non-ECMO Group Research Articles

Impact of extracorporeal membrane oxygenation on voriconazole plasma concentrations: A retrospective study.

Aims: We aimed to assess the impact of extracorporeal membrane oxygenation (ECMO) on voriconazole exposure. Methods: Adult critically ill patients with or without ECMO support receiving intravenous voriconazole therapy were included in this retrospective study conducted in a tertiary referral intensive care unit. The first therapeutic drug monitoring (TDM) results of voriconazole in ECMO patients and non-ECMO patients were collected, and the prevalence of subtherapeutic concentrations was analyzed. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure. Results: A total of 132 patients (including 66 patients with ECMO support) were enrolled and their respective first voriconazole trough concentrations (Cmin) were recorded. The median Cmin of the ECMO group and the non-ECMO group was 1.9 (1.4–4.4) and 4.4 (3.2–6.9) mg/L, respectively (p = 0.000), and the proportion of the two groups in subtherapeutic concentrations range (<2 mg/L) was 51.5% and 7.6%, respectively (p = 0.000). Multiple linear regression analysis of voriconazole Cmin identified that the use of ECMO and coadministration of glucocorticoids were associated with significantly reduced concentrations, while increasing SOFA score and increasing daily dose were associated with significantly increased concentrations. The model accounted for 32.2% of the variability of voriconazole Cmin. Furthermore, binary logistic regression demonstrated that the use of ECMO was an independent risk factor (OR = 7.78, p = 0.012) for insufficient voriconazole exposure. Conclusion: Our findings showed that, in addition to the known drug interactions, ECMO is a significant covariable affecting voriconazole exposure. In addition, SOFA score was identified as a factor associated with increased voriconazole concentration.

Impact of Extracorporeal Membrane Oxygenation on Right Ventricular Function After Heart Transplantation.

AimsAcute right ventricular failure remains a common challenging clinical syndrome in heart transplant (HTx) recipients. While extracorporeal membrane oxygenation (ECMO) is a proven strategy for the treatment of this condition, the outcomes after weaning and during follow up remain understudied. We aimed to evaluate the right-sided heart function in ECMO survivors following HTx.MethodsBetween September 2005 and December 2019, 205 patients with end-stage heart failure who underwent standard orthotopic HTx were enrolled. In total, 68 (33.2%) patients were included in the ECMO group and 137 (66.8%) patients were included in the non-ECMO group.ResultsOf the 68 patients in the ECMO group, 42 (61.8%) were successfully weaned from ECMO. After a median follow-up period of 53 months, there were 25 (59.5%) and 27 (23.7%) deaths in the ECMO and non-ECMO groups (P = 0.023), respectively. Systolic pulmonary artery pressure (SPAP) before discharge (P = 0.003) was the unique predictor of all-cause mortality during follow up. Meanwhile, patients in the ECMO group with more than moderate SPAP increase before discharge had higher mortality than patients in the non-ECMO group without such increase (P = 0.005).ConclusionsRecipient right-sided heart characteristics were strong predictors of ECMO need after HTx. ECMO patients had high mortality in the perioperative and follow-up periods, and the changes in right ventricular function in ECMO patients may be associated with pulmonary vessel injury before and after HTx.

Extracorporeal membrane oxygenation support for lung transplantation: Initial experience in a single center in China and a literature review.

