Extracorporeal Membrane Oxygenation Survival Research Articles

Bivalirudin in Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a mechanical support treatment modality utilized in patients with refractory cardiac and/or pulmonary failure. Bleeding and thrombotic complications associated with ECMO are inherent concerns that require careful management. Anticoagulation optimization may help mitigate these risks by providing more adequate therapeutic anticoagulation and lessen the bleed risk. Heparin, the most utilized anticoagulant, carries concerns for heparin-induced thrombocytopenia and possible resistance given its dependence on co-factors and circulating proteins to exert its pharmacologic effect. In contrast, bivalirudin, a direct thrombin inhibitor, exerts its effect independent of co-factors or plasma proteins, and possesses thrombin-binding and metabolism features that may confer advantages in ECMO management. This review of the evidence for bivalirudin utilization in ECMO suggests favorable outcomes in circuit-related thrombosis, bleeding, and dosing reliability. Additionally, blood product utilization, circuit interventions, and success in ECMO decannulation and survival were positive findings associated with bivalirudin that merit consideration. Common questions and concerns relative to bivalirudin utilization, including laboratory monitoring, utilization in low flow states, dosing considerations in renal replacement therapy, reversibility, and cost are also discussed in this review. Moreover, this review suggests that bivalirudin utilization presents the opportunity for ECMO management simplification.

Clinician Prediction of Survival vs Calculated Prediction Scores in Patients Requiring Extracorporeal Membrane Oxygenation.

Determining appropriate extracorporeal membrane oxygenation (ECMO) candidacy ensures appropriate utilization of this costly resource. The current ECMO survival prediction scores do not consider clinician assessment of patient viability. This study compared clinician prediction of survival to hospital discharge versus prediction scores. The aim of this study was to compare clinician prediction of patients' survival to hospital discharge versus prognostic prediction scores (Respiratory ECMO Survival Prediction [RESP] or Survival After Veno-Arterial ECMO [SAVE] score) to actual survival. This was an observational descriptive study from January 2020 to November 2021 conducted with interviews of nurses, perfusionists, and physicians who were involved during the initiation of ECMO within the first 24 hours of cannulation. Data were retrieved from the medical record to determine prediction scores and survival outcomes at hospital discharge. Accuracy of clinician prediction of survival was compared to the RESP or SAVE prediction scores and actual survival to hospital discharge. Accurate prediction of survival to hospital discharge for veno-venous ECMO by nurses was 47%, 64% by perfusionists, 45% by physicians, and 45% by the RESP score. Accurate predictions of patients on veno-arterial ECMO were correct in 54% of nurses, 77% of physicians, and 14% by the SAVE score. Physicians were more accurate than the SAVE score, P = .021, and perfusionists were significantly more accurate than the RESP score, P = .044. There was no relationship between ECMO specialists' years of experience and accuracy of predications. Extracorporeal membrane oxygenation clinicians may have better predictions of survival to hospital discharge than the prediction scores. Further research is needed to develop accurate prediction tools to help determine ECMO eligibility.

Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis

BackgroundAn increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-analysis aim to assess the incidence and risk factors of NIs in adult.MethodsWe searched PubMed, Scopus, Web of Science, and ProQuest databases up to 2022. The primary endpoint was incidence of NI. Secondary endpoints included time to infection, source of infection, ECMO duration, Intensive care and hospital length of stay (LOS), ECMO survival and overall survival. Incidence of NI was reported as pooled proportions and 95% confidence intervals (CIs), while dichotomous outcomes were presented as risk ratios (RR) as the effective index and 95% CIs using a random-effects model.ResultsAmong the 4,733 adult patients who received ECMO support in the 30 included studies, 1,249 ECMO-related NIs per 1000 ECMO-days was observed. The pooled incidence of NIs across 18 studies involving 3424 patients was 26% (95% CI 14–38%).Ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) were the most common NI sources. Infected patients had lower ECMO survival and overall survival rates compared to non-infected patients, with risk ratio values of 0.84 (95% CI 0.74–0.96, P = 0.01) and 0.80 (95% CI 0.71–0.90, P < 0.001), respectively.ConclusionResults showed that 16% and 20% lower of ECMO survival and overall survival in patients with NI than patients without NI, respectively. However, NI increased the risk of in-hospital mortality by 37% in infected patients compared with non-infected patients. In addition, this study identified the significant positive correlation between ECMO duration and ECMO-related NI.

