Receiving Extracorporeal Membrane Oxygenation Therapy Research Articles

Prevalence of FXII-Deficiency and Its Relevance to Monitoring Anticoagulation in Adults Receiving Extracorporeal Membrane Oxygenation.

During extracorporeal membrane oxygenation (ECMO) blood is exposed to artificial surfaces, resulting in contact activation of the intrinsic coagulation pathway initiated by coagulation factor XII (FXII). Little is known about the prevalence of acquired FXII-deficiency, especially during ECMO. The primary outcome was the prevalence of acquired FXII-deficiency (FXII activity <60%) during ECMO. Secondary outcomes included differences in hemorrhagic/thromboembolic complications, doses of unfractionated heparin administered, and time points of anticoagulation within target ranges between patients with and without FXII-deficiency. Of 193 adults receiving ECMO therapy between 2013 and 2021, FXII testing was performed in 64 (33%) patients. Of these, 89% ( n = 57) had an acquired FXII-deficiency. Median complication-free intervals were not different between patients with and without acquired FXII-deficiency (bleeding: 28 days [6-145] vs. 12 days [11-not available], p = 0.85; thromboembolism: 16 days [8-54] vs. 13 days [3-15], p = 0.053). Patients with acquired FXII-deficiency received less heparin (16,554 IU/day vs. 25,839 IU/day; p = 0.009) and were less likely to be within aPTT-target ranges (23.1% [14.3%-36.4%] vs. 37.8% [33.7%-58.3%], p = 0.005). Acquired FXII-deficiency is common during ECMO and may affect monitoring of anticoagulation. The impact of FXII-activity on complications needs to be determined in future studies.

Extracorporeal membrane oxygenation for acute respiratory distress syndrome in patients with COVID-19

COVID-19 can lead to acute respiratory distress syndrome (ARDS). In some patients for whom conventional mechanical ventilation is insufficient, venovenous (VV) extracorporeal membrane oxygenation (ECMO) can be life-saving. Retrospective analysis of data from patients with ARDS triggered by COVID-19 who received ECMO therapy between March 2020 and February 2022. Premorbid health condition, course of respiratory distress and respiratory support before, during and after ECMO therapy were registered. Thirty patients received ECMO therapy. Median age was 57 years, median body mass index 28kg/m2, and 23 patients were men. Median duration of lung protective mechanical ventilation with tidal volume 5.8 mL/kg predicted body weight before initiation of ECMO therapy was 8 days. Treatment indication was primarily severe hypoxaemia, frequently combined with hypercapnia. Twenty-three patients developed at least one severe complication while receiving ECMO therapy. Sixteen patients died, 13 during ongoing ECMO therapy. Fourteen were discharged from hospital. Median duration of ECMO and mechanical ventilation was 27 and 37 days, respectively. ECMO therapy for patients with ARDS triggered by COVID-19 can be life-saving, but the treatment is accompanied by severe complications and a high mortality rate.

Eliminate Unnecessary Laboratory Work to Mitigate Iatrogenic Anemia and Reduce Cost for Patients on Extracorporeal Membrane Oxygenation.

Laboratory testing is a helpful tool for clinicians, but can be costly and harmful to patients. A quality improvement project was initiated to reduce laboratory testing for patients receiving extracorporeal membrane oxygenation (ECMO) in a pediatric intensive care unit (PICU) at a tertiary care center. Preliminary data was gathered to demonstrate preimplementation practice, cost, and patient need for packed red blood cell (pRBC) transfusions. A new protocol was created by an interprofessional team based on best practice and benchmarking with high-performing organizations. The project was evaluated using two comparison groups, pre- and postimplementation for anyone receiving ECMO therapy in the PICU. The average laboratory tests per ECMO day decreased by 52% (128.4 vs. 61.1), cost per case decreased by 14.7%, pRBC transfusions decreased from 100% to 85%, length of stay (LOS) decreased by 8 days, and mortality rates decreased by 9.5%. The revised pediatric ECMO laboratory testing guidelines were successfully implemented and reduced laboratory cost without adverse effects on mortality rates or LOS.

