Venoarterial Extracorporeal Membrane Oxygenation Patients Research Articles

Mortality prediction in pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation: A comparison of scoring systems.

BackgroundPediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO) patients have high mortality and morbidity. There are currently three scoring systems available to predict mortality: the Pediatric Extracorporeal Membrane Oxygenation Prediction (PEP) model, Precannulation Pediatric Survival After VA-ECMO (Pedi-SAVE) score, and Postcannulation Pedi-SAVE score. These methods provide risk stratification scores for pediatric patients requiring ECMO for cardiac support. However, comparative validation of these scoring systems remains scarce. We aim to assess the ability of these models to predict outcomes in a cohort of pediatric patients undergoing VA-ECMO after cardiac surgery, and identify predictors of in-hospital mortality.MethodsA retrospective analysis of 101 children admitted to Fuwai Hospital who received VA-ECMO from January 1, 2010 to December 31, 2020 was performed. Patients were divided into two groups, survivors (n = 49) and non-survivors (n = 52) according to in-hospital mortality. PEP model and Pedi-SAVE scores were calculated. The primary outcomes were the risk factors of in-hospital mortality, and the ability of the PEP model, Precannulation Pedi-SAVE and Postcannulation Pedi-SAVE scores to predict in-hospital mortality.ResultsPostcannulation Pedi-SAVE score accessing the entire ECMO process had the greatest area under receiver operator curve (AUROC), 0.816 [95% confidence interval (CI): 0.733–0.899]. Pre-ECMO PEP model could predict in-hospital mortality [AUROC = 0.691 (95% CI: 0.565–0.817)], and Precannulation Pedi-SAVE score had the poorest prediction [AUROC = 0.582(95% CI: 0.471–0.694)]. Lactate value at ECMO implantation [OR = 1.199 (1.064–1.351), P = 0.003] and infectious complications [OR = 5.169 (1.652–16.172), P = 0.005] were independent risk factors for in-hospital mortality.ConclusionPediatric cardiac ECMO scoring systems, including multiple risk factors before and during ECMO, were found to be useful in this cohort. Both the pre-ECMO PEP model and the Postcannulation Pedi-SAVE score were found to have high predictive value for in-hospital mortality in pediatric postcardiotomy VA-ECMO.

Sixteen-Year National Trends in Use and Outcomes of VA-ECMO in Cardiogenic Shock

There is a lack of data on contemporary trends in the use and outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) for cardiogenic shock (CS) at a national level. Patients with CS admitted during January 1st, 2002-December 31, 2018, were identified from the United States National Inpatient Sample. Among all patients admitted with CS, those who received VA-ECMO were identified. We report the trends in use and outcomes in terms of mortality, exit strategies and complications among all patients who received VA ECMO for CS. Among a total of approximately 1.6 million patients admitted with CS during the period from January 1st, 2002 to December 31, 2018; 25, 621(1.5 %) received VA-ECMO. There has been a 23-fold increase in the use of VA-ECMO over the study period, from 0.1 % in 2002 to 3 % in 2018, with a simultaneous decreasing trend of in hospital mortality from 77 % in 2002 to 50 % in 2018. Only approximately 15 % of VA-ECMO patients are discharged home with most survivors discharged to a skilled nursing facility or short-term rehabilitation. Moreover, only a minor proportion of patients on VA ECMO are bridged to heart replacement therapy with durable LVAD (6 %) or cardiac transplantation (2.5 %). In conclusion, the use of VA-ECMO in CS has increased 23-fold from January 2002 to December 2018 with a concomitant decrease in mortality from 77 % in 2002 to 50 % in 2018, only a minority of patients on VA-ECMO for CS are bridged to durable LVAD or cardiac transplantation.

Outcomes of Transferred Adult Venovenous and Venoarterial Extracorporeal Membrane Oxygenation Patients: A Single Center Experience.

