VA Extracorporeal Membrane Oxygenation Research Articles

Extracorporeal membrane oxygenation (ECMO) assisted huge mediastinal tumor resection combined with superior vena cava replacement: A case report and literature review.

As to huge solid mediastinal tumor which direct compression or invasion of the superior/inferior vena cava (SVC/IVC), surgical resection remains the main lifesaving treatment. However, it would present formidable anesthetic challenges due to the extremely high risks of cardiorespiratory compromise, drastic hemodynamic fluctuations and death at all perioperative stages. Here, we report a case of huge anterior mediastinal tumor resection combined with SVC replacement under the assistance of venoarterial extracorporeal membrane oxygenation (VA ECMO), and stable hemodynamics were maintained as well as high internal jugular vein pressure being avoided during the operation procedure. He was weaned off ECMO successfully just after surgery and eventually discharged. No signs of postoperatively neurological complications occurred. Therefore, the use of ECMO assistance in huge mediastinal tumor resection combined with SVC replacement is feasible and safe, which may provide the possibility of surgical treatment for such patients and improve outcomes.

Cardiac Extracorporeal Membrane Oxygenation in Community Cardiac Surgery Program: Are the Results Comparable?

Extracorporeal membrane oxygenation (ECMO) outcomes in small centers are commonly considered less favorable than in large-volume centers. New ECMO protocols and procedures were established in our regional community hospital system as part of a cardiogenic shock initiative. This retrospective study aims to evaluate the outcomes of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) in a community hospital system with cardiac surgery capability and assess whether protocol optimization and cannulation standards result in comparable outcomes to larger centers whether the outcomes of this new ECMO program at the community hospital setting were comparable to the United States averages. Our regional system comprises five hospitals with 1500 beds covering southwestern New Jersey, with only one of these hospitals having cardiac surgery and ECMO capability. In May 2021, the new ECMO program was initiated. Patients were screened by a multidisciplinary call, cannulated by our ECMO team, and subsequently treated by the designated team. We reviewed our cardiac ECMO outcomes over two years, from May 2021 to April 2023, in patients who required ECMO due to cardiogenic shock or as a part of extracorporeal cardiopulmonary resuscitation (ECPR). A total of 60 patients underwent cardiac ECMO, and all were VA ECMO, including 18 (30%) patients who required ECPR for cardiac arrest. The overall survival rate for our cardiac ECMO program turned out to be 48% (29/60), with 50% (22/42) in VA ECMO excluding ECPR and 39% (7/18) in the ECPR group. The hospital survival rate for the VA ECMO and ECPR groups was 36% (15/42) and 28% (5/18), respectively. The ELSO-reported national average for hospital survival is 48% for VA ECMO and 30% for ECPR. Considering these benchmarks, the hospital survival rate of our program did not significantly lag behind the national average. With protocol, cannulation standards, and ECMO management optimized, the VA ECMO results of a community hospital system with cardiac surgery capability were not inferior to those of larger centers.

What Are the Real Issues in Providing Extracorporeal Membrane Oxygenation (ECMO) Support: A Survey.

By using a novel survey our study aimed to assess the challenges ECMO and Critical Care (CC) teams face when initiating and managing patient's ECMO support. A qualitative survey-based observational study was performed of members of 2 Critical Care Medicine organizations involved in decision-making around the practice of Extracorporeal Membrane Oxygenation (ECMO). The range of exploratory questions covered ethical principles of informed consent, autonomy and goals of care discussions, beneficence, non-maleficence (offering life-sustaining treatments in end-of-life care), and justice (insurance-related limitations of treatment). Questions also covered pragmatic practice and quality improvement areas, such as exploring whether palliative care or ethics teams were involved in such decision-making. 305 members received the survey links, and a total of 61 completed surveys were received, for an overall response rate of 20% among all eligible members. Only 70% of the participants who manage ECMO patients are involved in the ECMO initiation decision process. The majority do not involve Ethics or Palliative care at the initial ECMO initiation decision step. Of the ethical and moral dilemmas reported, the majority revolved around 1. Prognostication of patients receiving VV and VA ECMO support, 2. Lack of knowledge of patient's wishes and goals, 3. Disconnect between expectations of families and outcomes and 4. Staff moral distress around when to stop ECMO in case of futility. Our survey highlights areas of distress and dilemma which have been stressed before in the initiation, management, and outcomes of ECMO patients, however with the increasing use of this modality of cardiopulmonary mechanical support being offered, the survey results can offer a guidance using sound ethical principles.