Eliminate Unnecessary Laboratory Work to Mitigate Iatrogenic Anemia and Reduce Cost for Patients on Extracorporeal Membrane Oxygenation

Laboratory testing is a helpful tool for clinicians, but can be costly and harmful to patients. A quality improvement project was initiated to reduce laboratory testing for patients receiving extracorporeal membrane oxygenation (ECMO) in a pediatric intensive care unit (PICU) at a tertiary care center. Preliminary data was gathered to demonstrate preimplementation practice, cost, and patient need for packed red blood cell (pRBC) transfusions. A new protocol was created by an interprofessional team based on best practice and benchmarking with high-performing organizations. The project was evaluated using two comparison groups, pre- and postimplementation for anyone receiving ECMO therapy in the PICU. The average laboratory tests per ECMO day decreased by 52% (128.4 vs. 61.1), cost per case decreased by 14.7%, pRBC transfusions decreased from 100% to 85%, length of stay (LOS) decreased by 8 days, and mortality rates decreased by 9.5%. The revised pediatric ECMO laboratory testing guidelines were successfully implemented and reduced laboratory cost without adverse effects on mortality rates or LOS.

Indications, outcomes and complications after ECMO implantation in the cath lab - a single-center retrospective study

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite the increase of extracorporeal membrane oxygenation (ECMO) employment around the globe over the last decades, studies describing the emergency use of venoarterial (VA)-ECMO in the cardiac catheterization laboratory (CCL) are scarce. Purpose The aim of this study was to describe the patient population that received ECMO in the CCL of a tertiary care center and the associated complications and outcomes. Methods In this single-center retrospective study we reviewed the baseline clinical and laboratory characteristics, indications and outcomes of adult patients, who received VA-ECMO between 2011 and 2019. Results In the given time period, ECMO use in the CCL increased drastically. Mean age of the 83 patients was 58.3 ± 12.5 years, 78.3% were male. From 2011 to 2018 ECMO-use in the CCL increased drastically. The most common indication for ECMO implantation was cardiac arrest (66%), followed by cardiogenic shock (12%), high-risk PCI (11%), and procedure-related complications (10%). While 30-day mortality in the total study population was 69%, it varied greatly depending on the underlying indication for ECMO therapy (cardiac arrest 78%, cardiogenic shock 20%, high-risk PCI 44%, procedure-related complications 88%). The most commonly occurring complications were acute kidney injury (20%) and cannula site bleeding (20%), followed by extremity complications (19%), sepsis (18%), major bleeding (10%) and stroke (8%). Of interest, patients receiving ECMO therapy after in-hospital cardiac arrest showed greater survival rates (28.2%) as compared to patients after out of hospital cardiac arrest (18.2%; p=0.045). High serum lactate levels (p=0.018) and low baseline pH values (p=0.001) at baseline were associated with a significantly increased 30-day mortality after ECMO implantation. Conclusion The emergency use of VA-ECMO in the CCL increased over the last years and was associated with a high 30-day mortality in our study population. Still, a &amp;gt;20% survival rate in the group of patients with refractory cardiac arrest, an otherwise futile situation, suggests that VA-ECMO implantation is reasonable in selected patients. As high admission serum lactate levels and the baseline pH are strong predictors of outcome, such parameters may be used to guide decision making.

Identifying the optimal timing of renal replacement therapy initiation among critically ill patients on extracorporeal membrane oxygenation therapy