ObjectivesExtracorporeal membrane oxygenation (ECMO) patients with or without transport both have high hospital mortality rate and there are few data on adult VA-ECMO transport patients. Hence, this study was designed to analyze factors that affect the outcomes of patients with ECMO transport.MethodsThis study retrospectively enrolled 126 ECMO patients transferred from regional hospital to the First Affiliated Hospital of Zhengzhou University by our ECMO team during June 2012 to Sept 2020. Data were calculated and analyzed.ResultsThe median distance of transportation was 141 (76–228) km, the median transport time consuming was 3 (1.3–4) h, the percentage of complications during transport was 40.5% (except for bleeding on cannula site, and no one death during transport), and the survival rate in hospital was 38.9%. Compared with survivors, the non-survivors were older and showed higher SOFA score, longer time with ECMO assisted, longer time in ICU and in hospital. However, after divided into VA-ECMO and VV-ECMO groups, the older age showed no significant difference between survivors and non-survivors groups of VA-ECMO patients. Moreover, the Cox regression survival analysis showed that higher SOFA score and lactate level indicated higher ICU mortality of VA-ECMO patients while higher SOFA score, higher lactate level, older age and lower MAP after transportation (<70mmHg) indicated higher ICU mortality of VV-ECMO patients. However, there was no significant difference of comorbidities and complications in survivors and non-survivors groups of ECMO patients.ConclusionsThe transportation for ECMO patients can be feasible performed although life-threatening complications might occur. The SOFA score and the lactate level could be used to evaluate the risk of ICU mortality of transportation ECMO patients. Besides, lower MAP after transportation (<70mmHg) had potential predictive value for short-term outcome of VV-ECMO patients.

The effect of tracheostomy on extracorporeal membrane oxygenation outcomes.

The optimal timing for pursuing tracheostomy in patients with prolonged mechanical ventilation with either veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is a discussion of risk versus benefit. Depending on the etiology, cardiothoracic surgical patients carry some of the highest risk for respiratory failure postprocedure.Given that patients with end-stage cardiopulmonary status may be fraught with substantial comorbidities, it is critically important to manage the risk-benefit profile of performing a tracheostomy procedure on a patient requiring ECMO support.These cohorts have risk factors that may depend on each patient's inflammatory state, lung de-recruitment peri-procedure and postprocedure and bleeding requiring transfusions to name a few.We provide a descriptive analysis of ECMO patients on both VA and VV configurations who survived to hospital discharge receiving tracheostomy either during or after their ECMO course. A retrospective single-institutional study collected all consecutive patients age 18 and above who received any form of ECMO between 2016 and 2020. Five hundred forty-fivepatients were screened based on having received ECMO. Patients with mixed EMCO modality were excluded due to heterogeneity of disease process. A total of 521 patients received either VV or VA ECMO. A total of 54 patients received tracheostomy and had sufficiently clean data for analysis. Tracheostomy patients were compared based on survival to discharge, tracheostomy surgical complications, ECMO duration, ECMO configuration, inotrope and vasopressor use, transfusion rates, total ventilator days, total days on intravenoussedation, and history of cardiotomy or heart transplant were assessed. Baseline characteristics of race, age, gender, and body mass index (BMI) were also collected. A total of 54 patients received tracheostomy. Twenty-nineof those patients received tracheostomy during the course of their ECMO, of whom 13 were on VV ECMO, 16 on VA ECMO. Another 25 patients underwent tracheostomy after successful ECMO explant; 8 of those were VV ECMO with the remaining 17 were on VA ECMO before explantation, with mean delay to tracheostomy, 10 and 19 days after explant between both modalities, respectively. A statistically significantly greater proportion of VV ECMO patients received a tracheostomy at any point versusVA ECMO patients (25.93% vs. 8.35%, p ≤ .0001). No statistically significant difference was noted in timing of tracheostomy when stratified by EMCO modality (VA 51.51% after explant vs. VV 38.10% after explant, p = .33).There was a greater frequency of minor tracheostomy complications in patients who were on ECMO at the time of their tracheostomy (p = .014) than in those who received their tracheostomy after being explanted. However, these minor complications did not contribute to a change in survival to hospital discharge (p = .58). Similarly, the small number of major complications (n = 13) did not impair survival to hospital discharge (p = .84).Finally, mean duration of ECMO was longer in those who received tracheostomy during ECMO versus after ECMO. (488.45 vs. 259.72 h, p < .01). Tracheostomy is known to increase patient mobility, clinical participation, and overall decrease in sedation use. Pursuing tracheostomy during ECMO is feasible, does not result in major bleeding, and is associated with only minor complications that overall do not decrease survival. While there is an increased duration of ECMO support in the tracheostomy cohort, this may be due to existing patient conditions, and may not be causal. Research is needed to further determine the external patient factors and specific timing to optimize both VV and VA ECMO courses. We hope that our analysis will pave the initial pathway for an evidence-based guideline on optimal timing of tracheostomy in ECMO patients, whether initiated during or after ECMO and taking into consideration ECMO configuration, its expected duration, and patient comorbidities.