BackgroundExtracorporeal membrane oxygenation (ECMO) is a versatile tool associated with favorable outcomes in the field of lung transplantation (LTx). Here, the clinical outcomes and complications of patients who underwent LTx with ECMO support, mainly prophylactically both intraoperatively and post-operatively, in a single center in China are reviewed.MethodsThe study cohort included all consecutive patients who underwent LTx between January 2020 and January 2022. Demographics and LTx data were retrospectively reviewed. Perioperative results, including complications and survival outcomes, were assessed.ResultsOf 86 patients included in the study, 32 received ECMO support, including 21 who received prophylactic intraoperative use of ECMO with or without prolonged post-operative use (pro-ECMO group), while the remaining 54 (62.8%) received no external support (non-ECMO group). There were no significant differences in the incidence of grade 3 primary graft dysfunction (PGD), short-term survival, or perioperative outcomes and complications between the non-ECMO and pro-ECMO groups. However, the estimated 1- and 2-year survival were superior in the pro-ECMO group, although this difference was not statistically significant (64.1% vs. 82.4%, log-rank P = 0.152; 46.5% vs. 72.1%, log-rank P = 0.182, respectively). After regrouping based on the reason for ECMO support, 30-day survival was satisfactory, while 90-day survival was poor in patients who received ECMO as a bridge to transplantation. However, prophylactic intraoperative use of ECMO and post-operative ECMO prolongation demonstrated promising survival and acceptable complication rates. In particular, patients who initially received venovenous (VV) ECMO intraoperatively with the same configuration post-operatively achieved excellent outcomes. The use of ECMO to salvage a graft affected by severe PGD also achieved acceptable survival in the rescue group.ConclusionsProphylactic intraoperative ECMO support and post-operative ECMO prolongation demonstrated promising survival outcomes and acceptable complications in LTx patients. Particularly, VV ECMO provided safe and effective support intraoperatively and prophylactic prolongation reduced the incidence of PGD in selected patients. However, since this study was conducted in a relatively low-volume transplant center, further studies are needed to validate the results.

Outcome of post-traumatic acute respiratory distress syndrome in young patients requiring extracorporeal membrane oxygenation (ECMO)

We aimed to evaluate the outcomes of post-traumatic acute respiratory distress syndrome (ARDS) in young patients with and without Extracorporeal membrane oxygenation (ECMO) support. A retrospective analysis was conducted for trauma patients who developed ARDS at a level I trauma facility between 2014 and 2020. Data were analyzed and compared between ECMO and non-ECMO group. We identified 85 patients with ARDS (22 patients had ECMO support and 63 matched patients managed by the conventional mechanical ventilation; 1:3 matching ratio). The two groups were comparable for age, sex, injury severity score, abbreviated injury score, shock index, SOFA score, and head injury. Kaplan Meier survival analysis showed that the survival in the ECMO group was initially close to that of the non-ECMO, however, during follow-up, the survival rate was better in the ECMO group, but did not reach statistical significance (Log-rank, p = 0.43 and Tarone-Ware, p = 0.37). Multivariable logistic regression analysis showed that acute kidney injury (AKI) (Odds ratio 13.03; 95% CI 3.17–53.54) and brain edema (Odds ratio 4.80; 95% CI 1.10–21.03) were independent predictors of mortality. Sub-analysis showed that in patients with severe Murray Lung Injury (MLI) scores, non-ECMO group had higher mortality than the ECMO group (100% vs 36.8%, p = 0.004). Although ARDS is uncommon in young trauma patients, it has a high mortality. ECMO therapy was used in a quarter of ARDS cases. AKI and brain edema were the predictors of mortality among ARDS patients. ECMO use did not worsen the outcome in trauma patients; however, the survival was better in those who had severe MLI and ECMO support. Further prospective study is needed to define the appropriate selection criteria for the use of ECMO to optimize the outcomes in trauma patients.

Trend of extracorporeal membrane oxygenation support in patients with acute respiratory distress syndrome in South Korea

We examined and compared the clinical characteristics of acute respiratory distress syndrome (ARDS) patients who received and did not receive extracorporeal membrane oxygenation (ECMO) support. The national health insurance database of South Korea was used to obtain real-world data. All adult patients admitted to intensive care units for ARDS treatment between 1 January 2014 and 31 December 2019 were included in this study. Of the 10,173 patients with ARDS included in the analysis, 740 (7.3%) received ECMO support for a mean duration of 1.6 days (standard deviation [SD]: 2.8 days) and were assigned to the ECMO group. The ECMO group had a significantly lower mean age at 57.0 years (SD: 15.7 years) than the non-ECMO group (71.8 Â years [SD: 15.1 Â years], P < 0.001). In multivariable logistic regression, a 1-year increase in age was associated with a 5% lower prevalence of ECMO support. The annual case volume was classified into four groups by quartile ratio (Q1 [lowest], Q2, Q3, and Q4 [highest]), and Q2, Q3, and Q4 groups showed a higher prevalence of ECMO support than the Q1 group. ECMO support was also performed more frequently in high case volume centers than in low case volume centers for ARDS patients.

Efficacy and Safety of Veno-Arterial Extracorporeal Membrane Oxygenation in the Treatment of High-Risk Pulmonary Embolism: A Retrospective Cohort Study.