Outcomes of extracorporeal membrane oxygenation treatment post open congenital heart surgery

Objective: ECMO (Extra-Corporeal Membrane Oxygenation) is a technique that temporarily supports heart and lung function by a cardiopulmonary bypass system to treat patients who have failed to respond to the conventional treatments for cardiac or respiratory after congenital heart surgery. The objective of this study is to evaluate the outcomes of ECMO treatment post congenital heart surgery at the National Children's Hospital. Subjects and methods: Descriptive, cross-sectional research method on 64 ECMO patients post open heart surgery from January 1, 2017 until August 30, 2023 at the Department of Surgical Cardiovascular Intensive Care, Cardiovascular Center, National Children's Hospital. Results: Of 64 patients analyzed, the median age of the study group was 1.6 months, 89.1% of patients were children younger than 12 months old; median weight is 3.6 kg. The success rate of ECMO weaning was 56.3%. Overall survival of the cohort was 43.8%. The mean ECMO duration was 5,7 (IQR, 3,7-10,6) days, the mean hospital stay was 32 (IQR, 21,5-50) days, the mean ICU stay was 19,5 (IQR, 13,3-29) days. Mechanical complications during ECMO support include cannula bleeding and circuit thrombus. Acute kidney injury, hypertransaminase, and DIC (disseminated intravascular coagulation) are the most common patient-related complications during ECMO. Conclusion: ECMO is a viable rescue strategy for cardiac surgery patients with ECMO weaning rate and survival rate were 56.3% and 43.8%, respectively, nearly equivalent to other heart centers.

Nutrition and outcomes in venovenous extracorporeal membrane oxygenation: An observational cohort study.

Overfeeding and underfeeding are associated with negative outcomes during critical illness. The purpose of this retrospective study was to assess the association between nutrition intake and outcomes for patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). Adults who received VV ECMO August 2017 to June 2020 were screened. Patients with <3 ECMO nutrition support days were excluded. Age, sex, height, weight, ideal body weight (IBW), body mass index, sequential organ failure assessment score, respiratory ECMO survival prediction score, energy, and protein goals were collected. All nutrition intake was collected for the first 14 days of ECMO or until death, decannulation, or oral diet initiation. Outcomes analyzed included mortality and VV ECMO duration. The relationship between nutrition delivery and outcomes was tested with multivariate analysis. Univariate analyses were conducted on obese and nonobese subgroups. A total of 2044 nutrition days in 178 patients were analyzed. The median estimated needs were 24 (interquartile range: 22.3-28.3) kcal/kg/day and 2.25 (interquartile range: 2.25-2.77) g/kg/day of protein using IBW in patients with obesity and actual weight in patients without obesity. Patients received 83% of energy and 63.3% of protein targets. Patients with obesity who received ≥2 g/kg IBW of protein had a significantly shorter ECMO duration (P = 0.037). Increased protein intake was independently associated with a reduced risk of death(odds ratio: 0.06; 95% confidence interval: 0.01-0.43). Higher protein intake was associated with reduced mortality. Optimal energy targets for patients receiving ECMO are currently unknown and warrant further study.

Prevalence and Survival of Prolonged Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: An Analysis of the Extracorporeal Life Support Organization Registry.

To examine trends in utilization and outcomes among patients with the acute respiratory distress syndrome (ARDS) requiring prolonged venovenous extracorporeal membrane oxygenation (VV ECMO) support. Retrospective observational cohort study. Adult patients in the Extracorporeal Life Support Organization registry. Thirteen thousand six hundred eighty-one patients that required ECMO for the support of ARDS between January 2012 and December 2022. None. Mortality while supported with VV ECMO and survival to hospital discharge based on ECMO duration were examined utilizing multivariable logistic regression. Among the 13,681 patients supported with VV ECMO, 4,040 (29.5%) were supported for greater than or equal to 21 days and 975 (7.1%) for greater than or equal to 50 days. Patients supported with prolonged VV ECMO were less likely to be discharged alive from the hospital compared with those with short duration of support (46.5% vs. 59.7%; p < 0.001). However, among patients supported with VV ECMO greater than or equal to 21 days, duration of extracorporeal life support was not significantly associated with mortality (odds ratio [OR], 0.99; 95% CI, 0.98-1.01; p = 0.87 and adjusted OR, 0.99; 95% CI, 0.97-1.02; p = 0.48). Even in those supported with VV ECMO for at least 120 days (n = 113), 52 (46.0%) of these patients were ultimately discharged alive from the hospital. Prolonged VV ECMO support of ARDS has increased and accounts for a substantial portion of cases. Among patients that survive for greater than or equal to 21 days while receiving VV ECMO support, duration is not predictive of survival to hospital discharge and clinical recovery may occur even after very prolonged VV ECMO support.

