Longer Extracorporeal Membrane Oxygenation Duration Research Articles

Acute Brain Injury Risk Prediction Models in Venoarterial Extracorporeal Membrane Oxygenation Patients with Tree-Based Machine Learning: An ELSO Registry Analysis

ObjectiveWe aimed to determine if machine learning (ML) can predict acute brain injury (ABI) and identify modifiable risk factors for ABI in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. MethodsWe included adults (≥18 years) receiving VA-ECMO or extracorporeal cardiopulmonary resuscitation (ECPR) in the Extracorporeal Life Support Organization Registry (2009-2021). Our primary outcome was ABI: central nervous system (CNS) ischemia, intracranial hemorrhage (ICH), brain death, and seizures. We utilized Random Forest, CatBoost, LightGBM and XGBoost ML algorithms (10-fold leave-one-out cross-validation) to predict and identify features most important for ABI. We extracted 65 total features: demographics, pre-ECMO/on-ECMO laboratory values, and pre-ECMO/on-ECMO settings. ResultsOf 35,855 VA-ECMO (non-ECPR) patients (median age=57.8 years, 66%=male), 7.7% (n=2,769) experienced ABI. In VA-ECMO (non-ECPR), the area under the receiver-operator characteristics curves (AUC-ROC) to predict ABI, CNS ischemia, and ICH was 0.67, 0.67, and 0.62, respectively. The true positive, true negative, false positive, false negative, positive, and negative predictive values were 33%, 88%, 12%, 67%, 18%, and 94%, respectively for ABI. Longer ECMO duration, higher 24h ECMO pump flow, and higher on-ECMO PaO2 were associated with ABI. Of 10,775 ECPR patients (median age=57.1 years, 68%=male), 16.5% (n=1,787) experienced ABI. The AUC-ROC for ABI, CNS ischemia, and ICH was 0.72, 0.73, and 0.69, respectively. Longer ECMO duration, older age, and higher 24h ECMO pump flow were associated with ABI. ConclusionsIn the largest study predicting neurological complications with ML in ECMO, longer ECMO duration and higher 24h pump flow were associated with ABI in non-ECPR and ECPR VA-ECMO.

Circuit change in neonatal and pediatric extracorporeal membrane oxygenation is associated with adverse outcomes.

Extracorporeal membrane oxygenation (ECMO) circuits may be changed during the run for multiple reasons; however, these circuit changes may be associated with adverse events. Predictors for undergoing a circuit change (CC) and their outcomes remain unclear. We hypothesized that neonatal and pediatric CC correlates with increased morbidity and mortality. Pediatric and neonatal patients who underwent one ECMO run lasting <30days at a tertiary children's hospital from 2011 through 2017 were retrospectively reviewed. Bivariate regression analysis evaluated factors associated with ECMO mortality and morbidity. LASSO logistic regression models identified independent risk factors for undergoing a CC. p < .05 was significant. One hundred 85 patients were included; 137 (74%) underwent no CC, while 48 (26%) underwent one or more. Undergoing a CC was associated with longer ECMO duration (p < .001), higher blood transfusion volumes (p < .001), increased hemorrhagic complications (p < .001) and increased mortality (p = .002). Increased platelet (p = .001) and FFP (p = .016) transfusion volumes at any time while on ECMO were independent factors associated with undergoing a CC. Changing the circuit during the ECMO run occurs frequently and may be associated with poorer outcomes. Understanding the outcomes and predictors for CC may guide management protocols for more efficient circuit changes given its important association with overall outcomes.

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.

Thrombotic Events Develop in 1 Out of 5 Patients Receiving ECMO Support: An 11-Year Referral Centre Experience.

