PE remain with a 50-60% short-term mortality risk. In such patients, extracorporeal membrane oxygenation (ECMO) is increasingly utilized for hemodynamic support. To evaluate the outcomes of the use of ECMO in patients with high-risk PE. Using the National Inpatient Sample (NIS) database, we identified patients with high-risk PE using ICD 10 codes and compared in-hospital outcomes of patients with and without ECMO support. We identified 38,035 patients with high-risk PE, of whom 820 had undergone ECMO placement. Most patients who underwent ECMO were male (54%), white (65%), and with a mean age of 53.7years. ECMO use was not associated with a meaningful difference in patient mortality when comparing treatment groups (OR, 1.32 ± 0.39; 0.74-2.35; p = 0.35). Rather, ECMO use was associated with a higher frequency of inpatient complications. ECMO use was not associated with a significant difference in patient mortality in patients with high-risk PE.

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.

Prone Positioning Under ECMO: A Retrospective Cohort of 34 Patients

<h3>Purpose</h3> Extracorporeal Membrane Oxygenation (ECMO) become standard therapy for refractory hypoxemia (veno-venous (VV)) and circulatory failure (veno-arterial (VA)). However, severe hypoxemia may persist in some patients under ECMO. Prone position (PP) has been shown to have a benefit on oxygenation in patients with acute respiratory distress syndrome. We performed a retrospective study to evaluate the change of oxygenation and the risks involved in positioning patients under ECMO in PP. <h3>Methods</h3> All patients who underwent PP under ECMO from August 2014 to December 2020 were included. PP was performed on two criteria: refractory hypoxemia defined by a P/F<80mmHg despite 100% FiO2 on ventilator and ECMO or persistent hypoxemia defined by a need to maintained FiO2 ≥80% on ECMO with posterior pulmonary condensations on CT scan. Ventilatory and ECMO parameters and PP-related complications were collected. <h3>Results</h3> From 556 patients under ECMO, 34 (6.1%) (median age 54 years) were included for 87 PP procedures (2.5 +/-2.4 sessions per patient). ECMO was VA for 6 patients, VV for 27 patients and VAV for one patient. 19 patients were placed in PP for refractory hypoxemia and 15 for persistent hypoxemia. Mean tidal volume was 4.5mL/kg +/-1.7, median positive end-expiratory pressure at 10 cmH20 (IQR 10-15), respiratory rate at 20/min (IQR 18-28). Mean PP session duration was 18 h +/-4.2. Median time from ECMO placement to first PP was 7 days (IQR 4-10). PP procedures resulted in a significant improvement in oxygenation, with increasing P/F_ECMO ratio from 92.6 to 133.2 on average (p<0.0001). Concomitantly the ventilator FiO2 decreased from 65% to 55% (p<0.0001).The most frequent complication was the presence of bedsores of the face and trunk (6 patients). The other complications reported were: 1 cardio respiratory arrest due to tamponade, 1 pump thrombosis, 1 displacement of limb reperfusion cannula, 1 tracheostomy decanulation. No ECMO decanulation occurred. At discharge, 9 of 34 patients with PP (26%) had died compared to 237 on 522 patients under ECMO without PP(45.4%) (p=0.033). <h3>Conclusion</h3> PP in hypoxemic patients under ECMO is effective for improving oxygenation. A beneficial effect on mortality is also suggested. In an expert center, less than 20% of patients experienced bedsores and 12% may suffer from severe complications requiring urgent treatment.

Outcomes by Severity of Obesity During Extracorporeal Membrane Oxygenation Support for COVID-19