Relationship between the Pre-ECMO and ECMO Time and Survival of Severe COVID-19 Patients: A Systematic Review and Meta-Analysis.

Coronavirus disease 2019 (COVID-19) is the etiology of acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used to support gas exchange in patients who have failed conventional mechanical ventilation. However, there is no clear consensus on the timing of ECMO use in severe COVID-19 patients. The aim of this study is to compare the differences in pre-ECMO time and ECMO duration between COVID-19 survivors and non-survivors and to explore the association between them. PubMed, the Cochrane Library, Embase, and other sources were searched until 21 October 2022. Studies reporting the relationship between ECMO-related time and COVID-19 survival were included. All available data were pooled using random-effects methods. Linear regression analysis was used to determine the correlation between pre-ECMO time and ECMO duration. The meta-analysis was registered with PROSPERO under registration number CRD42023403236. Out of the initial 2473 citations, we analyzed 318 full-text articles, and 54 studies were included, involving 13,691 patients. There were significant differences between survivors and non-survivors in the time from COVID-19 diagnosis (standardized mean difference (SMD) = -0.41, 95% confidence interval (CI): [-0.53, -0.29], p < 0.00001), hospital (SMD = -0.53, 95% CI: [-0.97, -0.09], p = 0.02) and intensive care unit (ICU) admission (SMD = -0.28, 95% CI: [-0.49, -0.08], p = 0.007), intubation or mechanical ventilation to ECMO (SMD = -0.21, 95% CI: [-0.32, -0.09], p = 0.0003) and ECMO duration (SMD = -0.18, 95% CI: [-0.30, -0.06], p = 0.003). There was no statistical association between a longer time from symptom onset to ECMO (hazard ratio (HR) = 1.05, 95% CI: [0.99, 1.12], p = 0.11) or time from intubation or mechanical ventilation (MV) and the risk of mortality (highest vs. lowest time groups odds ratio (OR) = 1.18, 95% CI: [0.78, 1.78], p = 0.42; per one-day increase OR = 1.14, 95% CI: [0.86, 1.52], p = 0.36; HR = 0.99, 95% CI: [0.95, 1.02], p = 0.39). There was no linear relationship between pre-ECMO time and ECMO duration. There are differences in pre-ECMO time between COVID-19 survivors and non-survivors, and there is insufficient evidence to conclude that longer pre-ECMO time is responsible for reduced survival in COVID-19 patients. ECMO duration differed between survivors and non-survivors, and the timing of pre-ECMO does not have an impact on ECMO duration. Further studies are needed to explore the association between pre-ECMO and ECMO time in the survival of COVID-19 patients.

Advanced Respiratory Support Days as a Novel Marker of Mortality in COVID-19 Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation.

Emerging evidence suggests prolonged use of noninvasive respiratory support may increase mortality of patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome who require extracorporeal membrane oxygenation (ECMO). Using a database of adults receiving ECMO for COVID-19, we calculated survival curves and multivariable Cox regression to determine the risk of death associated with pre-ECMO use of high-flow nasal oxygen (HFNO), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) days. We investigated the performance of a novel variable, advanced respiratory support days (composite of HFNO, NIV, and IMV days), on Respiratory ECMO Survival Prediction (RESP) score. Subjects (N = 146) with increasing advanced respiratory support days (<5, 5-9, and ≥10) had a stepwise increase in 90 day mortality (32.2%, 57.7%, and 75.4%, respectively; p = 0.002). Ninety-day mortality was significantly higher in subjects (N = 121) receiving NIV >4 days (81.8% vs. 52.4%, p < 0.001). Each additional pre-ECMO advanced respiratory support day increased the odds of right ventricular failure (odds ratio [OR]: 1.066, 95% confidence interval [CI]: 1.002-1.135) and in-hospital mortality (1.17, 95% CI: 1.08-1.27). Substituting advanced respiratory support days for IMV days improved RESP score mortality prediction (area under the curve (AUC) or: 0.64 vs. 0.71). Pre-ECMO advanced respiratory support days were associated with increased 90 day mortality compared with IMV days alone. Adjusting the RESP score for advanced respiratory support days improved mortality prediction.