The use of extracorporeal membrane oxygenation (ECMO) for critically ill patients is growing rapidly given recent developments in technology. However, adverse events are frequently reported that have potentially devastating impacts on patient outcomes. The information on predictors and risk factors for thrombotic events, especially that focusing on the comparison of veno-arterial and veno-venous ECMO configurations, are still inconsistent and sparse; therefore, we aimed to close this gap. We performed a retrospective analysis of all patients on extracorporeal life support admitted to the intensive care units of a tertiary university center in Europe. From 645 patients, 417 who received extracorporeal life support due to cardiogenic shock (290, 70%), respiratory failure (116, 28%) or hypothermia (11, 3%) were included. In total, 22% (92) of the patients experienced thrombotic events with a similar incidence in both ECMO configurations. Anticoagulation consisted of unfractionated heparin (296, 71%) and argatroban (70, 17%). Univariate Cox analyses identified hemoconcentration and increased maximal clot firmness (thromboelastometry) as risk factors for thrombosis. Moreover, the patients experiencing thrombosis had longer ECMO duration and intensive care stays. ECMO is a specialized life-support modality with a high risk of complications. A longer ECMO duration is associated with thrombosis occurrence in patients receiving ECMO support. Following hemorrhage, thromboembolic complications are common adverse events. However, in contrast to major bleeding, no impact on mortality was observed. The question arises if a protocol with less anticoagulation may have a role to play in the future.

Hemodynamic and Echocardiographic Predictors of Mortality in Pediatric Patients on Venoarterial Extracorporeal Membrane Oxygenation: A Multicenter Investigation

Venoarterial extracorporeal membrane oxygenation (ECMO) supports patients with advanced cardiac dysfunction; however, mortality occurs in a significant subset of patients. The authors performed a multicenter, prospective study to determine hemodynamic and echocardiographic predictors of mortality in children placed on ECMO for cardiac support. Over 8years, six heart centers prospectively assessed echocardiographic and hemodynamic variables on full and minimum ECMO flow. Sixty-three patients were enrolled, ranging in age from 1day to 16years. Hemodynamic measurements included heart rate, vasoactive inotropic score, arteriovenous oxygen difference, pulse pressure, and lactate. Echocardiographic variables included shortening fraction, ejection fraction (EF), right ventricular fractional area change, outflow tract Doppler-derived stroke distance (velocity-time integral [VTI]), and degree of atrioventricular valve regurgitation. Patients were stratified into two groups: those who were able to wean within 48hours of assessment and survived without ventricular assist devices or orthotopic heart transplantation (successful wean group) and those with unsuccessful weaning. For each patient, variables were compared between full and minimum ECMO flow for each group. Thirty-eight patients (60%) formed the unsuccessful group (two with ventricular assist devices, four with orthotopic heart transplantation, 24 deaths), and 25 constituted the successful wean group. At minimum flow, higher EF (53±16% vs 40±20%, P=.0094), less mitral regurgitation (0.8±0.9 vs 1.4±0.9, P=.0329), and lower central venous pressure (12.0±3.9 vs 14.7±5.4mm Hg), along with higher VTI (9.0±2.9 vs 6.8±3.7cm, P=.0154), correlated successful weaning. A longer duration of ECMO (8 vs 5days, P<.0002) was associated with unsuccessful weaning. Multivariate logistic regression predicted minimum-flow EF and VTI to independently predict successful weaning with cutoff values by receiver operating characteristic analysis of EF > 41% (area under the curve, 0.712; P=.0005) and VTI > 7.9cm (area under the curve, 0.729; P=.0010). Diminished VTI or EF during ECMO weaning predicts the need for orthotopic heart transplantation or ventricular assist device support or death in children on ECMO for cardiac dysfunction. Increased postwean central venous pressure or mitral regurgitation along with a prolonged ECMO course also predicted these adverse outcomes. These measurements should be used to help discriminate which patients will require alternative methods of circulatory support for survival.

292. Antibiotic Use Is Increased in Patients with Acute Respiratory Distress Syndrome (ARDS) Requiring Extracorporeal Membrane Oxygenation (ECMO) due to COVID-19 Compared with Influenza

