Utilization Of Extracorporeal Membrane Oxygenation Research Articles

Use of extracorporeal membrane oxygenation during a decompressive hemicraniectomy for severe traumatic brain injury: illustrative case.

Decompressive hemicraniectomy (DHC) can be a life-saving treatment for patients with severe traumatic brain injury (TBI) with a focal mass lesion who develop refractory elevated intracranial pressure (ICP). Nonetheless, successful completion of this procedure requires maintaining hemodynamic and respiratory stability. Extracorporeal membrane oxygenation (ECMO) use in patients with respiratory or cardiac failure is well described in the literature and has become routinely used in patients with refractory hypoxia unresponsive to traditional mechanical ventilation strategies, but few cases of its use have been reported in the neurosurgical literature. Herein, the authors describe a unique case in which a man presented after an unwitnessed fall that caused severe TBI without a focal mass lesion. The patient subsequently developed medically refractory elevated ICP secondary to traumatic cerebral edema. He required DHC, but the procedure could only be completed safely with the utilization of intraoperative ECMO. As more is learned about the techniques and pitfalls of ECMO, its indications are rapidly expanding. The case presented describes the safe use of ECMO during a major neurosurgical procedure, showing that the technique can be completed safely and offering a therapeutic option for effectively addressing refractory hypoxia and hypercarbia in patients with severe TBI who require urgent or emergency neurosurgical procedures. https://thejns.org/doi/10.3171/CASE24264.

Risk Factors and Outcomes of Perioperative Extracorporeal Membrane Oxygenation in Neonates and Infants Undergoing Truncus Arteriosus Repair.

Background: Despite surgical advances, neonatal truncus arteriosus repair remains high risk and approximately 10% of patients receive perioperative extracorporeal membrane oxygenation (ECMO). We aimed to assess factors and outcomes associated with the use of perioperative ECMO in infants undergoing truncus arteriosus repair. Methods: We conducted a retrospective cohort study of patients who underwent truncus arteriosus repair between 2004 and 2019, using administrative data from the Pediatric Health Information System database. Results: We identified 1,645 neonates and infants who underwent truncus arteriosus repair at 49 centers, of which 141 (8.6%) received ECMO. Prematurity (adjusted odds ratio [aOR], 2.06; 95% CI, 1.38-3.06; P < .001), truncal valve intervention (aOR, 4.69; 95% CI, 2.56-8.59; P < .001), and interrupted aortic arch repair (aOR, 1.80; 95% CI, 0.96-3.38; P = .07) were associated with perioperative ECMO. Hospital mortality occurred in 87 of 141 (62%) patients who received ECMO compared with 77/1504 (5.1%) who did not require ECMO(aOR, 13.39; 95% CI, 8.70-20.61; P < .001). In the 1,481 patients who survived to hospital discharge, ECMO was associated with higher rates of postoperative length of stay >30 days (63% [34/54] vs 28% [400/1427]; aOR 2.65; 95% CI, 1.24-5.64, P = .012) and hospital readmission within 90 days (61% [33/54 [ vs 33% [474/1427] [; aOR, 2.66; 95% CI, 1.47-4.82; P = .001). Conclusions: Prematurity, truncal valve intervention, and interrupted aortic arch repair are important risk factors that could help predict the use of perioperative ECMO. Extracorporeal membrane oxygenation utilization is strongly associated with greater odds of hospital mortality, prolonged postoperative length of stay, and higher rates of hospital readmission in surviving patients.

ECMO versus IABP for patients with STEMI complicated by cardiogenic shock undergoing primary PCI: a Chinese National Study and propensity-matched analysis