Feasibility and Outcomes of a Cardiovascular Medicine Inclusive Extracorporeal Membrane Oxygenation (ECMO) Service

BackgroundThere has been a significant increase in the utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in recent years. Cardiothoracic surgery teams have historically led VA-ECMO care teams, with little data available on alternative care models. MethodsWe performed a retrospective review of a cardiovascular medicine inclusive VA-ECMO service, analyzing patients treated with peripheral VA-ECMO at a large quaternary care center from 2018 to 2022. The primary outcome was death while on VA-ECMO or within 24 hours of decannulation. Univariate and multivariate analyses were used to identify predictors of the primary outcome. ResultsTwo hundred forty-four patients were included in the analysis (median age 61 years; 28.7% female), of whom 91.8% were cannulated by interventional cardiologists, and 84.4% were managed by a cardiology service comprised of interventional cardiologists, cardiac intensivists or advanced heart failure cardiologists. Indications for VA-ECMO included acute myocardial infarction (34.8%), decompensated heart failure (30.3%), and refractory cardiac arrest (10.2%). VA-ECMO was utilized during cardiopulmonary resuscitation in 26.6% of cases, 48% of which were peri-procedural arrest. Of the patients, 46% survived to decannulation, the majority of whom were decannulated percutaneously in the cardiac catheterization laboratory. There was no difference in survival following cannulation by a cardiac surgeon vs interventional cardiologist (50% vs 45%; P = .90). Complications included arterial injury (3.7%), compartment syndrome (4.1%), cannulation site infection (1.2%), stroke (14.8%), acute kidney injury (52.5%), access site bleeding (16%) and need for blood transfusion (83.2%). Elevated baseline lactate (odds ratio [OR], 1.13 per unit increase) and sequential organ failure assessment score (OR, 1.27 per unit increase) were independently associated with the primary outcome. Conversely, an elevated baseline survival after VA ECMO score (OR, 0.92 per unit increase) and 8-hour serum lactate clearance (OR, 0.98 per % increase) were independently associated with survival. ConclusionsThe use of a cardiovascular medicine inclusive ECMO service is feasible and may be practical in select centers as indications for VA-ECMO expand.

Impact of thrombocytopenia on short-term outcomes in patients undergoing mobile extracorporeal membrane oxygenation support.

The prolonged use of extracorporeal membrane oxygenation (ECMO) support is associated with increased consumption of platelets and hemolysis. The prognostic impact of thrombocytopenia prior to and during ECMO support on patient's short-, mid- and long-term outcomes has been critically evaluated and discussed over the last years. However, only few data have been published on thrombocytopenia caused by mobile ECMO support. The aim of this study was to evaluate the impact of thrombocytopenia on short-term outcomes and predictors of in-hospital mortality in patients supported by mobile ECMO for transportation and subsequent weaning in a tertiary centre. This retrospective single-centre study analyzed a total of 117 patients requiring mobile veno-arterial (va) ECMO support and subsequent transportation from referral hospitals to our department from January 2015 until December 2021. A total of 15 patients had to be excluded from the analysis for missing data regarding baseline platelet count. Patients were divided into two groups: thrombocytopenia group (<130 × 109/L, n = 44) and non-thrombocytopenia group (≥130 × 109/L, n = 58). The primary outcome was in-hospital mortality. Secondary outcomes were successful ECMO-weaning, and the incidence of associated complications (bleeding, acute hepatic failure, acute renal failure, dialysis, and septic shock). The dialysis rate before ECMO initiation was significantly higher (p = .041) in the thrombocytopenia group compared to the non-thrombocytopenia group. The rates of bleeding complications (p = .032) and limb ischemia (p = .003) were significantly higher in patients with low platelet count. Moreover, complication rates of acute hepatic failure (p < .001), acute renal failure (p < .001) and dialysis (p = .033) were significantly higher in the thrombocytopenia group. Also, in-hospital mortality was significantly higher (p = .002) in patients with low platelet count before initiation of ECMO support. Based on the results of the present study, patients with thrombocytopenia prior to mobile vaECMO support may be at significantly higher risk for associated complications and short-term mortality.