Introduction: Acute kidney injury (AKI) is one of the most frequent complications in patients with severe cardiopulmonary dysfunction on extracorporeal membrane oxygenation (ECMO) therapy. Although renal replacement therapy (RRT) is the standard of care for AKI, the timing of initiation of RRT remains controversial. Objectives: This study aimed to determine the optimal timing of RRT initiation among patients receiving ECMO therapy. Patients and Methods: We conducted a retrospective cohort study of 40 patients in a tertiary hospital centre from March 2014 until December 2019. The patients were divided into two groups according to the timing of RRT initiation, i.e. early RRT (within 72 hours) or late RRT after ECMO treatment. The primary outcome was 60-day mortality. The secondary outcomes were survival predictors of these patients. Results: The 60-day mortality was not significantly different between the two groups (76.9% in the early RRT initiation and 88.9% in the late group; P=0.321). The predictors of survival were RRT start within 72 hours of ECMO initiation (HR: 0.067, 95%, CI: 0.010-0.457), age ≥ 60 years (HR: 6.334, 95% CI: 1.268-31.625), fluid balance on day seven of ECMO (HR: 1.093, 95% CI: 1.007-1.187), and eGFR-EPI ≥ 60 mL/min/1.73 m2 (HR: 0.970, 95% CI: 0.946-0.996). Conclusion: Among patients with ECMO and RRT, early RRT within 72 hours of ECMO initiation was significantly associated with a decreased risk of death. Our findings suggest the survival benefit of early RRT in critically ill patients treated with ECMO.

Modalities of Exercise Training in Patients with Extracorporeal Membrane Oxygenation Support.

The aim of this qualitative systematic review is to summarize and analyze the different modalities of exercise training and its potential effects in patients on extracorporeal membrane oxygenation (ECMO) support. ECMO is an outbreaking, life-saving technology of the last decades which is being used as a gold standard treatment in patients with severe cardiac, respiratory or combined cardiorespiratory failure. Critically ill patients on ECMO very often present intensive care unit-acquired weakness (ICU-AW); thus, leading to decreased exercise capacity and increased mortality rates. Early mobilization and physical therapy have been proven to be safe and feasible in critically ill patients on ECMO, either as a bridge to lung/heart transplantation or as a bridge to recovery. Rehabilitation has beneficial effects from the early stages in the ICU, resulting in the prevention of ICU-AW, and a decrease in episodes of delirium, the duration of mechanical ventilation, ICU and hospital length of stay, and mortality rates. It also improves functional ability, exercise capacity, and quality of life. Rehabilitation requires a very careful, multi-disciplinary approach from a highly specialized team from different specialties. Initial risk assessment and screening, with appropriate physical therapy planning and exercise monitoring in patients receiving ECMO therapy are crucial factors for achieving treatment goals. However, more randomized controlled trials are required in order to establish more appropriate individualized exercise training protocols.

Acute Care Nurse Practitioner-Led Extracorporeal Membrane Oxygenation Simulation Training.

Acute Care Nurse Practitioner-Led Extracorporeal Membrane Oxygenation Simulation Training.

Carnitine deficiency among hospitalized pediatric patients: A retrospective study of critically ill patients receiving extracorporeal membrane oxygenation therapy.

BackgroundThe metabolic demands associated with critical illness place patients at risk for nutrition deficits. Carnitine is a small molecule essential for fatty acid oxidation and gluconeogenesis. Secondary carnitine deficiency can have clinically significant complications and has been observed anecdotally in patients receiving extracorporeal membrane oxygenation (ECMO) therapy at our institution. Guidelines for monitoring and supplementing carnitine are lacking. This retrospective study determined whether critically ill pediatric patients receiving ECMO have an increased risk of carnitine deficiency.MethodsAcylcarnitine analysis was performed on residual specimens from patients who received ECMO therapy. The control data were a convenience sample gathered by chart review of patients who had been tested for carnitine during a hospitalization.ResultsAcylcarnitines were measured in 217 non‐ECMO patients and 81 ECMO patients. Carnitine deficiency, based on age‐specific reference ranges, was observed in 41% of ECMO cases compared with 21% of non‐ECMO cases. Multivariable analysis of age‐matched patients identified that the odds of carnitine deficiency were significantly lower among patients on the floor compared with ECMO patients (odds ratio, 0.21; 95% CI, 0.10–0.44). Age‐specific frequency of qualitative carnitine deficiency ranged from 15% (patients >5 years old) to 56% (patients 1 week to 1 month old) in ECMO patients and 15% (patients >5 years old) to 34% (patients 1–5 years old) in non‐ECMO patients.ConclusionIn this study, ECMO patients were carnitine deficient more frequently compared with other inpatients, with the highest rates of deficiency among ECMO patients between 1 week and 1 month old.

The Use of Extracorporeal Membrane Oxygenation in Severely Burned Patients: A Survey of North American Burn Centers.