BackgroundDuring the COVID-19 pandemic, >50% of hospitalized patients (pts) received an antimicrobial. ECMO is increasingly used in COVID-19 pts with severe ARDS. ECMO has been used for ARDS due to influenza at our center in prior years. Pts on ECMO are at high risk for infections. We compared the rates of antibiotic (Ab) and antifungal (AF) use in pts on ECMO for COVID-19 vs influenza ARDS. MethodsThis was a retrospective review of pts on ECMO for COVID-19 (2020-2021) or influenza (2013-2019). Antimicrobials (Abs and AFs) were categorized as anti-MRSA, anti-pseudomonal β-lactams (AP-BL), carbapenems, and new broader spectrum β-lactams. We calculated total Ab and AF utilization, adjusted for ECMO duration.ResultsSeventy-one pts (36 COVID-19 and 35 influenza) were included. COVID-19 pts had longer ECMO duration (median: 25 vs 11 days, p=.03). 100% and 97% of pts with COVID-19 and influenza received ≥1 Ab, respectively, and 42% and 33% an AF, respectively. COVID-19 pts received longer duration of Abs (26 vs 10 days, p< 0.001) and but not AF. COVID-19 group (gp) were more likely to receive anti-MRSA Ab (69% vs 33%, p=.004); otherwise, there were no differences between gps in types of Abs used. When adjusted for ECMO days, COVID-19 gp received higher median number of Abs (1.23 vs 1, p=.06). Specifically, COVID-19 gp received higher median number of anti-MRSA Ab (0.2 vs 0, p=.007) and AP-BL (0.44 vs 0.28, p=.08). There was no difference in Ab-free days between gps, though the proportion of Ab-free days was lower (0.2 vs 0.36) in COVID-19 pts (p=.08). More COVID-19 pts had pathogens recovered from clinical cultures, especially S. aureus and Enterobacterales (Figure).Pathogens recovered from clinical cultures Patients recovered from clinical cultures of patients with COVID-19 and Influenza ARDS requiring ECMOConclusionAmong pts on ECMO, those with COVID-19 received significantly longer courses of Abs than those with influenza, even after adjusting for longer durations of ECMO. Differences were driven by receipt of anti-MRSA and AP-BLs. Recovery of pathogenic bacteria was greater in COVID-19 pts than influenza pts. Given difficulties in distinguishing pneumonia from airway colonization among ARDS pts on ECMO, development of diagnostic criteria for pt care, rational antimicrobial stewardship and further research are needed.Disclosures Cornelius J. Clancy, MD, Merck (Grant/Research Support)

Carboxyhemoglobin levels in children during extracorporeal membrane oxygenation support: a retrospective study.

Hemolysis is a common complication of extracorporeal membrane oxygenation (ECMO). There are few data on whether carboxyhemoglobin (COHb), a potential marker of hemolysis, are elevated during ECMO support. We conducted a single-center, retrospective study comparing peak COHb levels of children pre-, during, and post-ECMO from January 2017 to August 2020. There were 154 ECMO runs in 147 children (154 PICU admissions) included in the study. The median age was 3.5 (IQR 0.2, 39.2) months. Veno-arterial ECMO was the predominant mode: 146/154 (94.8%). Eighty-seven children (56.5%) underwent cardiac surgery. Peak COHb levels during ECMO were statistically significantly higher compared to pre ECMO (COHb 1.8% (IQR 1.4, 2.6) vs COHb 1.2% (IQR 0.7, 1.7), p < 0.001) and post ECMO (COHb 1.6% (IQR 1.3, 2.2), p = 0.009). Children with COHb ⩾2% were younger and had longer duration of ECMO support. Plasma hemoglobin weakly correlated with COHb level (r = 0.14; p = 0.04). Carboxyhemoglobin levels increased during ECMO support compared to the pre and post ECMO period. Younger age and longer ECMO duration were associated with COHb levels ⩾2%. Plasma hemoglobin weakly correlated with COHb level.

Promising candidates for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Precise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all Ps < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

Extracorporeal Membrane Oxygenation Support for Failure to Wean From Cardiopulmonary Bypass After Pediatric Cardiac Surgery: Analysis of Extracorporeal Life Support Organization Registry Data.