ObjectivesVeno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly used to treat high-risk pulmonary embolism (PE). However, its efficacy and safety remain uncertain. This retrospective cohort study aimed to determine whether ECMO could improve the clinical outcomes of patients with high-risk PE.MethodsForty patients with high-risk PE, who were admitted to Kaohsiung Chang Gung Memorial Hospital between January 2012 and December 2019, were included in this study. Demographic data and clinical outcomes were compared between patients treated without ECMO (non-ECMO group) and those treated with ECMO (ECMO group). Appropriate statistical tools were used to compare variables between groups and the survival was analyzed using the Kaplan–Meier method.ResultsThe overall in-hospital mortality rate was 55%, in which 65% (26/40) of patients presented with cardiac arrest with a mortality rate of 77%, which was higher than that of patients without cardiac arrest (14%). There was no significant difference in major complications and in-hospital mortality between the non-ECMO and ECMO groups. However, in subgroup analysis, compared with patients treated without ECMO, earlier ECMO treatment was associated with a reduced risk of cardiac arrest (P = 0.023) and lower in-hospital mortality (P = 0.036). A log-rank test showed a significantly higher cumulative overall survival in the earlier ECMO treatment group (P = 0.033).ConclusionsIn this retrospective cohort study, earlier ECMO treatment was associated with lower in-hospital mortality among unstable patients without cardiac arrest. Our findings suggest that ECMO can be considered as an initial treatment option for patients with high-risk PE in higher-volume hospitals.

Extracorporeal membrane oxygenation (ECMO) for critically ill patients with coronavirus disease 2019 (COVID-19): A retrospective cohort study.

PurposeThe role of extracorporeal membrane oxygenatio (ECMO) for rescue therapy of respiratory failure in critically ill coronavirus disease 2019 (COVID‐19) patients remains controversial. We aimed to evaluate the clinical outcomes of ECMO in the treatment of COVID‐19 compared with conventional ventilation support.MethodsIn this retrospective cohort study, data were collected on extremely critical patients with COVID‐19 from January 2020 to March 2020 in intensive care unit of a hospital in charge by national rescue team in Wuhan, China, the epicenter of pandemic. Patients were classified into the ECMO group and the conventional ventilation non‐ECMO group. Clinical characteristics, technical characteristics, laboratory results, mortality, and complications of the two groups were analyzed.Results88 patients with extremely critical COVID‐19 were screened; 34 received ECMO support and 31 received conventional ventilation support. Both groups had comparable characteristics at baseline in terms of age, gender, and comorbidities. Before ECMO or conventional therapy, patients in the two groups had sever acute respiratory distress syndrome with a mean partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) ratio of 69.6 and 75.4, respectively. At the time of reporting, patients in the ECMO had significantly lower in‐hospital mortality compared with the control group (58.8 vs. 93.5%, p = .001).ConclusionECMO is shown to decrease the mortality of extremely critical ill COVID‐19 patients compared with the conventional treatment. Although complications occurred frequently, ECMO could still be a rescue therapy for the treatment of COVID‐19 during the pandemic.

Role of Invasive Mechanical Ventilation and ECMO in the Management of COVID-19: A Systematic Review.

ObjectivesThis systematic review aims to provide insight into the outcome of extracorporeal membrane oxygenation (ECMO) and invasive mechanical ventilation use in critically ill COVID-19 patients.Data sourcesElectronic databases PubMed Central and PubMed were searched from January 2020 to June 2020 for published studies about ECMO and/or invasive mechanical ventilation use in COVID-19 patients. Data Extraction and Study Selection: The search strategy retrieved 766 articles, of which 19 studies consisting of 204 patients fulfilled the inclusion criteria and were included in the analysis.Data synthesisPrimary outcomes evaluated were discharge and/or clinical improvement and mortality rate. Secondary outcomes evaluated included reported complications and the mean number of days of hospitalization for survivors. Weighted averages of included studies were calculated, and data were pooled in forest plots. Nearly, 68.1% of the patients received invasive mechanical ventilation without ECMO support, and 31.9% were placed on ECMO. Also, 22.5% of the patients were discharged and/or clinically improved and 51.5% died. Twenty-six percent of the study population deteriorated but remained alive or experienced no improvement in clinical condition. And 75.2% of those who died belonged to the non-ECMO group and 24.8% to the ECMO group. The mortality rate in the non-ECMO group was 56.8% compared to 40% in the ECMO group.ConclusionThe utility of ECMO during a pandemic is uncertain as it is a resource-intensive modality, especially when the mortality rate in severely ill patients infected with COVID-19 virus is already known to be high.How to cite this articleNagraj S, Karia R, Hassanain S, Ghosh P, Shah VR, Thomas A. Role of Invasive Mechanical Ventilation and ECMO in the Management of COVID-19: A Systematic Review. Indian J Crit Care Med 2021;25(6):691–698.