Respiratory failure and acute respiratory distress syndrome can occur in burn patients with or without inhalational injury and can significantly increase mortality. For patients with severe respiratory failure who fail conventional therapy with mechanical ventilation, the use of venovenous extracorporeal membrane oxygenation (ECMO) may be a life-saving salvage therapy. There have been a series of case reports detailing the use of ECMO in burn patients over the last 20 years, but very little is currently known about the status of ECMO use at burn centers in North America. Using a web-based survey of burn center directors in Canada and the United States, we examined the rate of usage of ECMO in burn care, barriers to its use, and the perioperative management of burn patients receiving ECMO therapy. Our findings indicate that approximately half of the burn centers have used ECMO in the care of burn patients, but patient volume is very low on average (less than 1 per year). Of centers that do use ECMO in burn care, only 40% have a specified protocol for doing so. Approximately half have operated on patients being actively treated with ECMO therapy, but perioperative management of anticoagulation varies widely. A lack of experience and institutional support and a perceived lack of evidence to support ECMO use in burn patients were the most commonly identified barriers to more widespread uptake. Better collaboration between burn centers will allow for the creation of consensus statements and protocols to improve outcomes for burn patients who require ECMO.

P0245 / #1636: ECMO(EXTRACORPOREAL MEMBRANE OXYGENATION)ROLE IN NEONATES AND PEDIATRICS

Aims & Objectives: AIMs and Objectives: Clinical reports of extracorporeal support of patients with respiratory failure were described in the early 1970s though not very successful in adult ARDS (acute respiratory distress syndrome) patients. During the 2009 Australia and New Zealand outbreak, the significant number of H1N1 influenza cases receiving ECMO (Extra corporeal membrane oxygenation)survived leading to resurgence and use in Pediatric age group.Main objectives were To assess prevalence and outcomes of Neonatal and Pediatric ECMO in India for refractory hypoxemia or low cardiac out put syndrome refractory to inotropic support. Methods: Methods: This prospective multicenter survey was performed to describe current status of ECMO in Pediatric age group as of Dec31 2019 in tertiary care centres in India. A standard data sheet was sent to all ECMO program directors at participating centres for patients receiving ECMO therapy from 1st Jan 2011-Dec 31 2019 for all children aged 1day-16years. Demographic data, gestation, PRISM III score, indication of ECMO:Respiratory or cardiac,type of ECMO (VV:Venovenous or VA:Venoarterial), diagnosis, duration of ventilation, duration of ECMO, survival to discharge, complications if any. All patients were followed for long term complications and quality of life. Results: Results: Survival VV(Respiratory) ECMO 37/82(45.1%) and VA ECMO(Cardiac) 42/64(65.6%). No major disability was identified amongst survivors. Conclusions: Conclusions: Pediatric ECMO is a prevalent therapy at tertiary centers in India with good survival. Prospective randomized studies and long term clinical follow up is needed to assess quality of life in survivors.

Preventing Hospital-Acquired Pressure Injuries by Using a Tiered Protocol in Children Receiving ECMO in the Pediatric Intensive Care Unit.

Preventing Hospital-Acquired Pressure Injuries by Using a Tiered Protocol in Children Receiving ECMO in the Pediatric Intensive Care Unit.

Extracorporeal Membrane Oxygenation Therapy for Critically Ill Coronavirus Disease 2019 Patients in Wuhan, China: A Retrospective Multicenter Cohort Study