ECMO in adult patients with severe trauma: a systematic review and meta-analysis

BackgroundSevere trauma can result in cardiorespiratory failure, and when conventional treatment is ineffective, extracorporeal membrane oxygenation (ECMO) can serve as an adjunctive therapy. However, the indications for ECMO in trauma cases are uncertain and clinical outcomes are variable. This study sought to describe the prognosis of adult trauma patients requiring ECMO, aiming to inform clinical decision-making and future research.MethodsA comprehensive search was conducted on Pubmed, Embase, Cochrane, and Scopus databases until March 13, 2023, encompassing relevant studies involving over 5 trauma patients (aged ≥ 16 years) requiring ECMO support. The primary outcome measure was survival until discharge, with secondary measures including length of stay in the ICU and hospital, ECMO duration, and complications during ECMO. Random-effects meta-analyses were conducted to analyze these outcomes. The study quality was assessed using the Joanna Briggs Institute checklist, while the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.ResultsThe meta-analysis comprised 36 observational studies encompassing 1822 patients. The pooled survival rate was 65.9% (95% CI 61.3–70.5%). Specifically, studies focusing on traumatic brain injury (TBI) (16 studies, 383 patients) reported a survival rate of 66.1% (95% CI 55.4–76.2%), while studies non-TBI (15 studies, 262 patients) reported a survival rate of 68.1% (95% CI 56.9–78.5%). No significant difference was observed between these two survival comparisons (p = 0.623). Notably, studies utilizing venoarterial extracorporeal membrane oxygenation (VA ECMO) (15 studies, 39.0%, 95% CI 23.3–55.6%) demonstrated significantly lower survival rates than those using venovenous extracorporeal membrane oxygenation (VV ECMO) (23 studies, 72.3%, 95% CI 63.2–80.7%, p < 0.001). The graded assessment of evidence provided a high degree of certainty regarding the pooled survival.ConclusionsECMO is now considered beneficial for severely traumatized patients, improving prognosis and serving as a valuable tool in managing trauma-related severe cardiorespiratory failure, haemorrhagic shock, and cardiac arrest.

PEDS8: Continuous Renal Replacement Therapy In Pediatric Extracorporeal Membrane Oxygenation: Life Span And Cost Of Filter Changes With Bivalirudin.

Background: The utilization of additional extracorporeal support devices utilized in conjunction with Extracorporeal Membrane Oxygenation (ECMO) has increased with more complex and sicker patients. The use of Continuous Renal Replacement Therapy (CRRT) has increased five-fold over the past 3 years at our institution after implementing Pediatric Nephrology Stewardship (PNS) on ECMO. Bivalirudin is the primary anticoagulant used for ECMO and CRRT at our institution which has resulted in increased ECMO circuit and CRRT filter life. The Prismalflex HF1000 and HF20 filter has a prime volume of 165 ml and 58 ml, respectively, with prime components which include packed red blood cells (pRBC) and albumin. Manufacturer recommendations for changing the CRRT filter is defined as every 72 hours (3 days). We sought to extend the filter length by augmenting the indication for the CRRT filter change from manufacturer recommendation. Filter changes were determined based on monitoring the filter pressure, transmembrane pressure, and pressure drop to diagnosis clotting/clogging. CRRT filter was also changed out if disconnection from ECMO was warranted due to ECMO circuit change or travel. Methods: Retrospective ECMO and CRRT data was collected for pediatric veno-arterial or veno-venous ECMO patients at a tertiary care hospital from January 2021-December 2022. Results: CRRT was performed on 16% (7/44) of ECMO patients. 100% of the patients received bivalirudin as the anticoagulant. 71% (5/7) were supported by VA ECMO. 43% (3/7) were neonates. Mean ECMO duration was 14 days (3-133). Of the 7 ECMO patients on CRRT, 80% (265/332) of their time on ECMO included CRRT support. There was a total of 41 CRRT filter changes performed during 265 days on CRRT with an average filter change occurring every 6.46 days (table 1). Utilizing cost of CRRT filter set ($358.00) and approximate cost of 1 unit of pRBC ($200.00), there was a savings of $26,226 to the hospital ($22,878 vs. $49,104). Discussion: Utilization of an alternative indication versus manufacturer recommendation for CRRT filter change out prolonged filter length from 3 days to 6.46 days (110% decrease in filter change out). By reducing the number of CRRT filters and blood usage for a filter change, cost to the hospital and patients was significantly reduced even without considering labor for CRRT set up and blood preparation. With careful attention to detail and collaboration with Nephrology and Hematology services, it appears CRRT filter length can be safely extended past manufacturers recommendations.