PurposeObesity adversely impacts outcomes during COVID-19 but its relation to mortality in those receiving extracorporeal membrane oxygenation (ECMO) is uncertain.MethodsA retrospective multicenter study was conducted. Adult patients (≥18 years old) with severe COVID-19 infection placed on ECMO between March 1, 2020 to April 30, 2021, across the United States were included. A web-based database application, REDCap, was utilized to capture clinical characteristics and outcomes. Patients were grouped into tertiles of body mass index (BMI). The primary outcome was in-hospital mortality after ECMO placement assessed by a time-to-event analysis.ResultsOverall 444 patients (age 49, IQR: 38-57 years, 29% female, BMI: 33, IQR: 29-39 kg/m2) from 17 centers comprised the study cohort. Patients that expired during hospitalization had a similar BMI in comparison to those that were discharged (33, IQR: 29-38 vs. 34, IQR: 30-40 kg/m2, p=0.13). BMI across groups was 27, IQR: 25-29 (lowest tertile), 33, IQR: 32-34 (middle tertile), 41, IQR: 38-45 kg/m2 (highest tertile). At 90 days, in-hospital mortality between BMI tertiles was 53%, 59%, and 53%, p=0.99 (figure). After adjustment for clinical covariates including age, sex, presence of preexisting co-morbidities, cardiopulmonary arrest prior to ECMO, serum creatinine and arterial partial pressure of oxygen (PaO2) to inspired oxygen concentration (FiO2) ratio, there was no difference in hospital mortality in the middle (aHR:1.13, CI: 0.79-1.63, p=0.5) and highest (aHR: 1.38, CI: 0.95-2.01, p=0.09) tertiles in comparison to the lowest BMI tertile.ConclusionSeverity of obesity is not associated with death during hospitalization in patients placed on ECMO for COVID-19

Vascular complications based on mode of extracorporeal membrane oxygenation

BackgroundVascular complications remain a prevalent and devastating complication of extracorporeal membrane oxygenation (ECMO). Risks for vascular complications have risen as the volume and medical complexity of ECMO cases has rapidly increased in recent years. This study assesses occurrence and clinical impact of vascular complications across all ECMO modes and cannulation methods in a high-volume academic center. MethodsA retrospective single-institution review was performed of all ECMO cannulations for central or peripheral venovenous (VV) or venoarterial (VA) ECMO in 2019-2020. Patients who expired during cannulation were excluded. Primary outcomes of vascular consultation rates at or after ECMO placement, limb loss, and mortality were assessed during index hospitalization. ResultsA total of 229 patients were identified during the 2-year study period. VA ECMO was used in the majority of patients (n = 137, 60%), with 83% (N = 114) undergoing peripheral cannulation. Vascular surgery was consulted in 54 (23.6%) patients. Complication rates ranged from 33.9% in peripheral VA cannulation to 7% in jugular VV cannulation. Overall, 65% of vascular consults required operative intervention; interventions were highest in peripheral VA ECMO (n = 30 of 114, 26.3%). Across all ECMO types, acute limb ischemia (ALI) was the most common complication (n = 38, 16.5%), with rates ranging from 26.1% in central VA ECMO to 4.8% in jugular VV ECMO. Distal antegrade perfusion catheters (DPCs) were employed in n = 68 of 114 (59.6%) of all peripheral VA ECMO cases. Prophylactic DPCs were found to be incorrectly placed in 10.2% (n = 7 of 68) of cases, which obscured the ability to fully evaluate the effect of prophylactic DPCs on reducing rates of ALI. Major amputation (Below Knee Amputation/Above Knee Amputation) occurred in six peripheral VA patients (5.3%), two central VA patients (8.65), and two femoral-femoral VV patients (4%). Patients with ALI experienced significantly lower rates of in-hospital survival in Kaplan-Meier analysis (32.5% vs 54%, log-rank = 0.023). ConclusionsThis study highlights the prevalence of vascular complications, and their associated mortality impact, across all modes of ECMO and additionally identifies several areas for institutional performance improvement. ALI was the most common complication across all cohorts and was associated with decreased in-hospital survival. The impact of DPC on ALI was difficult to elucidate due to nonstandardized placement patterns and selective use. In the care of these medically complex patients on multidisciplinary teams, review of outcomes and group discussions targeting areas for improvement are critical to success; in this study, findings resulted in the development of a lower extremity perfusion management protocol.

Abstract 9449: Extracorporeal Membrane Oxygenation versus Impella in Patients with Cardiogenic Shock from Inferior Wall Myocardial Infarction: Analysis from the National Inpatient Sample