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: Propensity Score Matching.

The high mortality rate of patients with severe acute respiratory distress syndrome (ARDS) warrants aggressive clinical intervention. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for life-threatening hypoxemia. Randomized controlled trials of ECMO for severe ARDS comprise a number of ethical and methodological issues. Therefore, indications and optimal timing for implementation of ECMO, and predictive risk factors for outcomes have not been adequately investigated. We performed propensity score matching to match ECMO-supported and non-ECMO-supported patients at 48 h after ARDS onset for comparisons based on clinical outcomes and hospital mortality. A total of 280 severe ARDS patients were included, and propensity score matching of 87 matched pairs revealed that the 90-d hospital mortality rate was 56.3% in the ECMO group and 74.7% in the non-ECMO group (p = 0.028). Subgroup analysis revealed that greater severity of ARDS, higher airway pressure, or a higher Sequential Organ Failure Assessment score tended to benefit from ECMO treatment in terms of survival. Multivariate logistic regression revealed that hospital mortality was significantly lower among patients who received ECMO than among those who did not. Our findings suggested that early initiation of ECMO (within 48 h) may increase the likelihood of survival for patients with severe ARDS.

Extracorporeal Membrane Oxygenation for Fulminant Myocarditis: Increase of Cardiac Enzyme and SOFA Score Is Associated with High Mortality.

We aimed to evaluate the outcomes of patients with fulminant myocarditis and investigate the factors associated with mortality. This is a retrospective single-center cohort study that included adult and pediatric patients with fulminant myocarditis treated at Samsung Medical Center between September 2004 and December 2019. The primary outcome was in-hospital mortality. Among 100 patients, 71 underwent veno-arterial extracorporeal membrane oxygenation (ECMO) (ECMO group). Comorbidities were not significantly different between the ECMO and non-ECMO groups. Cardiac enzymes, creatinine, and median sequential organ failure assessment (SOFA) score at intensive care unit admission were significantly different between the groups. Twenty patients (28.7%) in the ECMO group and two (6.9%) in the non-ECMO group died in-hospital (p = 0.02). The significant risk factors of in-hospital mortality were creatine kinase MB fraction (CK-MB) and SOFA score (p = 0.009 and p = 0.001, respectively) in the ECMO group. In the receiver-operating characteristic curve analysis, the cutoffs of SOFA score and CK-MB were 12 and 94.74 ng/mL, respectively. The patients with both variables above the cutoffs showed significantly worse outcomes (p < 0.001). ECMO can be an effective treatment option for fulminant myocarditis. SOFA score and CK-MB are significant risk factors for in-hospital mortality.

Application of extracorporeal membrane oxygenation in the perioperative period of lung transplantation