Usefulness of the Yokohama Advanced Cardiopulmonary Help Team in patients with acute respiratory distress syndrome.

To evaluate whether establishing an extracorporeal membrane oxygenation (ECMO) specialist team, termed the Yokohama Advanced Cardiopulmonary Help Team (YACHT), affected the outcomes and centralization of patients requiring ECMO in Yokohama-Yokosuka regions. This retrospective observational study included patients aged ≥18 years and treated with venovenous-ECMO for severe acute respiratory distress syndrome (ARDS) from 2014 to 2023. The primary outcome was intensive care unit (ICU) mortality. The secondary outcomes included ICU-, mechanical ventilator-, and ECMO-free days and complications during the first 28 days. This study included 46 (12 without- and 34 with-YACHT) patients. Among with-YACHT patients, 24 were transferred to our hospital from other hospitals, 14 were assessed by dispatched ECMO physicians, and 9 were transferred after ECMO introduction. No without-YACHT patients were transferred from other hospitals. With-YACHT patients experienced coronavirus disease 2019-associated respiratory failure more frequently (0 vs. 27, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation II scores (19 vs. 24, p = 0.037) and lower Respiratory Extracorporeal Membrane Oxygenation Survival Prediction scores (4 vs. 2, p = 0.021). ICU mortality was not significantly different between the groups (2 vs. 4, p = 0.67). ICU- (14 vs. 9, p = 0.10), ventilator- (11 vs. 5, p = 0.01), and ECMO-free days (20 vs. 14, p = 0.038) were higher before YACHT establishment. The incidences of complications were not significantly different between the groups. Mortality was not significantly different pre- and post-YACHT establishment; however, it helped promote regionalization and centralization in Yokohama-Yokosuka areas. We will collect more cases to demonstrate YACHT's usefulness.

Extracorporeal membrane oxygenation in South Africa: Experience from a single centre in the private sector.

Extracorporeal membrane oxygenation (ECMO) is an advanced, resource-intensive technology used in a limited capacity in South Africa (SA). Minimal data on the use of ECMO in SA are available. To describe the indications, early outcome and comorbidities of patients placed on ECMO in the highest-volume ECMO centre in SA. We performed a single-centre retrospective review of all adult patients supported with any form of ECMO from August 2016 to December 2018. Operative and clinical records were reviewed. The primary objective of this study was to review the outcome of patients placed on ECMO in the form of survival to hospital discharge. The secondary objectives were to identify population-specific comorbidities and indications for ECMO that could be associated with non-survival and to compare outcome with known risk scores in the form of the Respiratory ECMO Survival Prediction (RESP) and Survival After Venoarterial ECMO (SAVE) scores. One hundred and seven patients were identified. The primary indication for ECMO was respiratory support in 78 patients and cardiac support in 29 patients. Forty-seven patients were discharged from hospital, with a 44.0% overall survival rate. Gender (p=0.039), age (p=0.019) and hypertension (p=0.022) were associated with death in univariate logistic regression analysis. However, after adjusting for potential confounding in multivariate logistic regression analysis, the association was no longer significant. In the all respiratory support group, patients in risk class IV had better than predicted survival according to the RESP score, while risk classes I, II and III had worse than predicted survival. In the circulatory support group, all risk classes had worse than predicted survival according to the SAVE score. We report ECMO outcomes in SA for the first time. We identified very high mortality rates for patients transferred on ECMO from other facilities and for patients converted from venovenous ECMO to venoarterial ECMO. Although our outcomes were comparable in some of the risk classes, further external validation of the SAVE and RESP scores will be needed to compare our outcomes with these scores. What the study adds. We report on extracorporeal membrane oxygenation (ECMO) outcomes in South Africa for the first time. We identified a high mortality rate in patients transferred on ECMO from other facilities, and in patients converted from venovenous ECMO to venoarterial ECMO.Implications of the findings. Transferred patients had a high mortality rate. The reason for this should be further investigated and may highlight the need for possible protocols to assist with appropriate timing of patient transfers and possible earlier intervention or transfer.