Introduction: Since the IABP-SHOCK II trial, extracorporeal membrane oxygenation (ECMO), and the percutaneous ventricular assist device, Impella have emerged as the preferred mechanical circulatory assist devices for cardiogenic shock (CS). Studies have shown similar clinical outcomes with Impella and ECMO in patients with CS from unspecified myocardial infarction (MI) locations; however, data in patients with inferior wall MI is lacking. Hypothesis: ECMO is associated with an increased likelihood of adverse inpatient complications and medical costs compared to Impella in patients with CS from an inferior wall MI. Methods: We queried the National Inpatient Sample (NIS) from 2016-2018 to identify patients 18 years and older with a discharge diagnosis of CS from inferior wall MI who underwent ECMO or Impella placement. To mitigate selection bias, 8-to-1 propensity scoring was used to select matched samples between patients with ECMO and patients with Impella. The scoring was based on a multivariate logistic regression model accounting for age, gender, race, hospital type, income, and medical comorbidities. Results: We identified 638 patients with inferior wall MI resulting in CS, 15% (n=96) underwent ECMO and 85% (n=542) received Impella. ECMO was not associated with increased inpatient mortality (52% vs 50.7%; p=0.86) or cardiac arrest (24% vs 15%, p=0.09) when compared to Impella. After applying the multivariate logistic regression model, ECMO was not associated with an increased risk for acute kidney injury (OR 0.67; 95% CI 0.28-1.6, p=0.36), cerebrovascular events (OR 1.06; 95% CI 0.33-3.36, p=0.92), cardiac tamponade (OR 6.85; 95% CI 0.89-52.83, p=0.06) or CPR (OR 1.89; 95% CI 0.9-3.98; p=0.09). However, ECMO was associated with increased blood transfusions (OR 3.56; 95% CI 0.26-10.06, p=0.02), increased length of hospitalization (13.2 days vs 9.4 days; p&lt;0.0001), and medical costs ($501,435 vs 403,120, p&lt;0.0001). Conclusions: Our study demonstrates that ECMO is not associated with increased mortality in patients with CS from inferior wall MI compared to Impella, although Impella remains the more cost-effective choice in these patients. Future randomized studies are warranted comparing these circulatory assist devices in patients with CS.

Out-of-hospital cardiac arrest due to refractory pulseless ventricular tachycardia and/or ventricular fibrillation

Abstract Background Survival rates for out-of-hospital cardiac arrest (OOHCA) are extremely low and neurologic recovery is poor. Extracorporeal cardiopulmonary resuscitation (ECPR), which combines extracorporeal membrane oxygenation (ECMO) with cardiopulmonary resuscitation (CPR), has emerged as a viable strategy to improve outcomes in OOHCA. A collaborative ECPR program for out-of-hospital refractory pulseless ventricular tachycardia (VT) and/or ventricular fibrillation (VF) has been developed between The Ohio State University Wexner Medical Center and Columbus Division of Fire Emergency Medical Services (EMS). Purpose Outcomes for patients who present as an ECPR alert from the field, but did not meet predefined criteria for placement of extracorporeal membrane oxygenation (ECMO) in the cardiac catheterization laboratory (CCL) is described. Methods Between September 15, 2017 and October 12, 2019, 50 subjects presented as an ECPR alert for OOHCA secondary to pulseless VT/VF refractory to defibrillation. All subjects were placed on an automated CPR device prior to transfer to the CCL. From these 50 individuals, 28 (56%) did not meet prespecified laboratory criteria (lactate ≤15 mg/dL, partial pressure of oxygen (PaO2) ≥50 mm Hg, end-tidal carbon dioxide (ETCO2) of ≥10) and did not have a shockable rhythm in the CCL, thus ECMO was not placed and usual care for cardiac arrest was administered. Results Nine (32%) of the 28 patients achieved return of spontaneous circulation (ROSC), while the remaining 19 (68%) where pronounced deceased in the CCL. All 9 patients who achieved ROSC underwent a coronary angiography with 4 (44%) requiring percutaneous coronary intervention and 4 (44%) requiring an acute mechanical circulatory support device (Impella with 1 change out to ECMO). Of the patients that achieved ROSC, 4 (44%) were discharged from the hospital with good neurologic recovery; the remaining 5 (56%) ultimately expired during the hospitalization. From the initial 28 patient cohort, there were 4 (14%) patients discharged alive. Patients who achieved ROSC as compared to no ROSC were found on presentation in the CCL to have a significantly lower lactate (12.3±4.3 vs 16.2±3.6, respectively; p=0.03) and greater PaO2 (145±125 vs 47±9, respectively; p=0.01); there was no significant differences between groups in ETCO2, age or emergency services dispatch to CCL arrival time. Conclusion This study demonstrates that an ECPR program for OOHCA due to refractory VT/VF may provide benefit to patients that do not meet the predefined criteria for ECMO. This may be due to minimizing no flow/low flow time by early recognition and ongoing CPR en route to the CCL by a skilled EMS team, high efficiency citywide expedited transport/triage, the provision of high quality uninterrupted chest compressions using the mechanical CPR device during transport, and the care provided by highly trained multidisciplinary team members in the CCL. Funding Acknowledgement Type of funding sources: None.