ObjectiveThis study investigated the association between the utilization of extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pump (IABP) and in-hospital mortality among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock undergoing primary percutaneous coronary intervention (PCI). MethodsData encompassing 9635 cases of STEMI complicated by cardiogenic shock and treated with primary PCI using ECMO/IABP support were retrieved from the Chinese Cardiovascular Association database (2019–2021). We conducted an analysis to assess the in-hospital survival disparities among percutaneous mechanical circulatory device recipients and explore the potential advantages of ECMO through multivariable logistic regression analysis within a propensity score–matched (1:2) cohort population. ResultsECMO was administered to 2028 patients, whereas IABP was used in 7607 patients. Patients supported by ECMO showed a lower in-hospital mortality than those supported by IABP (7.2% versus 15.1%, p < 0.001). Within the propensity-matched (case: control = 1:2) cohort, we noted a 34% reduced risk of in-hospital mortality among patients supported by ECMO compared with those supported by IABP (7.7% versus 11.7%; odds ratio = 0.66; 95% CI, 0.53–0.80; p < 0.001) independent of age, sex, systolic blood pressure, obesity, smoke, hypertension, diabetes, dyslipidemia, family history of coronary artery disease, coronary artery disease, stroke, atrial filiation, peripheral artery disease, chronic kidney disease, vascular lesion sites, 3A-grade hospital, and regional distributions in China. ConclusionAmong patients undergoing primary PCI for STEMI complicated by cardiogenic shock, ECMO was associated with better in-hospital survival than IABP.

Research progress on the pathogenesis of AKI complicated by ECMO.

Extracorporeal membrane oxygenation (ECMO) stands as a pivotal intervention for patients grappling with cardiopulmonary insufficiency. However, alongside its therapeutic benefits, ECMO carries the risk of complications, with acute kidney injury (AKI) emerging as a significant concern. The precise pathophysiological underpinnings of AKI in the context of ECMO remain incompletely elucidated. A comprehensive literature review was conducted to explore the epidemiology and pathophysiological mechanisms underlying the utilization of ECMO in the management of AKI. ECMO initiates a multifaceted cascade of inflammatory reactions, encompassing complement activation, endothelial dysfunction, white blood cell activation, and cytokine release. Furthermore, factors such as renal hypoperfusion, ischemia-reperfusion injury, hemolysis, and fluid overload exacerbate AKI. Specifically, veno-arterial ECMO (VA-ECMO) may directly induce renal hypoperfusion, whereas veno-venous ECMO (VV-ECMO) predominantly impacts pulmonary function, indirectly influencing renal function. While ECMO offers significant therapeutic advantages, AKI persists as a potentially fatal complication. A thorough comprehension of the pathogenesis underlying ECMO-associated AKI is imperative for effective prevention and management strategies. Moreover, additional research is warranted to delineate the incidence of AKI secondary to ECMO and to refine clinical approaches accordingly.

Developments in the epidemiology of calcium channel blocker poisoning and implications for management

Purpose of review The aim of this study was to outline recent developments in calcium channel blocker (CCB) poisoning. The dihydropyridine CCB amlodipine is commonly prescribed in the United States, and amlodipine poisoning is increasing in frequency, presenting new challenges for clinicians because current paradigms of CCB poisoning management arose from literature on non-dihydropyridine agents. Recent findings Amlodipine is now the most common CCB involved in poisoning. High-dose insulin is a potent inotrope and vasodilator; as such, it should be used cautiously, and typically in conjunction with vasopressors, as it theoretically may worsen vasodilation in amlodipine poisoning. High-dose insulin is best used when some degree of cardiogenic shock is suspected. Venoarterial extracorporeal membrane oxygenation utilization in CCB poisoning appears to be increasing, but high flow rates may be needed to combat amlodipine-induced vasoplegia. Intravenous lipid emulsion cannot be routinely recommended but may have a role in peri-arrest situations. Adjunct treatments such as angiotensin II, methylene blue, and hydroxocobalamin offer theoretical benefit but warrant further study. Summary Amlodipine causes most cases of CCB poisoning and can induce both cardiogenic and distributive shock through multiple mechanisms. Clinicians should tailor treatment to suspected shock etiology, be aware of adjunct treatments for refractory shock, and consult an expert in poisoning.

Post cardiotomy extracorporeal membrane oxygenation in pediatric patients: Results and neurodevelopmental outcomes.