Anticoagulation strategies in patients with extracorporeal membrane oxygenation: A network meta-analysis and systematic review.

Extracorporeal membrane oxygenation (ECMO) plays an important role in providing temporary life support for patients with severe cardiac or pulmonary failure, but requires strict anticoagulation and monitoring. This network meta-analysis systematically explored the most effective anticoagulation and monitoring strategies for patients receiving ECMO. MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched up to January 31, 2023, for studies comparing unfractionated heparin (UFH), argatroban (Arg), bivalirudin (Biv), and/or nafamostat mesylate (NM) in patients receiving ECMO. The primary outcomes included device-related thrombosis, patient-related thrombosis, and major bleeding events. The secondary outcomes included ECMO survival, ECMO duration, and in-hospital mortality. A total of 2522 patients from 23 trials were included in the study. Biv was associated with a decreased risk of device-related thrombosis (odd ratio [OR] 0.51, 95% confidence interval [CI]: 0.33-0.84) compared with UFH, whereas NM (OR 2.2, 95% CI: 0.24-65.0) and Arg (OR 0.92, 95% CI: 0.43-2.0) did not reduce the risk of device-related thrombosis compared with UFH. Biv was superior to Arg in decreasing the risk of device-related thrombosis (OR 0.14, 95% CI: 0.03-0.51). Biv reduced the risk of patient-related thrombosis compared with UFH (OR 0.44, 95% CI: 0.18-0.85); NM (OR 0.65, 95% CI: 0.14-3.3) and Arg (OR 3.1, 95% CI: 0.94-12.0) did not decrease risk of patient-related thrombosis compared with UFH. No significant difference was observed in the risk of major bleeding between three alternatives and UFH: Biv (OR 0.54, 95% CI: 0.23-1.3), Arg (OR 1.3, 95% CI: 0.34-5.8), and NM (OR 0.60, 95% CI: 0.13-2.6). NM showed a reduced risk of in-hospital mortality compared with UFH (OR 0.27, 95% CI: 0.091-0.77), whereas Arg (OR 0.43, 95% CI: 0.15-1.2) and Biv (OR 0.75, 95% CI: 0.52-1.1) did not decrease risk of in-hospital mortality. Compared with UFH and Arg, Biv reduces the risk of thrombosis and appears to be a better choice for patients requiring ECMO. NM was associated with a reduced risk of in-hospital mortality.

COVID-19 Is an Independent Risk Factor for Detrimental Invasive Fungal Disease in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: A Retrospective Study.

Invasive fungal disease (IFD) is associated with the mortality of patients on extracorporeal membrane oxygenation (ECMO). Several risk factors for IFD have been identified in patients with or without ECMO. Here, we assessed the relevance of coronavirus disease (COVID-19) for the occurrence of IFD in patients on veno-venous (V-V) ECMO for respiratory failure. In a retrospective analysis of all ECMO cases between January 2013 and December 2022 (2020-2022 for COVID-19 patients), active COVID-19 and the type, timing and duration of IFD were investigated. Demographics, hospital, ICU length of stay (LoS), duration of ECMO, days on invasive mechanical ventilation, prognostic scores (Respiratory ECMO Survival Prediction (RESP) score, Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS)-10, Sequential Organ Failure Assessment (SOFA) score and Simplified Acute Physiology Score (SAPS)-II) and length of survival were assessed. The association of COVID-19 with IFD was investigated using propensity score matching and uni- and multivariable logistic regression analyses. We identified 814 patients supported with ECMO, and 452 patients were included in further analyses. The incidence of IFD was 4.8% and 11.0% in patients without and with COVID-19, respectively. COVID-19 status represented an independent risk factor for IFD (OR 4.30; CI 1.72-10.85; p: 0.002; multivariable regression analysis). In patients with COVID-19, 84.6% of IFD was candidemia and 15.4% represented invasive aspergillosis (IA). All of these patients died. In patients on V-V ECMO, we report that COVID-19 is an independent risk factor for IFD, which is associated with a detrimental prognosis. Further studies are needed to investigate strategies of antifungal therapy or prophylaxis in these patients.