P3: ECMO and Calcium Channel Blocker Overdose: A Systematic Review

Introduction: The increasing indications and prevalence of extracorporeal membrane oxygenation (ECMO) are evident by the exponential increase in ECMO in the last decade. In recent literature, ECMO use has sustained patients who have intentionally or unintentionally overdosed on cardiac medications. Specifically, calcium channel blocker overdose (CCBOD) can lead to significant cardiopulmonary dysfunction and has increased in recent years. Calcium channel blockers (CCB) block L-type voltage gated calcium channels throughout the body, and overdose results in cardiac depression, vasoplegia, and hyperglycemia. Expert consensus and poison control centers both recommend treatment with calcium, high dose insulin, inotropes, and vasopressors. Our systematic review evaluated when to initiate ECMO in the CCBOD population and the mortality rate with ECMO use. Methods: An electronic literature review was conducted to identify all relevant studies for CCB use and ECMO. PRISMA guidelines for systematic review were followed. Rayyan was used as a screening tool for blinding the authors from each other, and abstracts and full texts were reviewed by three independent authors. Inclusion criteria were strictly limited to CCB ingestion without polypharmacy. A data collection tool was devised and data was independently collected by two authors prior to statistical analysis. Data points included demographics, a list of currently recommended medical treatments for CCBOD, ECMO cannulation type, and survival to hospital discharge. Results: After exclusion of duplicates, 314 abstracts were reviewed; of these 25 papers were included from 6 different countries, with the median year of the study publication 2019. From the 25 papers, 26 patients were studied with an average patient age of 32.7 years with 42% male and 58% female. Between male and female there was no significant difference in age, type of CCB taken, or days on ECMO. Average time on ECMO was 4.3 days. Venoarterial and venovenous ECMO use were 92.3% and 7.7%, respectively. Survival to hospital discharge was 84.6%. Prior to ECMO cannulation, patients received up to six medical treatments for CCBOD, with the majority receiving four to five treatments (53.8%). There was no correlation between number of therapies and days on ECMO (r=0.092, P=0.684). Conclusion: Our systematic review demonstrates that ECMO is a newly used and possibly valuable therapy for CCBOD when medical treatment fails. Most patients received aggressive medical therapies and still were unstable enough to require ECMO. Survival to discharge after ECMO for CCBOD is substantially higher than standard VV or VA ECMO uses. While medical management is still the main therapy for CCBOD, our results show that a persistently unstable patient may benefit from prompt evaluation at an ECMO center for treatment.

Comparison of mNGS and conventional culture in non-organ transplant critically ill patients supported by ECMO: a single-center study.

Infection is one of the important causes of death in intensive care unit (ICU) patients. At present, there are few articles focused on the detailed analysis of pathogenic microorganisms detected in different therapy periods of critically ill patients supported by extracorporeal membrane oxygenation (ECMO). From October 2020 to October 2022, ECMO-assisted patients who underwent multiple times of both metagenomic next-generation sequencing (mNGS) test and conventional culture were enrolled continuously in the First Affiliated Hospital of Zhengzhou University. The baseline data, laboratory test results, and pathogenic microorganisms detected by mNGS and traditional culture in different time periods were recorded and analyzed. In the present study, 62 patients were included finally. According to whether the patients survived at discharge, they were divided into the survivor group (n = 24) and the non-survivor group (n = 38). Then, according to the different types of ECMO support, they were divided into the veno-venous ECMO (VV ECMO) group (n = 43) and the veno-arterial ECMO (VA ECMO) group (n = 19). The summit period of specimens of traditional culture and mNGS detection of ECMO patients was 7 days after admission, and the largest number of specimens of surviving patients appeared after ECMO withdrawal. The total number of traditional culture specimens was 1,249, the positive rate was 30.4% (380/1,249), and the positive rate of mNGS was 79.6% (82/103). A total of 28 kinds of pathogenic microorganisms were cultured from conventional culture, and 58 kinds of pathogenic microorganisms were detected by mNGS, including Mycobacterium, Rickettsia, and Chlamydia psittaci. In conventional culture, the most frequent Gram-negative bacteria, Gram-positive bacteria, and fungi were Klebsiella pneumoniae, Corynebacterium striatum, and Candida glabrata, and those with the highest frequency of occurrence in mNGS detection were Acinetobacter baumannii, Enterococcus faecium, and Aspergillus flavus. Throughout the whole treatment process, different kinds of suspicious biological specimens of high-infection-risk ICU patients supported by ECMO should undergo both mNGS detection and traditional culture early and repeatedly.

SuPAR as a risk Prediction Biomarker in Extracorporeal Membrane Oxygenation

suPAR is a promising biomarker of cardiovascular diseases, as it reflects “low-grade inflammation” and is associated with lifestyle factors such as smoking, alcohol, and an inactive lifestyle. suPAR is expressed in various cells involved in the development of atherosclerosis, including macrophages, endothelial cells, and smooth muscle cells, and an accumulation of suPAR in the atheroma has also been found. suPAR plays a role in the coagulation cascade during plasminogen activation and fibrinolysis. This abstract provides description of three case series showing the utility of suPAR as a risk prediction biomarker on VA extracorporeal membrane oxygenation (ECMO). We used SUPAR in 15 patients undergoing cardiac surgery of which three went on VA ECMO. Herein, we describe in detail three such patients and discuss each with good review of the literature.