Complications of Peripheral Cannulation Site in Obese Patients on Adult Extracorporeal Membrane Oxygenation.

Placement of extracorporeal membrane oxygenation (ECMO) in obese patients has been challenging; however, cannulation risk in obese patients has not been clearly investigated. We therefore explored ECMO cannulation complications in this obese population. Data were reviewed from adult ECMO database from 2010 to 2019. Patients were stratified by body mass index (BMI) (normal weight [NW] [BMI 18.5-24.9], overweight [BMI 25-29.9], class I [BMI 30-34.9], class II [BMI 35-39.9], class III [BMI >40]). Patients with central cannulation were excluded from this study. Combined ECMO cannulation complications and survival data were retrospectively analyzed. There were 233 patients, 156 venoarterial (VA) ECMO patients (45 [28%] NW, 51 [33%] overweight, 37 [24%] class I, 12 [8%] class II, and 11 [7.0%] class III) and 77 venovenous (VV) ECMO patients (14 [18%] NW, 13 [17%] overweight, 17 [22%] class I, 11 [14%] class II, and 22 [29%] class III). There were significantly more cannulation site bleeds in VA class III (55%) patients compared with VA NW patients (22%), p = 0.006. There was no significant difference in cannulation site bleeding between BMI groups for VV ECMO. There was no difference in 30 day mortality, ECMO survival for all BMI groups in both VA and VV ECMO. There is significant increased risk of bleeding with peripheral VA cannulation of obese patients with BMI > 35. Cannulating surgeon should be aware of this bleeding risk in morbidly obese patient who undergo VA ECMO.

Risk Stratification for ECMO Requirement in COVID-19 ICU Patients Using Quantitative Imaging Features in CT Scans on Admission.

(1) Background: Extracorporeal membrane oxygenation (ECMO) therapy in intensive care units (ICUs) remains the last treatment option for Coronavirus disease 2019 (COVID-19) patients with severely affected lungs but is highly resource demanding. Early risk stratification for the need of ECMO therapy upon admission to the hospital using artificial intelligence (AI)-based computed tomography (CT) assessment and clinical scores is beneficial for patient assessment and resource management; (2) Methods: Retrospective single-center study with 95 confirmed COVID-19 patients admitted to the participating ICUs. Patients requiring ECMO therapy (n = 14) during ICU stay versus patients without ECMO treatment (n = 81) were evaluated for discriminative clinical prediction parameters and AI-based CT imaging features and their diagnostic potential to predict ECMO therapy. Reported patient data include clinical scores, AI-based CT findings and patient outcomes; (3) Results: Patients subsequently allocated to ECMO therapy had significantly higher sequential organ failure (SOFA) scores (p < 0.001) and significantly lower oxygenation indices on admission (p = 0.009) than patients with standard ICU therapy. The median time from hospital admission to ECMO placement was 1.4 days (IQR 0.2–4.0). The percentage of lung involvement on AI-based CT assessment on admission to the hospital was significantly higher in ECMO patients (p < 0.001). In binary logistic regression analyses for ECMO prediction including age, sex, body mass index (BMI), SOFA score on admission, lactate on admission and percentage of lung involvement on admission CTs, only SOFA score (OR 1.32, 95% CI 1.08–1.62) and lung involvement (OR 1.06, 95% CI 1.01–1.11) were significantly associated with subsequent ECMO allocation. Receiver operating characteristic (ROC) curves showed an area under the curve (AUC) of 0.83 (95% CI 0.73–0.94) for lung involvement on admission CT and 0.82 (95% CI 0.72–0.91) for SOFA scores on ICU admission. A combined parameter of SOFA on ICU admission and lung involvement on admission CT yielded an AUC of 0.91 (0.84–0.97) with a sensitivity of 0.93 and a specificity of 0.84 for ECMO prediction; (4) Conclusions: AI-based assessment of lung involvement on CT scans on admission to the hospital and SOFA scoring, especially if combined, can be used as risk stratification tools for subsequent requirement for ECMO therapy in patients with severe COVID-19 disease to improve resource management in ICU settings.