Extracorporeal membrane oxygenation has been used to support children who fail to wean from cardiopulmonary bypass after pediatric cardiac surgery, but little is known about outcomes. We aimed to describe epidemiology and extracorporeal membrane oxygenation factors associated with inhospital mortality in these patients. Retrospective multicenter registry-based cohort study. International pediatric extracorporeal membrane oxygenation centers. Children less than 18 years old supported with extracorporeal membrane oxygenation for failure to wean from cardiopulmonary bypass after cardiac surgery during 2000-2016 and reported to Extracorporeal Life Support Organization's registry. None. The primary outcome measure was inhospital mortality. Cardiac surgical procedural complexity was assigned using risk adjustment in congenital heart surgery-1. Multivariable logistic regression was used to identify factors independently associated with the primary outcome. We included 2,322 patients, with a median age of 26 days (interquartile range, 7-159); 47% underwent complex surgical procedures (risk adjustment in congenital heart surgery 4-6 categories). Inhospital mortality was 55%. The multivariable model evaluating associations with inhospital mortality showed noncardiac congenital anomalies (odds ratio, 1.78; CI, 1.36-2.32), comorbidities (odds ratio, 1.59; CI, 1.30-1.94), preoperative cardiac arrest (odds ratio, 1.67; CI, 1.20-2.34), preoperative mechanical ventilation greater than 24 hours (odds ratio, 1.49; CI, 1.21-1.84), preoperative bicarbonate administration (odds ratio, 1.42; CI, 1.08-1.86), longer cardiopulmonary bypass time (> 251 min; odds ratio, 1.50; CI, 1.13-1.99), complex surgical procedures (odds ratio, 1.43; CI, 1.13-1.81), longer extracorporeal membrane oxygenation duration (> 104 hr, odds ratio, 1.54; CI, 1.17-2.02), and extracorporeal membrane oxygenation complications increased the odds of inhospital mortality. Age greater than 26 days (odds ratio, 0.56; CI, 0.42-0.75) reduced the odds of mortality. Children supported with extracorporeal membrane oxygenation for failure to wean from cardiopulmonary bypass after cardiac surgery are at high risk of mortality (55%). Younger patients, those with congenital abnormalities and comorbidities, undergoing complex procedures, requiring longer cardiopulmonary bypass, and experiencing extracorporeal membrane oxygenation complications and longer extracorporeal membrane oxygenation duration have higher mortality risk. These data can help assessing prognosis in this high-risk population.

Risk Factors for Brain Injury in Newborns Treated with Extracorporeal Membrane Oxygenation.

This study aimed to assess the association of clinical risk factors with severity of magnetic resonance imaging (MRI) brain injury in neonatal extracorporeal membrane oxygenation (ECMO) patients. This is a single-center retrospective study conducted at an outborn level IV neonatal intensive care unit in a free-standing academic children's hospital. Clinical and MRI data from neonates treated with ECMO between 2005 and 2015 were reviewed. MRI injury was graded by two radiologists according to a modified scoring system that assesses parenchymal injury, extra-axial hemorrhage, and cerebrospinal fluid spaces. MRI severity was classified as none (score = 0), mild/moderate (score = 1-13.5), and severe (score ≥ 14). The relationship between selected risk factors and MRI severity was assessed by Chi-square, analysis of variance, and Kruskal-Wallis tests where appropriate. Combinative predictive ability of significant risk factors was assessed by logistic regression analyses. MRI data were assessed in 81 neonates treated with ECMO. Veno-arterial (VA) patients had more severe injury compared with veno-venous patients. There was a trend toward less severe injury over time. After controlling for covariates, duration of ECMO remained significantly associated with brain injury, and the risk for severe injury was significantly increased in patients on ECMO beyond 210 hours. Risk for brain injury is increased with VA ECMO and with longer duration of ECMO. Improvements in care may be leading to decreasing incidence of brain injury in neonatal ECMO patients. · Veno-arterial ECMO is associated with more brain injury by MRI compared with veno-venous ECMO.. · Longer duration of ECMO is significantly associated with severe brain injury by MRI.. · Risk for neurologic injury may be decreasing over time with advances in neonatal ECMO..

Extracorporeal Membrane Oxygenation in Infants Undergoing Truncus Arteriosus Repair