349: EVALUATING CONCORDANCE BETWEEN LAB HEMOGLOBIN/HEMATOCRIT AND POINT-OF-CARE TESTS IN PEDIATRIC ECMO

Introduction: Accuracy of point-of-care (POC) hemoglobin (Hgb) and hematocrit (Hct) testing in critically ill patients on extracorporeal membrane oxygenation (ECMO) support is unknown. Advantages of POC testing include immediate results and smaller blood volume, however inaccurate results can lead to repeat testing and could contribute to increased blood transfusion. The objectives of this study were to quantify agreement between lab-based and POC tests for Hgb and Hct in critically ill pediatric patients on ECMO. Methods: A single center retrospective study from January 1, 2013 to December 31, 2021. Lab and POC results were recorded if obtained within 5 minutes of each other. A single set of values was recorded per day, using the values closest to 4AM if multiple sets were obtained, and up to 10 days of an individual ECMO course were included. POC measures included in-line hematocrit monitor and bedside blood gas analyzer. Discordance was a priori defined as > 0.5g/dL (Hgb) or > 1.5% (Hct) discrepancy. Exclusion criteria were: > 18 years of age, cannulated at outside hospital, converted to other mechanical circulatory support, ECMO support during OR only, and subsequent ECMO courses during the study. Results: 136 patients were included with an average age of 2 months. 51% were female. 66% VA ECMO and 34% VV ECMO. Diagnoses included sepsis (8.1%), trauma (2.9%), cardiac s/p CPB (29%), cardiac non-CPB (15%), congenital diaphragmatic hernia (CDH) (12%), and non-CDH respiratory (31%). The average ECMO duration included in analyses was 7 days. 279 values compared lab-based to in-line, of which 27% were discordant for Hgb and 24% for Hct. 59 values compared lab-based to blood gas analyzer, of which 32% were discordant for Hgb and 36% for Hct. All discordant results had a lower POC value. Conclusions: Lab-based hemoglobin and hematocrit values compared to both blood gas analyzer and in-line hematocrit monitor were often discordant. In all cases, POC measures were lower, raising concerns that use of POC to guide transfusions could increase transfusion burden. Further study is needed to evaluate factors predictive of discordance and to determine effects of POC hemoglobin/hematocrit measures on transfusion burden in pediatric ECMO patients.

1093: ACUTE KIDNEY INJURY AFTER TRIPLE CANNULATION IN EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a temporary means to provide cardiorespiratory hemodynamic support in critically ill patients. Both patient and circuit-related factors are responsible for changes in modifications of conventional VA and VV ECMO circuits for optimal support. Despite the benefits, ECMO is associated with a multitude of adverse effects including acute kidney injury. AKI aggravates the morbidity and mortality in these populations. Triple cannulation further adds to the complexity of the circuit which can aggravate renal injury. This Systematic review and meta-analysis aimed to determine the mortality and development of AKI after triple ECMO cannulation. Methods: A comprehensive literature search was conducted across the Ovid MEDLINE® database using the terms “Extracorporeal Membrane Oxygenation” or “ECMO” or “veno-arteriovenous” or “Triple Cannulation ECMO” or “veno-veno-arterial” or “veno-arterio-venous” or “veno-pulmonary-arterial” or “veno-arteriovenous ECMO” etc. The inclusion criteria were: age ≥18 years, retrospective analysis of patients who required Triple Cannulation ECMO at some point during their hospital course; the study was conducted in or after 2000; they described patients who developed acute Kidney Injury/required renal replacement therapy after initiation of ECMO. Review Manager 5.4 was used to evaluate the odds ratio (OR) with respective 95% confidence intervals (CI) using a random-effects model. Results: In total 60 studies were included for abstract review. The full-text review was done for 17 articles. 11 articles were selected for meta-analysis. The total number of patients was 328. The average age of the study population was 49.8 years (+/- 7.17). The odds of in-hospital mortality were 1.15 (0.86, 1.53). The Odds ratio for developing Acute kidney injury after versus before triple cannulation ECMO came out to be 21.8 (7.4, 64.18). Conclusions: Triple cannulation strategies in ECMO-supported patients are associated with increased odds of developing acute kidney injury. Moreover, the kidney injury was severe in most of the cases necessitating renal replacement therapy. Factors accounting for this observation could be explained by the clinical severity of the patient population and the increased complexity of the circuit.