The increasing complexity of congenital cardiac surgery has led to greater utilization of extracorporeal membrane oxygenation (ECMO) support for children post-surgery. This study aims to identify risk factors for mortality and brain injury in pediatric patients requiring post-cardiotomy ECMO and to evaluate their neurological outcomes. This retrospective study includes pediatric patients with congenital heart diseases who required ECMO after surgery. Risk factors for in-hospital mortality and brain injury were assessed. Neurodevelopmental status was determined using the Pediatric Cerebral Performance Category (PCPC) Scale at discharge and during follow-up. Between October 2014 and May 2021, 2651 pediatric patients underwent cardiac surgery, with 90 (3.4%) requiring ECMO. The mean age was 0.6 years, ranging from 1 day to 13 years and 7 months. ECMO was implemented for 45 patients due to CPB weaning failure (NW-CPB), 24 due to postoperative low-cardiac output syndrome (LCOS), and 21 for extracorporeal cardiopulmonary resuscitation (E-CPR). ECMO weaning was achieved in 73 patients (81%), with an overall mortality rate of 36%. Pre-implant lactate levels (OR: 1.13, 95% CI: 1.03-1.25; p = 0.009) and peak bilirubin levels (OR: 1.04, 95% CI: 0.87-1.24; p = 0.69) were risk factors for in-hospital mortality. Survival rates were 79% for LCOS, 60% for NW-CPB, and 48% for E-CPR. Brain injury incidence was 33%, with E-CPR being a significant risk factor (p = 0.006) and NW-CPB being protective (p = 0.001). Follow-up in November 2023 showed significant improvement in neurodevelopmental status (p < 0.001). Elevated pre-implant lactate and elevated bilirubin levels during ECMO are major risk factors for mortality. E-CPR is the primary risk factor for brain injury. Follow-up revealed significant improvements in neurodevelopmental outcomes.

Risk factors, incidence, and outcomes of neonatal respiratory extracorporeal membrane oxygenation including association with therapeutic hypothermia in California during 2013-2020.

To evaluate the incidence, indications and outcomes with neonatal extracorporeal membrane oxygenation (ECMO) and its association with therapeutic hypothermia (TH) among infants undergoing invasive mechanical ventilation (IMV) in California during 2013-2020. We analyzed data on neonates ≥34 weeks gestation with ≥4 h of IMV over an 8-year period (2013-2020) from the California Perinatal Quality Care Collaborative (CPQCC) database. Between 2013 and 2020, the ranges for utilization of iNO (13.9 to 17.2%), ECMO (2.1 to 2.5%), TH (10.2 to 15.7%) and TH + ECMO (0.4 to 0.8%) were observed. The most common association with neonatal ECMO was TH (148 cases, OR 3.2, 95% CI 2.6-4.3, p < 0.01). The combination of meconium aspiration syndrome (MAS) and hypoxic ischemic encephalopathy (HIE) increased risk of iNO and ECMO use (OR 11.3, 1.5-86.9), p = 0.02). Ventilated infants ≥34 weeks gestational age undergoing TH are at risk for iNO/ECMO use and need close monitoring.

In Patients with Cardiogenic Shock, Extracorporeal Membrane Oxygenation Is Associated with Very High All-Cause Inpatient Mortality Rate.

Background: The goal of this study was to evaluate the effect of extracorporeal membrane oxygenation (ECMO) on mortality in patients with cardiogenic shock excluding Impella and IABP use. Method: The large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of ECMO in adults over the age of 18 and mortality and complications with a diagnosis of cardiogenic shocks. Results: ICD-10 codes for ECMO and cardiogenic shock for the available years 2016-2020 were utilized. A total of 796,585 (age 66.5 ± 14.4) patients had a diagnosis of cardiogenic shock excluding Impella. Of these patients, 13,160 (age 53.7 ± 15.4) were treated with ECMO without IABP use. Total inpatient mortality without any device was 32.7%. It was 47.9% with ECMO. In a multivariate analysis adjusting for 47 variables such as age, gender, race, lactic acidosis, three-vessel intervention, left main myocardial infarction, cardiomyopathy, systolic heart failure, acute ST-elevation myocardial infarction, peripheral vascular disease, chronic renal disease, etc., ECMO utilization remained highly associated with mortality (OR: 1.78, CI: 1.6-1.9, p < 0.001). Evaluating teaching hospitals only revealed similar findings. Major complications were also high in the ECMO cohort. Conclusions: In patients with cardiogenic shock, the use of ECMO was associated with the high in-hospital mortality regardless of comorbid condition, high-risk futures, or type of hospital.