Infants undergoing truncus arteriosus (TA) repair suffer one of the highest mortality rates of all congenital heart defects. Extracorporeal membrane oxygenation (ECMO) can support patients undergoing TA repair, but little is known about factors contributing to mortality in this cohort. The objective of this study was to identify risk factors for mortality in infants with TA requiring perioperative ECMO. Data from the Extracorporeal Life Support Organization from 2002 to 2017 for infants less than 60 days old undergoing TA repair were analyzed. Demographics, clinical characteristics, and ECMO characteristics and complications were compared between survivors and nonsurvivors. Multivariable logistic regression was used to evaluate independent risk factors for mortality. Of 245 patients analyzed, 92 (37.6%) survived to discharge. Nonsurvivors had a lower weight and a longer ECMO duration. A higher proportion of nonsurvivors suffered complications on ECMO, including mechanical complications, circuit thrombus, bleeding, and need for renal replacement therapy. In multivariable analysis lower weight (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.95), duration of ECMO (OR, 1.1; 95% CI, 1.02-1.18), need for renal replacement therapy (OR, 3.23; 95% CI, 1.68-6.2), cardiopulmonary resuscitation on ECMO (OR, 11.52; 95% CI, 1.3-102.33), and infection on ECMO (OR, 4.47; 95% CI, 1.2-16.64) were independently associated with mortality. Many factors associated with mortality for infants requiring perioperative ECMO with TA repair are related to complications suffered on ECMO. Thoughtful patient selection and meticulous ECMO management to prevent complications are essential in improving outcomes for these infants.

Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation

This study aimed to identify outcome determinants for extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) at our institution.This retrospective single-center study reviewed patients on ECMO between 2010 and 2018 and compared clinical characteristics between patients who underwent successful-BTT and those who did not. Additionally, we examined differences between actively versus emergently listed patients and reasons for failure-to-list. Seventy-six patients were placed on ECMO with the intent to bridge to transplant. Of those, 42 were actively on the waitlist (AWL) prior to ECMO initiation, 20 were emergently evaluated and waitlisted (EWL) after ECMO initiation, and 14 failed-to-list. Of the 62 listed patients, 42 (68%) were successfully transplanted. Risk factors of failed-BTT included right ventricular dysfunction prior to ECMO initiation, longer ECMO duration, reduced mobility status, shorter stature, higher prevalence of blood type B, worse kidney and liver function, and increased transfusion requirements. The number of patients transitioned to central VA-ECMO was higher in the failed-BTT group. Thirty-day survival post-transplantation was 98%, with 90% successfully discharged; 1-year survival conditional upon discharge was 97%. AWL and EWL groups had comparable outcomes. Reasons for failure-to-list are not readily modifiable. ECMO-BTT has become a viable option with satisfactory 1-year survival in patients with irreversible lung injury. Our results support rescue transplant for emergently evaluated and waitlisted patients on ECMO. Our data suggests that modification in national organ allocation policies especially as they pertain to high-acuity recipients with rare blood types and short stature could enhance successful outcome.

1165. Risk Factors for Bloodstream Infections During Extracorporeal Membrane Oxygenation (ECMO)

BackgroundAlthough bloodstream infections (BSIs) are important complications of ECMO, data on clinical characteristics of ECMO-associated BSIs remain limited. This study aimed to investigate clinical characteristics of ECMO-associated BSIs and evaluate the role of routine active surveillance cultures (ASCs) in predicting subsequent BSIs.MethodsWe reviewed the medical records of adult patients who received ECMO for >48 hours in 2 teaching hospitals between January 2013 and March 2019. ECMO-associated BSIs were defined as bacteremia occurring from 48 hours after ECMO initiation. ASCs for multidrug-resistant organisms were obtained from nasal, axillary, inguinal, and rectal swabs when patients were admitted to the ICUs.ResultsOverall, 28 of 110 (25.4%) patients had BSIs within the median 7 days after ECMO initiation. Table 1 shows the clinical characteristics of patients with ECMO-associated BSIs. Among BSI cases, the most common pathogens were Candida spp. (25%). Longer ECMO days (P < 0.01), steroid use (P = 0.02), and more blood transfusions (P < 0.01) were associated with BSIs. However, there was no association between the results of ASCs and subsequent pathogens of BSIs.ConclusionBSIs during ECMO were associated with longer ECMO duration, steroid use and blood transfusion. The pathogens of BSIs could not be related to ASCs. Disclosures All authors: No reported disclosures.