POST – CARDIOTOMY EXTRACORPOREAL LIFE SUPPORT IN OCTOGENARIANS: SINGLE CENTER EXPERIENCE

<h3>Background</h3> Recently extracorporeal membrane oxygenation (ECMO) is becoming the first line treatment option for post-cardiotomy cardiac failure. The age limit for the use of support is yet to be defined. The aim of our study was to evaluate outcomes of octogenarians supported with ECMO following cardiac surgery in our institution. <h3>Methods</h3> Retrospective review of consecutive elderly patients (age ≥ 70 years) supported with ECMO following surgery during 13 years period in a tertiary care center. Patient's demographic variables, comorbidities, pre-existing medical conditions, perioperative data and outcomes were collected from patient medical records. Data of octogenarian patients were compared with the septuagenarian patient group. The primary endpoint of the study was in-hospital mortality. <h3>Results</h3> Sixty patients in our study were ≥ 70 years old and were included in the final analysis as "elderly group". Eleven patients (18,3 %) in the elderly group were octogenarians (aged 80 years or above) and forty nine (81,7 %) were septuagenarians (aged 70 – 79 years). There was no difference except age in all demographic and preoperative variables between groups. In the majority of cases VA ECMO was initiated in the intensive care unit after surgery (n=37, 61,7 %) and 23 cases (38,3 %) were initiated in the operating room. Central cannulation was more common in septuagenarian group than octogenarian group (83,7 % vs 54,5 %, p = 0,034 respectively). The median duration of ECMO support was 148 (71 – 288) hours and was longer in septuagenarian group (178 (92 – 300) hours vs 70 (46 – 93) hours in octogenarian group, p = 0,007). Pre ECMO Save, SOFA, SAPS – II and inotropic scores were significantly higher in septuagenarians than octogenarians. Pre ECMO data are shown in Table 1. Thirty one patient (52 %) were successfully weaned form ECMO and 13 (22 %) patients survived to hospital discharge. There was no statistically significant difference in hospital mortality between groups (7 (64%) octogenarian group vs. 40 (82%) septuagenarian group, p = 0,19). <h3>Conclusion</h3> ECMO could be successfully used in selected octogenarian patients undergoing cardiac surgery to support failing heart function with acceptable survival rate. Further studies needed to evaluate long term outcomes.

Long-Term Survival and Quality of Life in Non-Surgical Adult Patients Supported with Veno-Arterial Extracorporeal Oxygenation.

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for hemodynamic support is on the rise. Not much is known about the impact of extracorporeal membrane oxygenation (ECMO) and its complications on long-term survival and quality of life. In this single-center, cross-sectional study, we evaluated the survival and quality of life in patients treated with VA ECMO between May 2009 and July 2019. Follow-up was conducted between November 2019 and January 2020. Overall, 118 patients were evaluated in this study. Of the 37 patients who were alive at hospital discharge, 32 answered the EuroQol-5 dimensional-5-level questionnaire (EQ-5D-5L). For patients discharged alive from the hospital, mean survival was 8.1 years, 8.4 years for cardiogenic shock, and 5.0 years for patients with refractory cardiac arrest. EQ-5D-5L index value of ECMO survivors was not significantly different from the general age-matched population. Neurologic complications and major bleeding during index hospitalization limit long-term quality of life. Patients treated with VA ECMO have high in-hospital mortality, with extracorporeal membrane oxygenation cardio-pulmonary resuscitation patients being at higher risk of early death. However, once discharged from the hospital, most patients remain alive with a reasonable quality of life.

A phased intervention bundle to decrease the mortality of patients with extracorporeal membrane oxygenation in intensive care unit.

To evaluate whether a phased multidimensional intervention bundle would decrease the mortality of patients with extracorporeal membrane oxygenation (ECMO) and the complication incidence. We conducted a prospective observational study in comparison with a retrospective control group in six intensive care units (ICUs) in China. Patients older than 18 years supported with ECMO between March 2018 to March 2022 were included in the study. A phased intervention bundle to improve the outcome of patients with ECMO was developed and implemented. Multivariable logistic regression modeling was used to compare the mortality of patients with ECMO and the complication incidence before, during, and up to 18 months after implementation of the intervention bundle. The cohort included 297 patients in 6 ICUs, mostly VA ECMO (68.7%) with a median (25th-75th percentile) duration in ECMO of 9.0 (4.0-15.0) days. The mean (SD) APECHII score was 24.1 (7.5). Overall, the mortality of ECMO decreased from 57.1% at baseline to 21.8% at 13-18 months after implementation of the study intervention (P < 0.001). In multivariable analysis, even after excluding the confounding factors, such as age, APECHII score, pre-ECMO lactate, and incidence of CRRT during ECMO, the intervention bundle still can decrease the mortality independently, which also remained true in the statistical analysis of V-V and V-A ECMO separately. Among all the ECMO-related complications, the incidence of bloodstream infection and bleeding decreased significantly at 13-18 months after implementation compared with the baseline. The CUSUM analysis revealed a typical learning curve with a point of inflection during the implementation of the bundle. A phased multidimensional intervention bundle resulted in a large and sustained reduction in the mortality of ECMO that was maintained throughout the 18-month study period. [ClinicalTrials.gov], identifier [NCT05024786].

Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome in children with leukemia/lymphoma: A retrospective case series.