#75 Extracorporeal membrane oxygenation (ECMO) in patients with acute kidney injury (AKI): a prospective, observational, multi-center study

Abstract Background and Aims Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with severe respiratory and/or cardiovascular failure. Acute kidney injury (AKI) is a frequent complication in ECMO, resulting in increased morbidity and mortality. We aim to evaluate impact of ECMO on AKI outcome in Kuwait. Method Demographics, comorbidities, management, and 30-day kidney and patient outcome data for adult inpatients with native kidneys with AKI who received ECMO in seven public hospitals in Kuwait from 1/January to 31/December 2021, were prospectively collected and analyzed. Results Total number of AKI cases during study period was 3744, but only 121 patients received ECMO, or only 3.2%, with mean age of 56.3 years; and mean baseline eGFR of 81.6 ml/min. Males were 62.8% of the cohort, and 91.7% of cases were hospital-acquired AKI. Only 21.5% had pre-existing CKD (mainly diabetic kidney disease), and only 26.5% were older than 65, however, 58.7% were diabetics, and 48% were hypertensive. COVID-19 infection was a cause for AKI in 69% of patients. ECMO was veno-venous in 90% of cases, and AKI developed before ECMO initiation in 62.8% of cases. Dialysis was provided for 92% with continuous kidney replacement therapy (CKRT) accounting for 97%, and 93% of patients were in ICU (all on inotropic support). At 30 days, 86.8% of the whole group died (91% of those died on dialysis), six patients remained alive on dialysis, and only four patients recovered kidney function completely. Conclusion Although ECMO utilization in patients with AKI is limited in our AKI cohort, and despite relatively young age and reasonable baseline eGFR for the cohort, ECMO is associated with high need for ICU admission, high incidence of AKI, high need for dialysis, and high mortality rates.

Web-based Dashboard on ECMO Utilization in Germany: An Interactive Visualization, Analyses, and Prediction Based on Real-life Data

In Germany, a comprehensive reimbursement policy for extracorporeal membrane oxygenation (ECMO) results in the highest per capita use worldwide, although benefits remain controversial. Public ECMO data is unstructured and poorly accessible to healthcare professionals, researchers, and policymakers. In addition, there are no uniform policies for ECMO allocation which confronts medical personnel with ethical considerations during health crises such as respiratory virus outbreaks.Retrospective information on adult and pediatric ECMO support performed in German hospitals was extracted from publicly available reimbursement data and hospital quality reports and processed to create the web-based ECMO Dashboard built on Open-Source software. Patient-level and hospital-level data were merged resulting in a solid base for ECMO use analysis and ECMO demand forecasting with high spatial granularity at the level of 413 county and city districts in Germany.The ECMO Dashboard (https://www.ecmo-dash.de/), an innovative visual platform, presents the retrospective utilization patterns of ECMO support in Germany. It features interactive maps, comprehensive charts, and tables, providing insights at the hospital, district, and national levels. This tool also highlights the high prevalence of ECMO support in Germany and emphasizes districts with ECMO surplus – where patients from other regions are treated, or deficit – origins from which ECMO patients are transferred to other regions. The dashboard will evolve iteratively to provide stakeholders with vital information for informed and transparent resource allocation and decision-making.Accessible public routine data could support evidence-informed, forward-looking resource management policies, which are urgently needed to increase the quality and prepare the critical care infrastructure for future pandemics.

ECMO as a bridge to heart transplantation: Insights into stratification by heart failure etiology

PurposeRevisions to the heart allocation criteria in 2018 motivated an increased use of extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation. Studies have demonstrated inferior post-transplant outcomes in patients bridged with ECMO but do not account for underlying diagnosis. Our objective was to elucidate the differential impact of ECMO on outcomes by heart failure (HF) etiology. MethodsThe United Network of Organ Sharing (UNOS) database was queried for adults who underwent isolated heart transplantation after October 2018. Patients were stratified by ECMO utilization at time of transplantation, and then by HF etiology. After baseline statistical comparisons, survival analysis relied on Kaplan-Meier estimates and Cox proportional models. Results13,203 patients were included, of whom 761 (5.8%) were supported with ECMO. ECMO patients were younger (48 vs. 54 years, p<0.001), less likely to have diabetes (24% vs 30%, p<0.001), smoke cigarettes (31% vs 41%, p<0.001) or have prior cardiac surgery (29% vs. 36%, p<0.001), more likely to require dialysis (20% vs. 5%, p<0.001), and spent fewer days on the waitlist (59 vs. 190, p<0.001). After adjustment, ECMO was associated with increased mortality (HR 1.85, p<0.001) in the full cohort. After incorporating HF etiology, this increased mortality risk persisted in all subgroups except restrictive cardiomyopathy and congenital heart disease (CHD). ConclusionsOur findings illustrate that HF etiology is associated with differing outcomes when bridging with ECMO. ECMO patients with restrictive cardiomyopathy or CHD did not have increased mortality risk. With ECMO utilization increasing, these data are hypothesis-generating and serve as a basis for further studies.