2271. Bacteremia Due to Multi-Drug-Resistant Organisms Is an Independent Risk Factor for Death Among Patients Supported by Extracorporeal Membrane Oxygenation (ECMO)

BackgroundECMO is a type of life-support for patients with refractory respiratory and/or cardiac failure. Our objective was to determine the incidence, resistance patterns and risk factors for development of blood stream infections (BSI) in patients receiving ECMO therapy.MethodsThis was a retrospective cohort study of a single intensive care unit. All patients receiving ECMO therapy between 7/1/13 and 4/28/18 were evaluated. Multidrug-resistant (MDR) pathogens were defined as non-susceptible to ≥1 agent in ≥3 antimicrobial classes, and vancomycin-resistant Enterococcus (VRE).Results471 patients received ECMO, accounting for 4,739 ECMO days. Thirty-six patients (7.6%) had ≥1 episode of BSI; 47 episodes occurred, resulting in 10 events per 1,000 ECMO days. The most common organisms were Enterobacteriaceae (26%), 33% of which were MDR. Staphylococcus aureus (17%), coagulase-negative Staphylococcus (17%), Enterococcus faecium (11%) and Candida spp. (6%) were also identified. Overall, 20% of BSI were due to MDR bacteria. Median duration of BSI was significantly longer for infections due to VRE (8.5 days), than other organisms (1 day; P = 0.0006). Duration of ECMO (P < 0.0001), continuous renal replacement therapy (P = 0.01), units of blood transfused (P = 0.0001) and end-stage lung disease (ESLD) awaiting transplant (P = 0.004) were risk factors for BSI. Duration of ECMO, units of blood transfused and ESLD were independent risk factors for BSI. VV vs. VA-ECMO or central vs. peripheral cannulation were not significant risk factors. By logistic regression, MDR bacterial BSI was associated with longer duration of ECMO (P = 0.001) and number of units of blood transfused (P = 0.01). 1-year mortality after initiation of ECMO was 48%. Independent risk factors for 1-year mortality were age (P < 0.0001) and BSI due to MDR bacteria (P = 0.049).ConclusionThe rate of BSIs during ECMO is relatively low, but these infections are commonly caused by MDR bacteria and associated with high 1-year mortality. Clinicians should consider empiric antibiotic coverage for MDR bacteria in patients with BSI on prolonged ECMO, and in patients on ECMO who received multiple blood transfusions. Since MDR bacterial BSI is an independent risk factor for mortality, future research on preventive strategies are warranted in high-risk ECMO cohorts.Disclosures All authors: No reported disclosures.

Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study.

To assess the variation in timing of left atrial decompression and its association with clinical outcomes in pediatric patients supported with venoarterial extracorporeal membrane oxygenation across a multicenter cohort. Multicenter retrospective study. Eleven pediatric hospitals within the United States. Patients less than 18 years on venoarterial extracorporeal membrane oxygenation who underwent left atrial decompression from 2004 to 2016. None. A total of 137 patients (median age, 4.7 yr) were included. Cardiomyopathy was the most common diagnosis (47%). Cardiac arrest (39%) and low cardiac output (50%) were the most common extracorporeal membrane oxygenation indications. Median time to left atrial decompression was 6.2 hours (interquartile range, 3.8-17.2 hr) with the optimal cut-point of greater than or equal to 18 hours for late decompression determined by receiver operating characteristic curve. In univariate analysis, late decompression was associated with longer extracorporeal membrane oxygenation duration (median 8.5 vs 5 d; p = 0.02). In multivariable analysis taking into account clinical confounder and center effects, late decompression remained significantly associated with prolonged extracorporeal membrane oxygenation duration (adjusted odds ratio, 4.4; p = 0.002). Late decompression was also associated with longer duration of mechanical ventilation (adjusted odds ratio, 4.8; p = 0.002). Timing of decompression was not associated with in-hospital survival (p = 0.36) or overall survival (p = 0.42) with median follow-up of 3.2 years. In this multicenter study of pediatric patients receiving venoarterial extracorporeal membrane oxygenation, late left atrial decompression (≥ 18 hr) was associated with longer duration of extracorporeal membrane oxygenation support and mechanical ventilation. Although no survival benefit was demonstrated, the known morbidities associated with prolonged extracorporeal membrane oxygenation use may justify a recommendation for early left atrial decompression.

Evaluation of Calcium Homeostasis and Dietary Supplementation for Pediatric and Neonatal Patients Receiving Extracorporeal Membrane Oxygenation Support.