SummaryCurrently, little in-depth evidence is known about the application of extracorporeal membrane oxygenation (ECMO) therapy in coronavirus disease 2019 (COVID-19) patients. This retrospective multicenter cohort study included patients with COVID-19 at 7 designated hospitals in Wuhan, China. The patients were followed up until June 30, 2020. Univariate and multivariate logistic regression analyses were performed to identify the risk factors associated with unsuccessful ECMO weaning. Propensity score matching was used to match patients who received veno-venous ECMO with those who received invasive mechanical ventilation (IMV)-only therapy. Of 88 patients receiving ECMO therapy, 27 and 61 patients were and were not successfully weaned from ECMO, respectively. Additionally, 15, 15, and 65 patients were further weaned from IMV, discharged from hospital, or died during hospitalization, respectively. In the multivariate logistic regression analysis, a lymphocyte count ≤0.5×109/L and D-dimer concentration >4× the upper limit of normal level at ICU admission, a peak PaCO2 >60 mmHg at 24 h before ECMO initiation, and no tracheotomy performed during the ICU stay were independently associated with lower odds of ECMO weaning. In the propensity score-matched analysis, a mixed-effect Cox model detected a lower hazard ratio for 120-day all-cause mortality after ICU admission during hospitalization in the ECMO group. The presence of lymphocytopenia, higher D-dimer concentrations at ICU admission and hypercapnia before ECMO initiation could help to identify patients with a poor prognosis. Tracheotomy could facilitate weaning from ECMO. ECMO relative to IMV-only therapy was associated with improved outcomes in critically ill COVID-19 patients.

Outcomes among Patients Treated with Renal Replacement Therapy during Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Study

Background: Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are modalities used in critically ill patients suffering organ failure and metabolic derangements. Although the effects of CRRT have been extensively studied, the impact of simultaneous CRRT and ECMO is less well described. The purpose of this study is to evaluate the incidence and the impact of CRRT on outcomes of patients receiving ECMO. Methods: A single center, retrospective chart review was conducted for patients receiving ECMO therapy over a 6-year period. Patients who underwent combined ECMO and CRRT were compared to those who underwent ECMO alone. Intergroup ­statistical comparisons were performed using Wilcoxon/Kruskal-Wallis and chi-square tests. Logistic regression was performed to identify independent risk factors for mortality. Results: The demographic and clinical data of 92 patients who underwent ECMO at our center were reviewed including primary diagnosis, indications for and mode of ECMO support, illness severity, oxygenation index, vasopressor requirement, and presence of acute kidney injury. In those patients that required ECMO with CRRT, we reviewed urine output prior to initiation, modality used, prescribed dose, net fluid balance after 72 h, requirement of renal replacement therapy (RRT) at discharge, and use of diuretics prior to RRT initiation. Our primary endpoint was survival to hospital discharge. During the study period, 48 patients required the combination of ECMO with CRRT. Twenty-nine of these patients survived to hospital discharge. Of the 29 survivors, 6 were dialysis dependent at hospital discharge. The mortality rate was 39.5% with combined ECMO/CRRT compared to 31.4% among those receiving ECMO alone (p = 0.074). Of those receiving combined therapy, nonsurvivors were more likely to have a significantly positive net fluid balance at 72 h (p = 0.001). A multivariate linear regression analysis showed net positive fluid balance and increased age were independently associated with mortality. Conclusions: Use of CRRT is prevalent among patients undergoing ECMO, with over 50% of our patient population receiving combination therapy. Fluid balance appears to be an important variable associated with outcomes in this cohort. Rates of renal recovery and overall survival were higher compared to previously published reports among those requiring combined ECMO/CRRT.

Left Ventricular Assist Device (LVAD) Implantation Transiently Increases Plasma TGF-β1 in Heart Failure Patients: Potential Impact of Lvad on Platelet Activation