Association of Interhospital Transfer With Outcomes of Extracorporeal Membrane Oxygenation: A Contemporary Analysis.

Extracorporeal membrane oxygenation (ECMO) has emerged as a life-sustaining measure for individuals with end-stage cardiopulmonary derangements. An estimated one-third of patients must be transferred to a specialized center to receive this intervention. Therefore, the present study sought to characterize the impact of interhospital transfer (IHT) status on outcomes following ECMO. The 2016-2020 National Inpatient Sample was queried to identify all adult (≥18 years) hospitalizations for ECMO. Patients were stratified based on transfer status from another acute care hospital. Multivariable regression models were developed to assess the association between transfer status and outcomes of interest. Patient and operative factors associated with IHT were identified using regression. Of an estimated 61,180 hospitalizations entailing ECMO, 21,410 (35.0%) were transfers. Annual transfer volume doubled over the study period, from 2915 to 5945 (nptrend < .001). The predicted morality risk of non-transfers decreased between 2016 and 2020 but remained similar in transferred patients. Following adjustment, transfer was associated with increased odds of in-hospital mortality, complications, duration of stay, and hospitalization costs. Patients experiencing transfer were less likely to be of black race and private insurance status. Despite increasing transfer volume and utilization of ECMO, IHT was associated with significant mortality and hospital complication risks. Further work to reduce adverse outcomes, resource burden, and socioeconomic differences within IHT may improve accessibility to this life-saving modality.

Extracorporeal Membrane Oxygenation as Circulatory Support in Adult Patients with Septic Shock: A Systematic Review.

The utilization of extracorporeal membrane oxygenation (ECMO) in adult patients experiencing septic shock is a subject of ongoing debate within the medical community. This study aims to comprehensively address this issue through a systematic review conducted in accordance with the PRISMA guidelines. The primary objective of this study is to assess the outcomes of ECMO utilization in adult patients diagnosed with septic shock, thereby providing insights into the potential benefits and uncertainties associated with this treatment modality. Our research encompassed a thorough search across electronic databases for relevant English-language articles published up until April 2023. The inclusion criteria were based on studies reporting on ECMO usage in adult patients with septic shock. Among the eligible studies meeting these criteria, a total of eleven were included in our analysis, involving a cohort of 512 patients. The mean age of the participants was 53.4 years, with 67.38% being male. In the pooled analysis, the mean survival rate following ECMO treatment was found to vary significantly across different ECMO modalities. Patients receiving venovenous-ECMO (VV-ECMO) and veno-venous-arterial ECMO (VVA-ECMO) demonstrated higher survival rates (44.5% and 44.4%, respectively) compared to those receiving venoarterial-ECMO (VA-ECMO) at 25% (p<0.05). A chi-square test of independence indicated that the type of ECMO was a significant predictor of survival (χ2(2) = 6.63, p=0.036). Additionally, patients with septic shock stemming from respiratory failure demonstrated survival rates ranging from 39% to 70%. Predictors of mortality were identified as older age and the necessity for cardiopulmonary resuscitation (CPR). In septic shock patients, ECMO outcomes align with established indications like respiratory and cardiogenic shock. VV-ECMO and VVA-ECMO suggest better prognoses, though the optimal mode remains uncertain. Patient selection should weigh age and CPR need. Further research is vital to determine ECMO's best approach for this population.

Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence.

High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.

Insurance-based Disparities in Outcomes and Extracorporeal Membrane Oxygenation Utilization for Hospitalized COVID-19 Patients.

The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.

Is Extracorporeal Membrane Oxygenation a Panacea?