Objective: To investigate the application of extracorporeal membrane oxygenation (ECMO) in the perioperative period of lung transplantation, and summarize the experience. Methods: The clinical data of 19 patients receiving lung transplantation operation in Renmin Hospital of Wuhan University from December 2016 to December 2020 were retrospectively analyzed. Patients were divided into groups according to whether ECMO support was used, and their clinical data were compared. Results: Among the 19 patients, there were 5 cases of chronic obstructive pulmonary disease, 3 cases of bronchiectasis, 4 cases of pneumoconiosis, 4 cases of idiopathic pulmonary fibrosis, 1 case of connective tissue disease interstitial pulmonary fibrosis, 1 case of Kartagener syndrome, and 1 case of COVID-19 with advanced pulmonary fibrosis. Among the 10 patients in the non-ECMO group, 1 died during the operation, 1 died after abandoning treatment, and 1 was discharged after abandoning treatment. There were 9 patients in the ECMO group, 2 patients received ECMO bridged treatment before surgery, and the remaining 7 patients received ECMO adjuvant treatment after anesthesia. In the ECMO group, 1 patient died, 1 patient was discharged after abandoning treatment, and the rest patients were all improved and discharged after successful weaning of ECMO. The two groups only differed in the way of preoperative respiratory support (P=0.033). There were no significant differences in gender, age, preoperative assessment, surgical process, length of hospital stay, ICU stay, postoperative multi-drug resistant organism infection, and outcome. Conclusion: ECMO is an important auxiliary tool during the perioperative period of lung transplantation. The use of ECMO did not increase the risk of postoperative infection with multidrug-resistant bacteria, nor did it lead to an increase in mortality. In the other hand, the choice of preoperative respiratory support method has reference for perioperative patients whether to use ECMO. © 2021, Editorial Board of Medical Journal of Wuhan University. All right reserved.

Financial implications of using extracorporeal membrane oxygenation following heart transplantation

Primary graft dysfunction after heart transplant is associated with high morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) can be used to wean patients from cardiopulmonary bypass. This study retrospectively reviews a single-centre experience of post-transplant ECMO in regard to outcomes and associated costs. Between May 2006 and May 2019, a total of 267 adult heart transplants were performed. We compared donor and recipient variables, ECMO duration and the incidence of renal failure, bleeding, infection and cost analysis between ECMO and non-ECMO groups. ECMO support was required postoperatively to manage primary graft dysfunction in 72 (27%) patients. The mean duration of ECMO support was 6 ± 3.2 days. Mean ischaemic times were similar between the groups. There was a significantly higher proportion of ventricular assist device explant to transplant in the ECMO group versus non-ECMO (38.2% vs 14.1%; P < 0.0001). ECMO patients had a longer duration of stay in the intensive care unit (P < 0.0001) and total hospital stay (P < 0.0001). Greater mortality was observed in the ECMO group (P < 0.0001). The median cost of providing ECMO was £18000 [interquartile range (IQR): £12750-£24000] per patient with an additional median £35225 (IQR: £21487.25-£51780.75) for ITU stay whilst on ECMO. The total median cost per patient inclusive of hospital stay, ECMO and dialysis costs was £65737.50 (IQR: £52566.50-£95221.75) in the non-ECMO group compared to £145415.71 (IQR: £102523.21-£200618.96) per patient in the ECMO group (P < 0.0001). Patients with primary graft dysfunction following heart transplantation who require ECMO are frequently bridged to a recovery; however, the medium and longer-term survival for these patients is poorer than for patients who do not require ECMO.

Association between Extracorporeal Membrane Oxygenation (ECMO) and Mortality in the Patients with Cardiac Arrest: A Nation-Wide Population-Based Study with Propensity Score Matched Analysis.

We attempted to determine the impact of extracorporeal membrane oxygenation (ECMO) on short-term and long-term outcomes and find potential resource utilization differences between the ECMO and non-ECMO groups, using the National Health Insurance Service database. We selected adult patients (≥20 years old) with non-traumatic cardiac arrest from 2007 to 2015. Data on age, sex, insurance status, hospital volume, residential area urbanization, and pre-existing diseases were extracted from the database. A total of 1.5% (n = 3859) of 253,806 patients were categorized into the ECMO group. The ECMO-supported patients were more likely to be younger, men, more covered by national health insurance, and showed, higher usage of tertiary level and large volume hospitals, and a lower rate of pre-existing comorbidities, compared to the non-ECMO group. After propensity score-matching demographic data, hospital factors, and pre-existing diseases, the odds ratio (ORs) of the ECMO group were 0.76 (confidence interval, (CI) 0.68–0.85) for 30-day mortality and 0.66 (CI 0.58–0.79) for 1-year mortality using logistic regression. The index hospitalization was longer, and the 30-day and 1-year hospital costs were greater in the matched ECMO group. Although ECMO support needed longer hospitalization days and higher hospital costs, the ECMO support reduced the risk of 30-day and 1-year mortality compared to the non-ECMO patients.

Abstract 13152: Do Survivors of Acute Coronary Syndrome Due to Unprotected Left Main Coronary Artery Occlusion Treated With Extracorporeal Membrane Oxygenation Have Higher Mortality in Chronic Phase?