Although the use of extracorporeal membrane oxygenation (ECMO) significantly improves survival in patients with persistent respiratory or cardiovascular failure, it also induces physiologic stress and disrupts homeostatic mechanisms. Patients undergoing ECMO support at our institution have required widely variable quantities of calcium supplementation for maintenance of normal calcium levels. Our primary objective was to assess the frequency of calcium abnormalities in pediatric and neonatal ECMO patients. Secondary objectives included quantifying electrolyte supplementation provided during ECMO and determining the relationships between calcium abnormalities and ECMO duration, mortality, and intensive care and hospital length of stay. We performed a single-center retrospective chart review of all patients less than 18 years of age who received ECMO support between July 1, 2013, and May 31, 2016. Clinical and laboratory data were reviewed for each patient for the duration of ECMO support, and the incidence of ionized calcium outside the reference range of 1.1 to 1.4 mmol/L beyond the first 24 hours of ECMO was recorded. Seventy-eight patients were included in the study: 51 patients (65%) experienced at least one reading outside the normal ionized calcium range, while 27 patients (35%) were normocalcemic during their ECMO course. There were no differences between groups in the quantities of calcium, phosphate, or vitamin D administered during ECMO. Abnormal calcium levels were associated with a longer duration of ECMO (median 9 days vs 6 days, p = 0.0054), prolonged ICU length of stay (median 33 vs 18 days, p = 0.0055), and prolonged hospital length of stay (median 52 vs 40 days, p = 0.0239). No significant differences were found in survival to decannulation or survival to hospital discharge. Calcium abnormalities occur frequently in pediatric and neonatal patients during ECMO and are associated with worse patient outcomes. The underlying physiology of these changes is thought to be related to ECMO-induced disruption of normal calcium homeostasis.

Incidence of general surgical procedures in adult patients on extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation use may predispose patients to developing conditions that require either consultation with a general surgeon or a general surgical procedure. We aimed to evaluate the incidence and outcomes of adult extracorporeal membrane oxygenation patients who underwent general surgical procedure. This was a single institution retrospective study of adult extracorporeal membrane oxygenation patients from 2012 to 2015. Outcomes were compared between patients who underwent general surgical procedure with those that did not. Of the 115 patients, 54 (46.9%) required a general surgeon while 42 (36.5%) required a general surgical procedure. No significant differences were observed in mortality (35.7% vs. 46.6%; p = 0.256) and extracorporeal membrane oxygenation-related complications (45.7% vs. 32.5%; p = 0.175). Patients with general surgical procedure had longer extracorporeal membrane oxygenation duration (13 vs. 5 days; p < 0.0001), longer length of stay (36 vs. 15 days; p = 0.0005), more wound infections (19.05% vs. 5.5%; p = 0.029), more urinary tract infections (38.1% vs. 10.96%; p = 0.0006), and more pulmonary emboli (19.05% vs. 5.48%; p = 0.029). In general surgical procedure patients, no difference in bleeding complications was observed regardless of anti-coagulation status (29.4% vs. 16%; p = 0.44). Common general surgical procedures are safe and feasible in adult extracorporeal membrane oxygenation patients. Duration of extracorporeal membrane oxygenation was longer for patients requiring general surgical procedure. Despite the common use of anticoagulants, there was no increase in bleeding events in general surgical procedure patients.

Incidence of nosocomial infections in adult patients undergoing extracorporeal membrane oxygenation

IntroductionCritically ill patients requiring extracorporeal membrane oxygenation (ECMO) are at increased risk for developing nosocomial infections owing to their underlying disease process along with numerous invasive monitoring devices. MethodsWe retrospectively analyzed the rate, type, pathogens, outcomes, and risk factors of nosocomial infections that developed during adult patients on ECMO at our institution from 2012-2015. ResultsCompared to current ELSO reported adult nosocomial infections rate of 20.5%, we report our rate of 26% (CI 17.2%-34.7%). No significant differences were observed in mortality (42.3% vs. 36.5%; p=0.598), and presence of either antibiotics prior to ECMO (57.7% vs. 56.7%; p=0.934) or culture-proven infection prior to ECMO (19.2% vs. 32.4%; p=0.201). Patients who developed nosocomial infections had longer duration of ECMO (13 vs. 5 days; p<0.001), longer length of stay (36.5 vs. 18.5 days; p=0.004), and more days on ventilator (29 vs. 12.5; p=0.002). Duration of ECMO (OR=1.20, 95% CI 1.02-1.39; p=0.020) and duration of ECMO greater than 10 days (OR=14.65, 95% CI 1.81-118.78; p=0.012) were independent risk factors for developing nosocomial infections. However, there was no difference in mortality when duration of ECMO >10 days was compared with ≤10 days (28.5% vs. 43.1%; p=0.154). ConclusionNosocomial infections have no effect on survival in adult ECMO patients. Presence of either antibiotics or infection prior to ECMO has no effect on developing nosocomial infections while on ECMO. Duration of ECMO longer than 10 days is a major risk factor for developing nosocomial infection.