Extracorporeal membrane oxygenation (ECMO) has emerged as a vital life-support technique in critical care medicine, providing temporary circulatory and/or respiratory support for patients with severe cardiac or respiratory failure unresponsive to conventional therapies. This review aims to outline the importance of ECMO and provide a comprehensive overview of its main applications. Two primary types of ECMO, venoarterial extracorporeal membrane oxygenation and veno-venous extracorporeal membrane oxygenation, serve distinct functions in supporting patients with cardiac or pulmonary dysfunction, respectively. While ECMO ofers life-saving potential, its utilization requires careful consideration due to its cost and resou rce-intensiveness. Thus, a comprehensive evaluation of an individual patient's clinical condition, prognosis, and potential for recovery is crucial. Ongoing research and technological advancements continually refine ECMO techniques, enhance patient selection criteria, and improve long-term outcomes. Within this narrative review, we present an updated approach to patient selection and ECMO utilization, supported by a detailed literature review. By consolidating the current evidence, we aim to provide healthcare professionals with valuable insights into the ECMO's post-pandemic role.

Rates, Outcomes, and Resource Burden of Extracorporeal Membrane Oxygenation Use in Hospitalizations in the United States During the Pandemic.

Extracorporeal membrane oxygenation (ECMO) is a lifesaving medical intervention for patients with severe refractory cardiopulmonary dysfunction. This study aims to characterize hospitalizations and resource use burdens associated with ECMO use during the onset of the pandemic. We performed a retrospective analysis of ECMO use in United States (US) hospitals between 2019 and 2020, utilizing data from the National Inpatient Sample database. Patient demographics, comorbidities, admission characteristics, inpatient mortality, length of hospital stay (LOS), healthcare costs, and ECMO utilization trends were assessed. Of the 17,520 hospitalizations analyzed, the most common reasons for admission were diseases and disorders of the circulatory system (40.5%) and diseases and disorders of the respiratory system (31.2%). The average patient age was 52.5 years, with a male predominance (64.2%). Hospitalizations were predominantly for White Americans (59.5%), followed by Blacks (16.3%) and Hispanics (14.8%). Nearly 88.2% of cases were at an extremely high risk of mortality without intervention. Inpatient mortality was significantly associated with Hispanic descent, a higher Charlson Comorbidity Index (CCI) score, age >60 years, and a higher All Patients Refined Diagnosis Related Groups (APRDRG) risk of mortality. Hospitalizations involving ECMO had a significantly higher inpatient mortality rate compared to non-ECMO hospitalizations (43.1% vs. 2.1%, p<0.0001). The mean LOS was 26 days for ECMO hospitalizations, with ECMO initiation occurring approximately five days from admission. ECMO-related hospitalizations often involve over 10 unique procedures, resulting in an average healthcare cost of US$967,647 per hospitalization, totaling US$16.7 billion. Comparatively, non-ECMO hospitalizations had shorter LOS and lower mean costs (mean LOS, 4.7 days, and US$52,659, respectively). ECMO utilization increased significantly from 2019 to 2020, reflecting rising demand for this life-saving therapy. Compared to non-ECMO hospitalizations, ECMO patients had higher inpatient mortality, associated with Hispanic descent, higher CCI scores, an age >60 years, and a higher APRDRG risk. ECMO hospitalizations had longer stays (26 days) and higher costs (US$967,647 per case, US$16.7 billion total) compared to pre-pandemic levels. ECMO use increased significantly from 2019 to 2020, reflecting rising demand.

Current status of ECMO for massive pulmonary embolism.

Massive pulmonary embolism (MPE) carries significant 30-day mortality and is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Given the continued high mortality associated with MPE, there has been ongoing interest in utilizing extracorporeal membrane oxygenation (ECMO) to provide oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and RV pressure will improve outcomes. Two modalities can be employed: Veno-arterial-ECMO is a reliable process to decrease RV overload and improve RV function, thus allowing for hemodynamic stability and restoration of tissue oxygenation. Veno-venous ECMO can support oxygenation but is not designed to help circulation. Several societal guidelines now suggest using ECMO in MPE with interventional therapy. There are three strategies for ECMO utilization in MPE: bridge to definitive interventional therapy, sole therapy, and recovery after interventional treatment. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Considerable heterogeneity in studies is a significant weakness of the available literature. Applying ECMO is also associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, which must be factored into the outcomes. The application of ECMO in MPE should be combined with an aggressive pulmonary interventional program and should strictly adhere to the current selection criteria.