Introduction: Mortality in patients with acute coronary syndrome (ACS) due to unprotected left main coronary artery (LMA) occlusion is high. Extracorporeal membrane oxygenation (ECMO) could rapidly provide circulatory support. Hypothesis: This study aimed to verify the hypotheses that the patient who required circulatory support with ECMO in acute phase of LMA-ACS had greater cardiac function deterioration and had higher mortality in the chronic phase than those who did not require ECMO. Methods: Patients with LMA-ACS who underwent percutaneous coronary revascularization between 2000 and 2020 were enrolled in this study. The patients were divided into two groups based on whether or not they received ECMO. Thirty-day (acute phase) and 30-day to 6-year (chronic phase) survival curves were constructed by Kaplan-Meier method. The cause of death in acute and chronic phase were examined. Results: Among the 85 study patients, 23 (27%) were in the ECMO-group. Median age was younger in the ECMO-group (65 y [57 - 72] vs. 73 y [69 - 83], p &amp;lt; 0.01), and male sex (67% vs. 63%) were similar in ECMO group and non-ECMO groups respectively. The prevalence of ST elevation myocardial infarction (STEMI), non-STEMI, unstable angina were 52%, 48%, and 0% vs. 15%, 42%, and 44% in the ECMO group and non-ECMO group, respectively. The 30-day mortality was significantly higher in ECMO group (61% vs. 15%, p &amp;lt; 0.01); however, the 30-day to 6-year mortality was similar between the two groups (41% vs. 33%, p = 0.59) (Figure). The cause of death in the acute phase were cardiac failure (79% and 67%) and those in chronic phase were cardiac failure (50% and 25%), malignancy (0% and 13%), and infection (50% and 36%). Conclusions: The mortality in chronic phase in LMA-ACS patients who survived up to 30 days were similar in ECMO group and non-ECMO group. Moreover the patients whose cardiac function deteriorated severely and required ECMO in acute phase had similar prognosis to those that did not require ECMO.

Factors associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation

BackgroundIntraoperative Extracorporeal membrane oxygenation (ECMO) is increasingly being applied as life-support for lung transplantation patients. However, factors associated with this procedure in lung transplantation patients have not yet been characterized. The aim of this study was to identify preoperative factors of intraoperative ECMO support during lung transplantation and to evaluated the outcome of lung transplantation patients supported with ECMO.MethodsPatients underwent lung transplantation treated with and without ECMO in Guangzhou Institute of Respiratory Diseases between January 2015 to August 2018 were retrospectively reviewed. Patient demographics and clinical variables were collected and analyzed. Multivariate logistic regression was performed to identify factors independently associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation.ResultsDuring the study period, 138 patients underwent lung transplantation at our institution, the mean LAS was (56.63 ± 18.39) (range, 32.79 to 88.70). Fourty four patients were treated with veno-venous/veno-arterial ECMO. Among the patients, 32 patients wean successfully ECMO after operation, 12 patients remain ECMO after operation, and 32 patients (62.74%) survived to hospital discharge. In multiple analysis, the following factors were associated with intraoperative ECMO support: advanced age, high PAP before operation, duration of mechanical ventilation before operation, a higher APACHE II and primary diagnosis for transplantation. The overall survival rates at 1, 3, and 12 months were 90.91, 72.73, and 56.81% in the ECMO group, and 95.40, 82.76, and 73.56% in the non-ECMO group, respectively (log-rank P = 0.081). Patients who underwent single lung transplant had a lower survival rates in ECMO group as compared with non-ECMO group at 1, 3, and 12 months (90.47% vs 98.25, 71.43% vs 84.21, and 52.38% vs 75.44%) (log-rank P = 0.048).ConclusionsThe preoperative factors of intraoperative ECMO support during lung transplantation included age, high PAP before operation, preoperative mechanical ventilation, a higher APACHE II and primary diagnosis for transplantation based on multivariate analysis.