ObjectiveThe cancer patients with severe acute respiratory distress syndrome (ARDS) benefit from extracorporeal membrane oxygenation (ECMO) remains unanswered. We analyzed clinical characteristics and outcomes of pediatric patients with leukemia/lymphoma who developed ARDS and treated with ECMO.MethodsPediatric leukemia or lymphoma patients with ARDS who underwent ECMO between August 2017 and December 2021 were retrospectively analyzed in a tertiary pediatric intensive care unit (PICU).ResultsSeven patients with median age 53 (IQR 42–117) months and 4 males were included. Six cases of leukemia [5 of acute lymphocytic leukemia (ALL) and 1 of acute myelogenous leukemia (AML, M5)] and 1 of non-Hodgkin lymphoma with severe ARDS received ECMO on chemotherapy period. The etiology of ARDS is community or chemotherapy-associated bacterial or/and fungal or viral infection. All the patients received chemotherapy in the 2 weeks prior to ECMO and five were neutropenic at initial ECMO. Six cases underwent veno-arterial ECMO (VA ECMO) and 1 for veno-venous ECMO (VV-ECMO). The median duration of ECMO support was 122 (IQR 56–166) hours. Overall, 42.9% (three of seven) survived to hospital discharge and 6 months survival rate was 28.6% (two of seven). Bleeding was the main ECMO-associated complication occurring in 7 patients, followed by nosocomial infection in 4 cases. All the patients required vasopressor support, and 6 received continuous renal replacement therapy (CRRT).ConclusionOur experiences suggest that rescue ECMO provides a selective treatment strategy in childhood hematologic malignancies with severe ARDS.

Arterial and venous vascular complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation.

IntroductionThe aim of this study was to investigate the prevalence of arterial and venous complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) and its risk factors at the time of cannulation and during extracorporeal membrane oxygenation (ECMO) support and to assess vascular complications in association with decannulation.Material and methodsBetween January 2010 to January 2020, out of 1,030 eligible patients requiring VA-ECMO, 427 with analyzable vascular screening were included. Duplex sonography and/or CT scan after decannulation were used to screen for thrombosis and pulmonary embolism as well as arterial complications. Near-infrared spectrometry (NIRS) was established at the time of cannulation and was continuously monitored during the ECMO therapy.ResultsThe prevalence of venous complications was 27%. Thrombosis and pulmonary embolism were observed in 21 and 7% of patients, respectively. Pulmonary embolism was more frequently diagnosed in patients with thrombosis (22 vs. 3%, p < 0.001). In multivariate analysis, cannulation in the jugular vein was determined as a risk factor for venous thrombosis in contrast to the extent of anticoagulation. The prevalence of arterial complications was 37%, mainly ischemia followed by bleeding, dissection, and compartment syndrome. Vascular surgery was necessary for 19% of the patients, of whome 1% required major amputations. A distal perfusion cannula (DPC) was implanted at cannulation in 24% of patients and secondarily in 16% of patients after cannulation as required during ECMO support. In the multivariate analysis, risk factors for leg ischemia at the time of cannulation were elevated D-dimers, lower NIRS on the cannulated leg, and lack of a DPC. The best discriminative parameter was the difference in NIRS between the non-cannulated leg and the cannulated leg. In contrast, during ECMO support, only the lack of a DPC was associated with leg ischemia. A similar rate of complications associated with decannulation, mainly arterial thrombosis, ischemia, or bleeding, was seen with percutaneous and surgical approaches (18 vs. 17%, p = 0.295).ConclusionPatients requiring VA ECMO should be routinely screened for vascular complications. The decision to insert a DPC should be evaluated individually. However, NIRS monitoring of the cannulated leg and the non-cannulated leg is essential to identify the legs at risk for critical ischemia. As complications associated with decannulation were equally distributed between percutaneous and surgical approaches, the applied method may be chosen according to local experience.