Although survival and quality of life have improved in patients with advanced heart failure (HF) after implantation of left ventricular assist devices (LVADs), they still pose risks of hemocompatibility-related complications, including thrombosis and bleeding. Development of biomarkers predictive of these LVAD-associated complications could guide decision making for both clinicians and patients. Recently, we showed higher plasma TGF-β1 levels within one-week after implantation with a miniaturized mechanical-bearing axial-flow pump HeartMate II (HM-II), and reasoned that platelet activation by the rotor may have caused the release of TGF-β1 in plasma in HF patients (Mancini et al. Transl. Res. 2018; 192:15-29). Recent clinical trials with the newest LVAD, the Heartmate 3 (HM-3), which uses a fully magnetically-levitated pump, showed superior clinical outcomes, including significantly reduced incidences of pump thrombosis and stroke (Mehra et al. N Engl J Med. 2019; 380:1618-1627). In this study, we evaluated release of TGF-β1 in plasma following implantation of HM-II and HM-3 LVADs compared to either coronary artery bypass graft (CABG) surgery or extracorporeal membrane oxygenation (ECMO) therapy. We measured serial total TGF-β1 levels in 38 Stage-D HF patients (11 received HM-II and 27 received HM-3). As a control, we collected blood samples from 10 patients undergoing CABG surgery, and 10 patients receiving ECMO therapy following acute onset cardio-pulmonary failure. Blood samples were collected before and 4-8 hours after procedures, and thereafter daily for up to one week. Plasma was prepared by centrifuging blood at 12,000 rpm for 5 min at 4°C within 10 min of blood drawing, which reduces in vitro release of TGF-β1 from platelets and thus allows accurate measurement of plasma TGF-β1. Total TGF-β1 levels were measured after acidification and neutralization of samples using DUO-ELISA kit (R&amp;D Systems). Baseline total plasma TGF-β1 levels were higher in HF patients before LVAD implantation than in healthy controls [4.7 ± 1.9 ng/mL in HF patients (n= 38); 3.3 ± 0.8 ng/mL in healthy controls (n= 6); p=0.006)]. Total TGF-β1 levels surged transiently to 14.6 ± 6.1 ng/mL within 4-8 hours after LVAD implantation [(p&amp;lt;0.0001 compared to patients 4-12 hours after CABG surgery (3.6 ± 1.4 ng/mL) or ECMO therapy (4.9 ± 1.3 ng/mL)]. Interestingly, however, we found that the transient surge of TGF-β1 in HM-3 recipients was significantly lower than in HM-II recipients (Figure-1; p=0.04). TGF-β1 levels then gradually decreased and reached near basal levels 2-3 days after LVAD implantation, but remained significantly elevated in plasma of HM-II recipients until day 5 (p=0.049). TGF-β1 levels remained unchanged in both CABG and ECMO patients at all time points (Figure 1). We conclude that LVAD implantation causes a transient surge in total plasma TGF-β1 within a few hours after the procedure, presumably due to platelet activation by LVAD, not the surgery itself, as CABG or circulating blood through ECMO did not cause the surge. The observation that a reduced initial surge and lower levels of TGF-β1 in HM-3 vs. HM-II recipients needs further investigation to determine whether these differences are due to LVAD-specific factors (different rotors causing variable shear effects) or to confounding differences in implantation procedures, such as, by-pass time, cardiac tissue injury, number of platelet transfusions, blood suction with catheters etc. or other unknown factors. Our data suggest that serial TGF-β1 measurements after LVAD implantation may serve as a surrogate biomarker for platelet activation in association with hemocompatibility-related adverse events (Uriel et al. Circ. 2017; 135:2003-2012). Disclosures No relevant conflicts of interest to declare.

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.

Diagnostic value of plasma procalcitonin for bacterial infection in patients receiving extracorporeal membrane oxygenation

Objective To evaluate the diagnostic value of plasma procalcitonin (PCT) for bacterial infection in patients receiving extracorporeal membrane oxygenation (ECMO). Methods Clinical data of patients receiving ECMO therapy admitted between August 2016 and January 2018 in Department of Critical Care Medicine, Tongji Hospital of Tongji Medical College were analyzed retrospectively. All patients receiving ECMO with bacterial culture were eligible for inclusion. Plasma PCT, IL-6, CRP and WBC levels detected within 24 h of bacterial cultures were analyzed immediately. Bacterial infection in ECMO was determined through bacterial culture and clinical characteristics. Finally, receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic value of inflammatory markers for bacterial infection in ECMO patients. Results Seventeen patients met the inclusion criteria, including 15 patients with acute respiratory failure and 2 patients with acute circulatory failure. There were 37 positive bacterial cultures, and 91 plasma PCT levels were detected in the process of ECMO. Compared with IL-6, CRP and WBC, plasma PCT had significant clinical significance in the diagnosis of bacterial infection (AUC=0.818,P<0.001). The cut-off value of PCT was 1.0 ng/mL, with a sensitivity of 92% and a specificity of 43%. Conclusions Compared with other conventional inflammatory markers, plasma PCT has more diagnostic value for bacterial infection in ECMO patients. Key words: Procalcitonin; Extracorporeal membrane oxygenation; Bacteria; Infection; Diagnosis; Inflammatory markers; Respiratory failure; Circulatory failure