Extracorporeal membrane oxygenation in pediatric cardiac surgery: A retrospective review of trends and outcomes in Scotland.

Introduction:Around 3.2%–8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. The desired outcome is “bridge-to-recovery” in most cases. There is no universally agreed protocol, and given the associated costs and complications rates, the decisions as of when and when not to institute VA ECMO are largely empirical.Methods:A retrospective review of the ECMO database at the Scottish Pediatric Cardiac Services (SPCS) was undertaken. Inclusion criterion encompassed all children (<16 years of age) who were supported with VA ECMO following cardiac surgery between January 2011 and October 2016. The timing of ECMO support was divided into three distinct phases: “endofcase” or intheatre ECMO for patients unable to effectively wean from cardiopulmonary bypass (CPB), ECMO for cardiopulmonary resuscitation (“ECPR”), and Intensive Care Unit ECMO for “failing maximal medial therapy” following cardiac surgery. The patients were analyzed to identify survival rates, adverse prognostic indicators, and complication rates.Results:We identified 66 patients who met the inclusion criterion. 30day survival rate was 45% and survival rate to hospital discharge was 44% (the difference represents one patient). On followup (median: 960 days, range: 42–2010 days), all survivors to hospital discharge were alive at review date. “End-of-case” ECMO showed a trend toward better survival of the three subcategories (“end of case,” ECPR, and ECMO for “failing maximal medical therapy” survival rates were 47%, 41%, and 37.5%, respectively, P = 0.807). The poorest survival rates were in the younger children (<6 months, P = 0.502), patients who had prolonged CPB (P = 0.314) and aortic crossclamp times (P = 0.146), and longer duration of ECMO (>10 days, P = 0.177).Conclusions:Allcomers VA ECMO following pediatric cardiac surgery had survival to discharge rate of 44%. Elective “end-of-case” ECMO carries better survival rates and therefore ECMO instituted early maybe advantageous. Prolonged ECMO support has a direct correlation with mortality.

Histopathologic Findings in Lungs of Patients Treated With Extracorporeal Membrane Oxygenation

The outcome of extracorporeal membrane oxygenation (ECMO) might be influenced by its complications. Only limited information is available regarding the pathologic consequences of ECMO, especially in the era of modern ECMO technology. We studied the histopathologic findings in autopsy lungs of patients treated with ECMO compared with those without ECMO. Autopsy files were queried for cases with ECMO. An age- and sex-matched control group comprised of patients who died in the ICU without acute respiratory distress syndrome, pneumonia, or ECMO was compared with patients with ECMO for cardiac reason. Histopathology and medical records were reviewed. Seventy-six patients treated with ECMO (38 men; median age, 40 years) and 47 control patients (23 men; median age, 45 years) were included. Common histologic pulmonary findings in the ECMO group were pulmonary hemorrhage (63.2%), acute lung injury (60.5%), thromboembolic disease (47.4%), calcifications (28.9%), vascular changes (21.1%), and hemorrhagic infarct (21.1%). Pulmonary hemorrhage was associated with longer ECMO duration (median, 7.0 vs3.5months; P= .014), acute lung injury with venovenous ECMO (91.7%vs54.7%; P= .039) and longer ECMO (6.0 vs4.0months; P= .044), and pulmonary calcifications with infants (50.0%vs22.4%; P= .024). Patients with ECMO for cardiac reasons (n= 60) more frequently showed pulmonary hemorrhage (P< .001), diffuse alveolar damage (P= .044), thromboembolic disease (P= .004), hemorrhagic infarct (P= .002), pulmonary calcifications (P= .002), and vascular changes (P= .001) than patients in the non-ECMO group. Some findings are suspected to be associated with the patient's underlying disease, whereas others might be related to ECMO. Our results provide a better understanding of ECMO-related lung disease and might help to prevent it.