The Role of Extracorporeal Membrane Oxygenation in The Protective Lung Strategy after Cardiac Surgery in a Tertiary Intensive Care Unit

Background: In cases of respiratory failure, Lung-Protective Ventilation Strategy (LPVS) which limits ventilator-induced lung injury is recommended. However, CO2 retention is a major impediment for LPVS and Extracorporeal membrane oxygenation (ECMO) supplies enough time to the lungs for rest and recovery. We aimed to find out the connection between ECMO usage and the reduction of mechanical ventilatory values in patients who required ECMO therapy after cardiac surgery due to pulmonary failure. Methods: In this retrospective cohort study, we analyzed 21 consecutive patients receiving a venovenous ECMO for pulmonary failure after cardiac surgery and 19 patients non-ECMO group. Demographic variables including age, gender, predicted body weight, and heart rate and the arterial blood gas analysis data, mechanical ventilator parameters and clinical outcomes were derived from institutional database. Results: The mean age of the patients was 55.57 years and ECMO patients were younger than non-ECMO group patients (p=0.005). The other descriptive variables and clinical parameters did not differ between groups statistically. The mechanical ventilator parameters and arterial blood gas analysis were worse in the ECMO group before the procedure (p &lt;0.001) whereas improvement in data was more significant in the ECMO group after the procedure (p&lt;0.001 in Pplateau and PaO2) . The patients in the non-ECMO group stayed longer in hospital (35.68 days vs 16.9 days) and in ICU (31.11 days vs 13.33 days) than the patients in the ECMO group. The duration of the mechanical ventilatory support did not differ between groups. Conclusion: The intensivists had a big dilemma involving the balance between maintaining a sensible blood-gas exchange and protecting the lung from adverse effects of mechanical ventilatory support. The extracorporeal life support –ECMO- was advised until the pulmonary failure was resolved. We found that ECMO support was decreasing the high Plateau Pressure and respiratory rate more than the non-ECMO group.

Association between Pre-Transplant Allosensitization by ECMO Bridging and Adverse Postoperative Outcome of Lung Transplantation

Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation has raised concerns because it can induce pre-transplant allosensitization. Panel reactive antibody (PRA) or human leukocyte antigen (HLA) are examined for confirm pre-transplant sensitization since they are known to be associated with higher occurrence of adverse outcomes such as primary graft dysfunction (PGD), acute rejection and mortality. We examined the prevalence of sensitization in ECMO bridging and evaluated its impact on outcomes of lung transplantation. A single-center retrospective analysis was conducted. We include 211 patients who received a bilateral lung transplantation between January 2013 and June 2019. We defined sensitization either by high PRA (>50%) and/or high mean fluorescence intensity (MFI) (≥5000). Pre-transplant ECMO support was conducted in 64 patients (30.3%). Level of class I PRA was 12.3% and class II was 14.0% in ECMO group while 9.2% and 13.0% in the other group. Number of patients with class I and/or class II PRA greater than 50% was not significantly different between two groups (10 patients, 15.6% in ECMO group, 22 patients, 15.0% in non-ECMO group, p = 0.902). Number of patients with MFI higher than 5000 was also not significantly different (12 patients, 18.8% in ECMO, 24 patients, 26.6% in non-ECMO, p = 0.695). Prevalence of grade 3 PGD at post-operative 72 hours was slightly higher in ECMO group, but it was also not statistically different (18, 28.1% in ECMO group and 24, 16.3% in non-ECMO group, p = 0.061). Acute rejection, chronic lung allograft dysfunction (CLAD), and overall mortality were not significantly different. On multivariable logistic regression, sensitization and grade 3 PGD were not associated with ECMO bridging. Our report demonstrates the possible connection among pre-operative ECMO support, pre-transplant sensitization, and PGD. However, pre-transplant ECMO bridging is not seemed to be risk factors for pre-transplant sensitization nor PGD. Pre-transplant allosensitization might not adversely affect outcomes after lung transplantation.