Survival-to-Hospital Discharge in Neonates With Congenital Heart Disease Supported With Prolonged Extracorporeal Membrane Oxygenation

Factors that determine early outcomes in neonates with congenital heart disease (CHD) supported with prolonged venoarterial extracorporeal membrane oxygenation (ECMO) are not known and contemporary multicenter data are limited. This Extracorporeal Life Support Organization registry-based retrospective cohort study included all neonates (age ≤28days) with CHD supported with venoarterial ECMO >7days at 111 centers in the United States from January 2011 to December 2020. The primary outcome was survival-to-hospital discharge, and the secondary outcome was ECMO survival (successful decannulation before hospital discharge or death). Of the 2,155 total ECMO runs, 948 neonates received prolonged ECMO (gestational age [mean ± SD] 37.9 ± 1.8weeks; birth weight 3.1 ± 0.6kg; ECMO duration 13.6 ± 11.2days). The ECMO survival rate was 51.6% (489 of 948), and the survival-to-hospital discharge rate was 23.9% (226 of 948). Body weight at ECMO (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.44 to 0.78/kg), gestational age (OR 0.89, 95% CI 0.79 to 1.00 per week), risk-adjusted congenital heart surgery-1 score (OR 1.22, 95% CI 1.04 to 1.45), and pump flow at 24hours (OR 1.11, 95% CI 1.04 to 1.18 per 10ml/kg/min) were significantly associated with survival-to-hospital discharge. Pre-ECMO mechanical ventilation duration, time to extubation after ECMO decannulation, and length of stay were inversely associated with hospital survival. Patient-specific (higher body weight and gestational age) and CHD-related (lower risk-adjusted congenital heart surgery-1 score) attributes are associated with better outcomes in neonates who receive prolonged venoarterial ECMO. Further elucidation of the factors associated with reduced survival to discharge in ECMO survivors is needed.

Tickle Me ECMO…Differences and Outcomes Unearthed for Kids Requiring Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Syndrome Coronavirus 2-Associated Disease.

Tickle Me ECMO…Differences and Outcomes Unearthed for Kids Requiring Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Syndrome Coronavirus 2-Associated Disease.

Asthma Cases Treated With Inhaled Anesthetics or Extracorporeal Membrane Oxygenation: A Virtual Pediatric Systems Database Study of Outcomes.

Extracorporeal membrane oxygenation (ECMO) and/or inhaled anesthetics (IAs) are considered in the management of asthma when refractory to conventional therapy. We aimed to compare the outcomes of these two modalities in asthma PICU care and determine associated survival to hospital discharge among patients in a United States database. Retrospective analysis using the Virtual Pediatric Systems (VPS, LLC) database. PICUs participating in the VPS database. Patients less than 18 years old with diagnosis of asthma treated with IA and/or ECMO from January 2010 to December 2020. None. A total of 221 patients were included; 149 (67%) received ECMO, 62 (28%) received IA, and 10 (5%) received both interventions. We failed to identify any difference between the ECMO and IA groups in demographics, Pediatric Index of Mortality 2 percentage, Pediatric Risk of Mortality 3 score, Pediatric Logistic Organ Dysfunction score, or pre-intervention pH and Pa co2 levels. Use of ECMO versus IA was associated with lower pre-intervention Pa o2 (60 torr [7.99 kPa] vs 78 torr [10.39 kPa]; p < 0.001) and higher utilization of high-frequency oscillatory ventilation. We failed to identify an association between type of intervention (IA vs ECMO) and greater odds of survival (57/62 [92%] vs 128/149 [86%]; odds ratio [OR], 1.87; 95% CI, 0.67-5.21; p = 0.23). However, these data do not exclude the possibility that IA use is associated with more than five-fold greater odds of survival. ECMO use was associated with longer duration of intervention (5 vs 1.3 d; p < 0.001) and PICU length of stay (LOS) (13 vs 7 d; p < 0.001). As expected, ECMO versus IA was also associated with greater odds of undergoing bronchoscopy (34% vs 11%; OR, 3.7; 95% CI, 1.5-9.4; p = 0.004). In the VPS database of asthma management cases, we failed to identify an association between ECMO versus IA use and survival to hospital discharge. However, ECMO was associated with longer duration of intervention and PICU LOS.