Admission Functional Status is Associated With Intensivists Perception of Extracorporeal Membrane Oxygenation Candidacy for Pediatric Acute Respiratory Failure.

To determine the association between admission Functional Status Scale (FSS) category and perceived extracorporeal membrane oxygenation (ECMO) candidacy for pediatric acute respiratory failure. Prospective, cross-sectional study. Single-center, quaternary, and ECMO referral academic children's hospital between March 2021 and January 2022. Pediatric intensivists directly caring for patients admitted with acute respiratory failure secondary to shock or respiratory disease. None. Pediatric intensivists were surveyed about current patients within 72 hours of initiation or escalation of invasive mechanical ventilation on whether they would offer ECMO should their patient deteriorate. Baseline functional status was assessed using trichotomized admission FSS: 1) normal/mild dysfunction (6-9), 2) moderate dysfunction (10-15), and 3) severe dysfunction (> 16). Multivariable logistic regression clustered by physician was used to assess the association between admission FSS category with perceived ECMO candidacy. Thirty-seven intensivists participated with 76% (137/180) of survey responses by those with less than 10 years of experience. 81% of patients (146/180) were perceived as ECMO candidates and 19% of patients (34/180) were noncandidates. Noncandidates had worse admission FSS scores than candidates (15.5 vs. 9, p < 0.001). After adjustment for age, admission FSS category of severe dysfunction had lower odds of perceived ECMO candidacy compared with normal to mild dysfunction (odds ratio [OR] 0.18 [95% CI, 0.06-0.56], p < 0.003). Patients with an abnormal communication subscore domain had the lowest odds of being considered a candidate (unadjusted OR 0.44 [95% CI, 0.29-0.68], p < 0.0001). In this prospective, single-center, cross-sectional study, admission FSS category indicating worse baseline functional status impacted pediatric intensivists' perceptions of ECMO candidacy for patients with acute respiratory failure. Abnormal FSS subscores in the neurocognitive domains were the most important considerations. Future studies should better seek to define the decision-making priorities of both parents and medical specialists for the utilization of ECMO in children with acute respiratory failure.

Abstract 17295: In Situ Recovery of Multiple Organs Using Venoarterial ECMO in a Murine Model of Uncontrolled DCD

Introduction: The utilization of extracorporeal membrane oxygenation (ECMO) for Donation after Circulatory Death (DCD) can substantially increase the donor pool, organ yield per donor, and organ shelf life. Clinical attempts to recover organs for transplantation after uncontrolled DCD are very complex and hard to reproduce. As a preliminary strategy for completing this endeavor, experimental protocols employing feasible animal models are strongly recommended. Hypothesis: The objective of the investigation was to develop a mouse model of ECMO-based cadaver management protocol for uncontrolled DCD donation after "out-of-hospital" death. Methods: Following 10 min after confirmed death, murine cadavers (C57BL/6 background) were administered with heparin-streptokinase and cannulated for veno-arterial ECMO. Cadaver bodies were connected to a murine ECMO machine 1 h post-mortem and subjected to extracorporeal circulation for subsequent 2 hrs. Blood gas parameters, cardiac activity, and general organ state were assessed using BGA analysis, ECG, and histology, accordingly. We have designed and incorporated into an ECMO circuit a previously unreported, miniaturized murine hemodialysis for the treatment of severe hyperkalemia and metabolic acidosis that arose following death. Results: Control BGA parameters recorded 1 h after death were incompatible with normal physiology: extremely low blood pH, profound negative base excess, and extraordinarily high lactate and K + levels. Two hours after ECMO support, blood pH values of a cadaver body restored from &lt;6.5 to 7.3 ± 0.05, pCO 2 was lowered from &gt;130 to 41.7 ± 10.5 mmHg, sO2, base excess, and HCO 3 were all elevated from below detection thresholds to 99.5 ± 0.6%, -4 ± 6.2 and 22.0 ± 6.0 mmol/L, respectively (Student T-test, p &lt; 0.05). The implementation of hemodialysis resulted in a significant decrease in both hyperlactatemia and hyperkalemia. Conclusions: Our model presents novel opportunities for the management of cadaver organs in order to promote uncontrolled DCD donation, thereby contributing to the resolution of the organ shortage problem. Our approach enables the implementation of a variety of modern blood purification techniques in cadaveric organ recovery using ECLS.