Characteristics and outcomes of patients with COVID-19 supported by extracorporeal membrane oxygenation: A retrospective multicenter study.

ObjectiveTo determine characteristics, outcomes, and clinical factors associated with death in patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) support.MethodsA multicenter, retrospective cohort study was conducted. The cohort consisted of adult patients (18 years of age and older) requiring ECMO in the period from March 1, 2020, to September 30, 2020. The primary outcome was in-hospital mortality after ECMO initiation assessed with a time to event analysis at 90 days. Multivariable Cox proportional regression was used to determine factors associated with in-hospital mortality.ResultsOverall, 292 patients from 17 centers comprised the study cohort. Patients were 49 (interquartile range, 39-57) years old and 81 (28%) were female. At the end of the follow-up period, 19 (6%) patients were still receiving ECMO, 25 (9%) were discontinued from ECMO but remained hospitalized, 135 (46%) were discharged or transferred alive, and 113 (39%) died during the hospitalization. The cumulative in-hospital mortality at 90 days was 42% (95% confidence interval [CI], 36%-47%). Factors associated with in-hospital mortality were age (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.06-1.61 per 10 years), renal dysfunction measured according to serum creatinine level (aHR, 1.21; 95% CI, 1.01-1.45), and cardiopulmonary resuscitation before ECMO placement (aHR, 1.87; 95% CI, 1.01-3.46).ConclusionsIn patients with severe COVID-19 necessitating ECMO support, in-hospital mortality occurred in fewer than half of the cases. ECMO might serve as a viable modality for terminally ill patients with refractory COVID-19.

Prognostic Value of Preoperative Absolute Lymphocyte Count in Children With Tetralogy of Fallot.

BackgroundTetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Absolute lymphocyte count (ALC) is a low‐cost and easy‐to‐obtain inflammatory indicator; however, its association with the prognosis of patients with TOF remains unknown. This study aimed to determine the prognostic value of preoperative ALC in children with TOF.Methods and ResultsThis retrospective study included 707 patients aged <6 years who underwent corrective operations for TOF between January 2016 and December 2018 in Fuwai Hospital, China. The end points were mortality, extracorporeal membrane oxygenation placement, postoperative hospital stay >30 days, and severe postoperative complications; patients were grouped on the basis of prognosis: poor prognosis (n=76) and good prognosis (n=631). Univariable and multivariable logistic regression analyses were performed to identify the independent risk factors for poor prognosis, on which a risk scoring system was based. The receiver operating characteristic curve was used to assess model performance. Using another model without ALC, the effect of the addition of ALC was assessed. Results suggested that ALC was an independent factor with a cutoff point of 4.36×109/L. The addition of ALC improved the area under the curve from 0.771 to 0.781 (P<0.001). To avoid reverse causality and further control for confounding factors, the patients were further divided on the basis of ALC level, and a propensity score matching was performed; 117 paired patients were identified for further analysis. Low ALC levels had an odds ratio of 3.500 (95% CI, 1.413–8.672).ConclusionsLow preoperative ALC represents an independent predictor of poor prognosis in children with TOF.

Impella percutaneous left ventricular assist device as mechanical circulatory support for cardiogenic shock: A retrospective analysis from a tertiary academic medical center.

To describe hemodynamic efficacy and clinical outcomes of Impella percutaneous left ventricular assist device (pLVAD) in patients with cardiogenic shock (CS). Percutaneous LVADs are increasingly used in CS management. However, device-related outcomes and optimal utilization remain active areas of investigation. All CS patients receiving pLVAD as mechanical circulatory support (MCS) between 2011 and 2017 were identified. Clinical characteristics and outcomes were analyzed. A multivariable logistic regression model was created to predict MCS escalation despite pLVAD. Outcomes were compared between early and late implantation. A total of 115 CS patients (mean age 63.6 ± 13.8 years; 69.6% male) receiving pLVAD as MCS were identified, the majority with CS secondary to acute myocardial infarction (AMI; 67.0%). Patients experienced significant cardiac output improvement (median 3.39 L/min to 3.90 L/min, p=.002) and pharmacological support reduction (median vasoactive-inotropic score [VIS] 25.4 to 16.4, p=.049). Placement of extracorporeal membrane oxygenation (ECMO) occurred in 48 (41.7%) of patients. Higher pre-pLVAD VIS was associated with subsequent MCS escalation in the entire cohort and AMI subgroup (OR 1.27 [95% CI 1.02-1.58], p=.034 and OR 1.72 [95% CI 1.04-2.86], p=.035, respectively). Complications were predominantly access site related (bleeding [9.6%], vascular injury [5.2%], and limb ischemia [2.6%]). In-hospital mortality was 57.4%, numerically greater survival was noted with earlier device implantation. Treatment with pLVAD for CS improved hemodynamic status but did not uniformly obviate MCS escalation. Mortality in CS remains high, though earlier device placement for appropriately selected patients may be beneficial.