Characterization of Suboptimal Responses to Fetoscopic Endoluminal Tracheal Occlusion in Congenital Diaphragmatic Hernia

Introduction: The aim of the study was to characterize the changes in fetal lung volume following fetoscopic endoluminal tracheal occlusion (FETO) that are associated with infant survival and need for extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH). Methods: Fetuses with CDH who underwent FETO at a single institution were included. CDH cases were reclassified by MRI metrics [observed-to-expected total lung volume (O/E TLV) and percent liver herniation]. The percent changes of MRI metrics after FETO were calculated. ROC-derived cutoffs of these changes were derived to predict infant survival to discharge. Regression analyses were done to determine the association between these cutoffs with infant survival and ECMO need, adjusted for site of CDH, gestational age at delivery, fetal sex, and CDH severity. Results: Thirty CDH cases were included. ROC analysis demonstrated that post-FETO increases in O/E TLV had an area under the curve of 0.74 (p = 0.035) for the prediction of survival to hospital discharge; a cutoff of less than 10% was selected. Fetuses with a <10% post-FETO increase in O/E TLV had lower survival to hospital discharge [44.8% vs. 91.7%; p = 0.018] and higher ECMO use [61.1% vs. 16.7%; p = 0.026] compared to those with an O/E TLV increase ≥10%. Similar results were observed when the analyses were restricted to left-sided CDH cases. A post-FETO <10% increase in O/E TLV was independently associated with lower survival at hospital discharge (aOR: 0.073, 95% CI: 0.008–0.689; p = 0.022) and at 12 months of age (aOR: 0.091, 95% CI: 0.01–0.825; p = 0.036) as well as with higher ECMO use (aOR: 7.88, 95% CI: 1.31–47.04; p = 0.024). Conclusion: Fetuses with less than 10% increase in O/E TLV following the FETO procedure are at increased risk for requiring ECMO and for death in the postnatal period when adjusted for gestational age at delivery, CDH severity, and other confounders.

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock after acute myocardial infarction: Insights from a French nationwide database

BackgroundWe aimed to analyze the impact of timing of implantation (strategy-outcome relationship) and volume of procedures (volume-outcome relationship) on survival of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock complicating acute myocardial infarction (AMI). MethodsWe conducted an observational retrospective study through two propensity score-based analyses using a nationwide database between January 2013 and December 2019. We classified patients into early implantation (VA ECMO on the day of primary percutaneous coronary intervention [PCI]) and delayed implantation (VA ECMO beyond the day of PCI) groups. We classified patients into low- or high-volume groups based on the median hospital volume. ResultsDuring the study period 649 VA ECMO were implanted across 20 French hospitals. Mean age was 57.1 ± 10.4 years, 80% were male. Overall, 90-day mortality was 64.3%. Patients in the early implantation group (n = 479, 73.8%) did not show a statistical difference in 90-day mortality than in the delayed group (n = 170, 26.2%) (HR: 1.18; 95% CI 0.94–1.48; p = 0.153). The mean number of VA ECMO implanted during the study period by low-volume centers was 21.3 ± 5.4 as compared to 43.6 ± 11.8 in high-volume centers. There was no significant difference in 90-day mortality between high-volume and low-volume centers (HR: 1.00; 95% CI: 0.82–1.23; p = 0.995). ConclusionsIn this real-world nationwide study, we did not find a significant association between early VA ECMO implantation as well as high-volume centers and lower mortality in AMI-related refractory cardiogenic shock.

Same but Different-ECMO in COVID-19 and ARDS of Other Etiologies. Comparison of Survival Outcomes and Management in Different ARDS Groups.