Beneficial effects of levosimendan to wean patients from VA-ECMO: a systematic review and meta-analysis.

Patients with refractory cardiogenic shock can benefit from veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The use of levosimendan in VA-ECMO patients may facilitate weaning and enhance survival. MEDLINE, Scopus, Web of Science, and Cochrane were searched from inception to October 10th, 2021. Eligible clinical trials and observational studies reporting the use of levosimendan in VA-ECMO were searched. Two reviewers extracted data and independently assessed the risk of bias. To integrate the data, a random-effect model was applied. The success of weaning from VA-ECMO was the primary outcome. Ten observational studies, including a total of 987 patients, were identified. Levosimendan was associated with successful weaning (362/448) compared with controls (328/539) (OR 2.37, 95% CI 1.71-3.28; P=0.01) and reduced mortality (144/433 vs. 258/507) (nine studies, OR 0.53, 95% CI 0.36-0.78; P=0.01) compared with control. Levosimendan was associated with successful weaning and increased survival in VA-ECMO patients. Randomized trials should confirm these findings.

CARC13: Early Low Pulsatility in VA-ECMO is Associated with Acute Brain Injury

Background: Pulse pressure (or pulsatility) is a dynamic marker of cardiovascular function and is often decreased in patients on veno-arterial extracorporeal membrane oxygenation (VA-ECMO), which provides non-pulsatile flow. We explored the impact of pulse pressure on development of acute brain injury (ABI) in VA-ECMO patients. Methods: We retrospectively analyzed all adult (≥18 years old) patients receiving VA-ECMO at a single tertiary care center between 7/2016 and 1/2021. All patients received routine neurocritical care consultations with standardized neuromonitoring. ABI included intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, cerebral edema, seizure, and brain death. Blood pressure (BP) was recorded every 15 minutes during the first 24 hours after ECMO initiation. Pulse pressure (systolic minus diastolic pressure) was categorized as: very low (<10mmHg), low (1029mmHg), moderate (30-44mmHg), and high (≥45mmHg). Multivariable logistic regression, controlling for baseline illness severity, operative characteristics, and left ventricle (LV) venting strategy, was performed for the association of pulse pressure with ABI. LV venting strategies included intra-aortic balloon pump (IABP), percutaneous ventricular assist device, right superior pulmonary vein, and left ventricle apex vents. Results: We collected 9,179 pressure measurements from 123 VA-ECMO patients (median age=63, 63% male), of which 41 (33%) experienced ABI. Demographics, baseline clinical characteristics, and pre-ECMO arterial blood gases were not significantly different between those with and without ABI. Those with ABI had a lower median pulse pressure than those without (20 mmHg vs. 32, p=0.038). In a multivariable model controlling for cannulation site, preECMO lactate, and left ventricle venting strategy, low (adjusted odds ratio/aOR=7.04, 95%CI: 1.72-28.82, p=0.007) and very low pulse pressure (aOR=5.14, 95%CI: 1.18-22.34, p=0.029) were associated with ABI (Figure 1). In a model with the same covariates, every 10-mmHg decrease in pulse pressure was associated with a 1.29 increased adjusted odds of ABI (95%CI: 1.00-1.65, p=0.047) (Figure 2). In a sensitivity analysis, adjusting for systolic BP yielded similar associations between pulse pressure and ABI, suggesting pulse pressure acts independently of BP in mediating ABI. Conclusions: Decreased pulsatility in the first 24 hours of VA-ECMO was associated with ABI. Special attention should be given to management practices which sustain sufficient pulse pressure early during ECMO. Figure 1. Forest plot for multivariable model of pulse pressure and acute brain injury (ABI), with the covariates of central cannulation, lactate on ECMO day 1, and left ventricle venting strategy. Covariates are not shown in the figure. Dots represent adjusted odds ratios and brackets represent 95% confidence intervals. Low and very low pulse pressure were associated with increased odds of ABI. This model had a C-index of 0.76. Figure 2. Multivariable logistic regression model with pulse pressure treated as a continuous variable, with the covariates of central cannulation, lactate on ECMO day 1, and left ventricle venting strategy. The adjusted relative odds of acute brain injury decrease as pulse pressure increases.