Experience of 101 patients with coronavirus infectious disease 2019 (COVID-19) at a tertiary care center in Japan

IntroductionClusters of novel coronavirus infectious disease of 2019 (COVID-19) have spread to become a global pandemic imposing a significant burden on healthcare systems. The lack of an effective treatment and the emergence of varied and complicated clinical courses in certain populations have rendered treatment of patients hospitalized for COVID-19 difficult. MethodsTokyo Metropolitan Tama Medical Center, a public tertiary acute care center located in Tokyo, the epicenter of COVID-19 in Japan, has been admitting patients with COVID-19 since February 2020. The present, retrospective, case-series study aimed to investigate the clinical course and outcomes of patients with COVID-19 hospitalized at the study institution. ResultsIn total, 101 patients with COVID-19 were admitted to our hospital to receive inpatient care. Eleven patients (10.9%) received ECMO, and nine patients (8.9%) died during hospitalization after COVID-19 was diagnosed. A history of smoking and obesity were most commonly encountered among patients with a complicated clinical course. Most patients who died requested to be transferred to advanced palliative care in the early course of their hospitalization. ConclusionsOur experience of caring for these patients demonstrated a relatively lower mortality rate and higher survival rate in those with extracorporeal membrane oxygenation placement than previous reports from other countries and underscored the importance of proactive, advanced care planning in the early course of hospitalization.

Abstract 17294: Outcomes of ECMO Use in Cardiogenic Shock: Analysis From the Nationwide Readmissions Database

Introduction: Extracorporeal membrane oxygenation (ECMO) is being increasingly used for acute support in patients with cardiogenic shock (CS). Data regarding the indications, outcomes, and readmissions in these patients from a nationally representative sample is lacking. Methods: A secondary analysis of the Nationwide Readmission Database for years 2016-2017 was performed. Patients who were admitted with a primary diagnosis of CS were identified using ICD-10, Clinical Modification codes and were sub-grouped into those with acute coronary syndrome (ACS) and without ACS (non-ACS). Any readmission within 30 days of discharge was considered for analysis. Results: A total of 6,126 patients with CS received ECMO support, among which 35% had concurrent acute coronary syndrome (ACS). Patients on ECMO who had ACS were significantly older (60.5±11 vs 45.1±11 years, p&lt;0.001) compared to non-ACS patients. Time to ECMO placement was also significantly shorter in ACS patients (3.4±5 vs 6.9±15 days, p&lt;0.001). There was no difference in complications during index admission including vascular complications and stroke among the two groups. The length of index hospitalization was longer in the non-ACS group (32.8±36 vs 19.6±22.9 days, p&lt;0.001) whereas mortality was significantly higher in patients with ACS (58.21 vs 49.55%, p&lt;0.001). Every decade increase in the age above 50 years significantly increased odds of mortality in the non-ACS group whereas in the ACS group, mortality increased significantly only when the age is over 70 years [HR 2.32, CI(1.35-3.99), p=0.002]. The rate of readmission among patients who survived to discharge was 18.2% (17.3% in ACS group vs 18.9% in non-ACS group, p=0.35). The most common primary causes of readmission were local complications from ECMO placement (7.65%), CHF, (6.5%), sepsis (6.5%), critical illness poly-myopathy/neuropathy (2.9%) and stroke (1.46%). The mortality during readmission was 8.2%. Conclusions: Only 1 in every 2 patients with CS on ECMO survives to discharge. Survival to discharge in these patients differs significantly according to the presence or absence of ACS. Among the patients who survive to discharge, 18% of patients are readmitted within 30 days.