Background: COVID-19 has led to increased numbers of patients in need of venovenous extracorporeal membrane oxygenation (ECMO) support, but knowledge on management in comparison to acute respiratory distress syndrome (ARDS) of other etiologies is still lacking. We analyzed venovenous ECMO management and survival outcomes in patients with COVID-19 in comparison to influenza ARDS and pulmonary ARDS of other origin. Results: Retrospective analysis of prospective venovenous ECMO registry-based data collection was performed. One hundred consecutive venovenous ECMO patients with severe ARDS were included (41 COVID-19, 24 influenza A, 35 ARDS of other etiologies). Patients with COVID-19 had higher BMI (body mass index), lower SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation II) scores, lower C-reactive protein and procalcitonin levels and less vasoactive support at ECMO initiation. Significantly more patients were mechanically ventilated for more than 7 days prior to ECMO initiation in the COVID-19 group, however they were ventilated with lower tidal volumes and more often received additional rescue therapies prior to and on ECMO. COVID-19 patients had significantly more barotrauma and thrombotic events on ECMO. There were no differences in weaning of ECMO, however duration of ECMO runs and ICU length of stay was significantly longer in the COVID-19 group. The leading cause of death in the COVID-19 group was irreversible respiratory failure, while uncontrolled sepsis and multiorgan failure were leading causes in the other 2 groups. All patients who survived ICU treatment were discharged out of hospital, and there were no differences in survival among groups at 180 days. Conclusions: Survival outcomes of venovenous ECMO patients do not differ between COVID-19 and ARDS of other pulmonary etiologies. ARDS guidelines were in greater proportion adhered to in COVID-19 patients, with, however, longer time to ECMO initiation. COVID-19 ARDS seems specific as a more single-organ disease with longer ECMO duration and irreversible respiratory failure as a main cause of ICU mortality.

Evaluation of the discrimination and calibration of predictive scores of mortality in ECMO for patients with COVID-19.

The criteria for the selection of COVID-19 patients that could benefit most from ECMO organ support are yet to be defined. In this study, we evaluated the predictive performance of ECMO mortality predictive models in patients with COVID-19. We also performed a cost-benefit analysis depending on the mortality predicted probability. We conducted a retrospective cohort study in COVID-19 patients who received ECMO at two tertiary care hospitals between March 2020 to July 2021. We evaluated the discrimination (C-statistic), calibration (Cox calibration), and accuracy of the prediction of death due to severe ARDS in V-V ECMO score (PRESERVE), the Respiratory Extracorporeal Membrane Oxygenation Survival Score (RESP) score, and the PREdiction of Survival on ECMO Therapy-Score (PRESET) score. In addition, we compared the RESP score with Plateau pressure instead of Peak pressure. We included a total of 36 patients, 29 (80%) of them male and with a median (IQR) APACHE of 10 (8-15). The PRESET score had the highest discrimination (AUROCs 0.81 [95%CI 0.67-0.94]) and calibration (calibration-in-the-large 0.5 [95%CI -1.4 to 0.3]; calibration slope 2.2 [95%CI 0.7/3.7]). The RESP score with Plateau pressure had higher discrimination than the conventional RESP score. The cost per QALY in the USA, adjusted to life expectancy, was higher than USD 100 000 in patients older than 45 years with a PRESET > 10. The PRESET score had the highest predictive performance and could help in the selection of patients that benefit most from this resource-demanding and highly invasive organ support.

Multisystem inflammatory syndrome in adults with COVID-19 requiring mechanical ventilation: A retrospective cohort study.

Multisystem inflammatory syndrome in adults (MIS-A) is a hyperinflammatory multisystem condition associated with coronavirus disease (COVID-19). Critically ill COVID-19 patients may develop multiorgan damage and elevated inflammatory responses, thus making it difficult to differentiate between progression to organ damage due to COVID-19 itself or MIS-A. This study aimed to explore the characteristics and complications of MIS-A in critical COVID-19 patients. The Japan Extracorporeal Membrane Oxygenation (ECMO) Network and ICU Collaboration Network developed a web-based database system called the CRoss Intensive Care Unit Searchable Information System (CRISIS) to monitor critical COVID-19 patients throughout Japan. We retrospectively identified patients with MIS-A among critical COVID-19 patients enrolled from March 2020 to December 2021, using CRISIS. Our MIS-A definition required patients to be at least 18 years of age, have laboratory evidence of inflammation, severe dysfunction of at least two extrapulmonary organ systems, and no plausible alternative diagnoses. Of the 1052 patients, 26 (2.5%) were diagnosed with MIS-A. The MIS-A patients had a higher likelihood of using ECMO (13% vs. 46%, p < 0.001) and lower overall survival (77% vs. 42%, p < 0.001) than non-MIS-A patients. More than 80% of the MIS-A cases occurred 3 weeks after the COVID-19 onset. Multisystem inflammatory syndrome in adults can occur in 2.5% of critically ill COVID-19 patients, and the mortality rate is high. Multisystem inflammatory syndrome in adults may be considered when there is a re-elevation of the unexplained inflammatory response and severe dysfunction of at least two extrapulmonary organ systems several weeks after the onset of COVID-19.