Surgical Complications in Children with CDH: A Multivariate Analysis

IntroductionSeveral medical and surgical improvements in the treatment of congenital diaphragmatic hernia (CDH) patients have led to a higher survival rate. However, some of these improvements also lead to an increased morbidity rate. This study aims to determine the contribution different medical and surgical treatments have had on the development of surgical complications.MethodAll CDH patients treated in a single centre between 2000 and 2015 were retrospectively evaluated. Multivariate logistic regression was used to estimate the independent effects of several treatment options that could influence the surgical outcome by adjustment for multiple risk factors.ResultsSixty of the 197 surgically repaired CDH patients had surgical complications. There were more haemorrhagic complications in the ECMO compared to non-ECMO group (27% vs. 2%, p < 0.001). The use of inhaled nitric oxide was also significantly related to haemorrhage (OR = 13.0 (95% CI 1.1–159)). After adjustment for other risk factors, chylothorax was neither significantly associated with ECMO treatment (OR = 1.6 (95% CI 0.5–5.2) nor with patch repair (OR = 2.1: 95% CI 0.7–6.1). A recurrence occurred more often in patients with pulmonary hypertension (OR = 10.0 (95% CI 1.5–65.8) and after treatment with an abdominal patch (OR = 11.3: 95% CI 1.5–84.4).ConclusionECMO treatment and the inhalation of nitric oxide are used in the most severe CDH patients but are associated with a higher risk on surgical haemorrhage. The recurrence rate is associated with both the use of an abdominal patch and the presence of pulmonary hypertension, regardless of medical treatment.

Exploratory Observational Study of Extracorporeal Cardiopulmonary Resuscitation for Nonshockable Out-Of-Hospital Cardiac Arrest Occurring After an Emergency Medical Services Arrival: SOS-KANTO 2012 Study Report.

The outcomes of patients with nonshockable out-of-hospital cardiac arrest (OHCA) are poor, but may be improved by extracorporeal cardiopulmonary resuscitation (E-CPR). To examine the effects of veno-arterial extracorporeal membranous oxygenation (ECMO) as E-CPR in patients with nonshockable OHCA after emergency medical services (EMS) arrival for whom satisfactory cardiopulmonary resuscitation (CPR) was immediately performed. Among 16,452 patients enrolled in the SOS-KANTO 2012 study, we examined data on 531 patients aged ≥ 18years who performed activities of daily living (ADL) well or had moderate disability before the onset of cardiac arrest (CA) and those with normal spontaneous respiration or pulse palpation upon EMS arrival. CPR was performed immediately after CA onset, and advanced life support was provided upon hospital arrival for these patients. We divided patients into ECMO and non-ECMO groups. We retrospectively analyzed background factors and clinical outcomes. E-CPR was performed on 38 (7.2%) patients. In the univariate analysis, the mean age of the ECMO group was lower, ADL function before onset was more favorable, mean body weight was higher, and the mean interval from onset until hospital arrival was shorter than those in the non-ECMO group. One-to 3-month survival or favorable cerebral function outcome rates were higher in the ECMO group than in the non-ECMO group. In the multivariate analysis, ECMO use and the interval from onset until hospital arrival were independent prognostic factors for favorable cerebral functional outcomes at 1 and 3months. E-CPR may be associated with favorable outcomes in carefully selected patients with nonshockable OHCA.

Increased mobilization of mesenchymal stem cells in patients with acute respiratory distress syndrome undergoing extracorporeal membrane oxygenation.

The acute respiratory distress syndrome (ARDS) is characterized by pulmonary epithelial and endothelial barrier dysfunction and injury. In severe forms of ARDS, extracorporeal membrane oxygenation (ECMO) is often the last option for life support. Endothelial progenitor (EPC) and mesenchymal stem cells (MSC) can regenerate damaged endothelium and thereby improve pulmonary endothelial dysfunction. However, we still lack sufficient knowledge about how ECMO might affect EPC- and MSC-mediated regenerative pathways in ARDS. Therefore, we investigated if ECMO impacts EPC and MSC numbers in ARDS patients. Peripheral blood mononuclear cells from ARDS patients undergoing ECMO (n = 16) and without ECMO support (n = 12) and from healthy volunteers (n = 16) were isolated. The number and presence of circulating EPC and MSC was detected by flow cytometry. Serum concentrations of vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang2) were determined. In the ECMO group, MSC subpopulations were higher by 71% compared to the non-ECMO group. Numbers of circulating EPC were not significantly altered. During ECMO, VEGF and Ang2 serum levels remained unchanged compared to the non-ECMO group (p = 0.16), but Ang2 serum levels in non-survivors of ARDS were significantly increased by 100% (p = 0.02) compared to survivors. ECMO support in ARDS is specifically associated with an increased number of circulating MSC, most likely due to enhanced mobilization, but not with a higher numbers of EPC or serum concentrations of VEGF and Ang2.