Neurodevelopmental Outcomes After Neonatal and Pediatric ECMO

Neonatal and pediatric extracorporeal membrane oxygenation (ECMO) is an increasingly utilized, potentially life-saving therapy for critically ill patients. The immediate and long-term neurodevelopmental outcomes for patients who require ECMO is not fully understood or appreciated. There is a growing body of literature examining the neurodevelopmental outcomes of neonatal and pediatric survivors of ECMO. Estimates of ECMO patients’ long-term neurological disabilities range from 10 to 60% (Glass et al. Pediatrics 83:72–78, 1989; Boyle et al. Pediatr Crit Care Med 19:760–766, 2018). Multiple modalities of neurologic monitoring while on ECMO are being investigated for their ability to detect neurologic injury, but their impact on long-term neurodevelopmental outcome remains unknown. Improved knowledge about the long-term neurodevelopmental outcomes for patients receiving ECMO therapy may help providers to access better resources and support patients after recovery from their acute illnesses. This review seeks to highlight some of the current understanding of the risks for poor neurodevelopmental outcomes of patients supported on ECMO, modes of neurologic monitoring, and recent data on neurodevelopmental outcomes.

Effects of Nutritional Intervention on the Survival of Patients with Cardiopulmonary Failure Undergoing Extracorporeal Membrane Oxygenation Therapy.

This study aimed to examine the effects of nutritional intervention on the prognosis of patients with cardiopulmonary failure undergoing extracorporeal membrane oxygenation (ECMO) therapy in Taiwan. An institutional review board-approved retrospective study was conducted on patients receiving ECMO therapy in the intensive care unit of the China Medical University Hospital, Taiwan, from January 2013 to December 2013. The study included 102 patients with cardiopulmonary failure receiving ECMO therapy. The data indicated that higher survival rates were closely related to lower age and APACHE II scores among the patients. In addition, compared to patients who deceased, those who survived had a higher total calorie intake. Most patients could tolerate bolus feeding and polymeric formulas. Furthermore, patients who underwent nutritional therapy with nutritional goals greater than 80% achieved a better outcome and lower mortality than other patients. Early nutritional intervention could benefit patients undergoing ECMO, and those who reached the delivery goal of 80% had significantly better outcomes than other patients. Enteral feeding can begin early and was well tolerated by patients receiving ECMO therapy. Following individual nutrition goals is critical for better outcomes, and this analysis might be useful in establishing individualized nutrition goals for oriental population when caring for critically ill patients.

Outcomes following routine antithrombin III replacement during neonatal extracorporeal membrane oxygenation

BackgroundWe sought to examine the effect of routine antithrombin III (AT3) infusion on hemorrhagic and thrombotic complications, blood product utilization, and circuit lifespan in neonatal extracorporeal membrane oxygenation (ECMO). MethodsWe performed a retrospective cohort study of 162 infants placed on ECMO for hypoxic respiratory failure. Infants requiring ECMO for primary cardiac support were excluded. Demographic data, time on ECMO, blood product usage, coagulation profile, and complications were compared between 90 control patients and 72 patients treated with AT3. ResultsInfants receiving AT3 during ECMO had less thrombotic and similar bleeding complications as compared to infants receiving standard anticoagulation therapy. Total blood product infusion during ECMO was decreased (54.7±20.1 vs. 67.4±34.9mL/kg per day, p=0.001) in infants receiving AT3 during ECMO. Tighter control of activated clotting time and higher serum heparin anti-Xa levels were observed in the AT3 cohort during the first days of ECMO support. 1st ECMO circuit lifespan did not differ between groups. ConclusionsRoutine administration of AT3 in neonates receiving ECMO therapy was associated with tighter control of anticoagulation and a reduction in thrombotic events without increasing unwanted bleeding. However, circuit lifespan was unaffected. Level of evidenceLevel III.