Use Of Prone Positioning In Patients With Left Ventricular Assist Devices

BackgroundUse of prone position for treatment of acute respiratory distress syndrome (ARDS) has been effective for patients with COVID-191,2. While case reports exist on proning patients on extracorporeal membrane oxygenation (ECMO) there are limited reports of the safety and efficacy in patients with durable left ventricular assist devices (LVAD). 3,4.Case StudyPatient is a 76 year old Hispanic male with a past history for ischemic cardiomyopathy requiring HeartMate III (Abbott, IL) LVAD who presented to the emergency dept in January 2021 with two day history of dyspnea on exertion, chills and insomnia. He reports no known contact with COVID individuals. In the ED, noted severe hypoxia on arterial blood gas (ABG) pH 7.343, pO2 51.5. O2 saturation was 86% and chest x-ray revealed bilateral infiltrates suggestive of COVID 19 pneumonia. He was placed on a nonrebreather (NRB) mask and empiric antibiotics started. A nasopharyngeal swab was PCR positive for COVID19 and he was admitted for management. A repeat ABG on NRB had an increase of pO2 172. He was started on remdisivir and convalescent plasma. As part of management, was proned for 12 hours daily. The LVAD driveline was supported with pillows to avoid pressure and trauma. The LVAD controller was placed on the patient side for emergent access. Peripheral oxygenation saturation remained above 93% and his respiratory status continued to improve. He was cleared for discharge on day 6. No adverse events were noted on LVAD interrogation and he had no ill effects to the driveline.DiscussionProne positioning has been integral for patients with COVID 19 to decrease intubation with severe ARDS. Patients with a LVAD already have significant cardiac disease and thus important to avoid further decompensation with intubation, VA ECMO, and cardiac demise. Driveline infections can lead to high morbidity and mortality. Patients with COVID 19 are at a high risk for poor skin care and pressure injuries. Supporting the controller and driveline allowed for decrease in pressure injury and trauma at the driveline site. This allowed our ability to prone our patient and properly oxygenate which was tolerated.

Acute Circulatory Collapse and Advanced Therapies in Patients with COVID-19 Infection

IntroductionIn the current COVID era, ICU-level patients typically develop respiratory failure and acute respiratory distress syndrome (ARDS). While less frequent, the management of concomitant acute circulatory collapse has its own challenges and nuances. Early identification of acute circulatory collapse requires appropriate imaging and precise diagnosis of cardiogenic shock. Escalation to mechanical circulatory support such as intra-aortic balloon pump (IABP), Impella and extracorporeal membrane oxygenation (ECMO) have been useful in patients with circulatory collapse from COVID.Case Report42-year-old obese female presented with COVID bronchopneumonia 6 days after a positive outpatient COVID swab. In the ED, she was given 3L of fluid bolus for severe sepsis and developed flash pulmonary edema requiring emergent intubation. She also developed hemodynamic collapse, requiring inotrope and pressor support and a TTE demonstrated severely depressed left ventricular ejection fraction (LVEF) of < 10%. Peripheral VA ECMO was placed, and the patient was transferred to our tertiary care center for further management of fulminant COVID-myocarditis with cardiogenic shock. Patient did not have any significant obstructive coronary artery disease on catheterization. An Impella CP was placed for hemodynamic support. She was started on a high-dose steroid, one dose of tocilizumab for severe LV dysfunction, two rounds of IVIG, and CRRT for volume removal. On Day 11 she had improved hemodynamics and there were signs of LV recovery, after which she was decannulated. Impella support was continued until there was complete recovery. Patient was extubated on Day 17 and continues to recover at a long-term acute care facility.SummaryAcute circulatory collapse in COVID-19 infection is a serious complication with high morbidity and mortality. Early recognition of depressed LV function and cardiogenic shock by echocardiography, cardiac MRI, and/or Swan-Ganz catheter assessment is critical. ICU management of hemodynamic function, fluid status, and blood pressure management remains standardized, but prompt medical management with inotropes and mechanical support maximizes patient outcomes. IABP, Impella, and ECMO all play a key role in managing acute circulatory collapse.

Clinical Characteristics and Outcomes of Children With Extracorporeal Membrane Oxygenation in a Developing Country: An 11-Year Single-Center Experience.

Introduction: Extracorporeal Membrane Oxygenation (ECMO) is a lifesaving procedure for patients with refractory cardiac or respiratory failure. The indications for ECMO are growing, and it is increasingly being used to support cardiopulmonary failure in children. However, the risks and benefits of ECMO should be weighed before deploying it on the patients. The objectives of this study were to identify the mortality risk factors and to determine the ECMO outcomes.Methods: The retrospective chart reviews were done for all patients aged 1 day−20 years old receiving ECMO between January 2010 and December 2020.Results: Seventy patients were enrolled in the study. The median age was 31.3 months. The incidence of VA and VV ECMO was 85.7 and 14.3%, respectively. The most common indication for ECMO was the failure to wean off cardiopulmonary bypass after cardiac surgery. Pre-existing acute kidney injury (OR 4.23; 95% CI 1.34–13.32, p = 0.014) and delayed enteral feeding (OR 3.85, 95% CI 1.23–12.02, p = 0.020), and coagulopathy (OD 12.64; 95% CI 1.13–141.13, p = 0.039) were associated with the higher rate of mortality. The rates of ECMO survival and survival to discharge were 70 and 50%, respectively.Conclusion: ECMO is the lifesaving tool for critically ill pediatric patients. Pre-existing acute kidney injury, delayed enteral feeding, and coagulopathy were the potential risk factors associated with poor outcomes in children receiving ECMO. However, ECMO setup can be done successfully in a developing country.