Impact of extracorporeal CPR with transcatheter heart pump support (ECPELLA) on improvement of short-term survival and neurological outcome in patients with refractory cardiac arrest – A single-site retrospective cohort study

AimExtracorporeal cardiopulmonary resuscitation (E-CPR) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a novel lifesaving method for refractory cardiac arrest. Although VA-ECMO preserves end-organ perfusion, it may affect left ventricular (LV) recovery due to increased LV load. An emerging treatment modality, ECPELLA, which combines VA-ECMO and a transcatheter heart pump, Impella, can simultaneously provide circulatory support and LV unloading. In this single-site cohort study, we assessed impact of ECPELLA support on clinical outcomes of refractory cardiac arrest patients. MethodWe retrospectively reviewed 165 consecutive cardiac arrest patients, who underwent E-CPR by VA-ECMO with or without intra-aortic balloon pump (IABP) or ECPELLA from January 2012 to September 2021. We assessed 30-day survival rate, neurological outcome, hemodynamic data, and safety profiles including hemolysis, acute kidney injury, blood transfusion and embolic cerebral infarction. ResultsAmong 165 E-CPR patients, 35 patients were supported by ECPELLA, and 130 patients were supported by conventional VA-ECMO with or without IABP. Following propensity score matching of 30 ECPELLA and 30 VA-ECMO patients, the 30-day survival (ECPELLA: 53%, VA-ECMO: 20%, p < 0.01) and favorable neurological outcome determined by the Cerebral Performance Category score 1 or 2 (ECPELLA: 33%, VA-ECMO: 7%, p < 0.01) were significantly higher with ECPELLA. Patients receiving ECPELLA also showed significantly higher total mechanical circulatory support flow and lower arterial pulse pressure for the first 3 days (p < 0.01) of treatment. There were no statistical differences in safety profiles between treatment groups. ConclusionECPELLA may be associated with improved 30-day survival and neurological outcome in patients with refractory cardiac arrest.

Central VA-ECMO Support without Full Anticoagulation is Feasible During Lung Transplant

<h3>Purpose</h3> Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is increasingly used instead of cardiopulmonary bypass (CPB) during lung transplant for mechanical circulatory support. In this study, we analyzed the feasibility of central VA-ECMO without full anticoagulation during lung transplantation. We also analyzed the incidence of morbidity including ischemic and thrombotic complications, stroke, and postoperative outcomes. <h3>Methods</h3> This is a retrospective review of an institutional lung transplant database. We included consecutive patients from March 2018 through January 2021. Patients were stratified into two cohorts: those undergoing central VA-ECMO during lung transplant and those undergoing traditional cardiopulmonary bypass. Patients undergoing VA-ECMO did not receive systemic anticoagulation at the time of surgery. 109 total patients were included in the study. <h3>Results</h3> 57 patients underwent central VA-ECMO during lung transplant while 52 underwent traditional cardiopulmonary bypass. The VA-ECMO patients had longer operative time and ischemic time then non VA-ECMO patients (7.9 ± 1.4 vs 6.4 ± 2.0, p<0.001, 5.3 ± 1.1 vs 4.2 ± 2.0, p<0.001). However, there was no significant difference in all of blood transfusion between two groups. Post-lung transplant complications between the VA-ECMO and non-VA-ECMO patients were similar, with the exception of AKI which was higher in VA-ECMO patients (52.2% vs 25.0%, p=0.01). Intensive care unit stay and overall hospital stay was not significantly different between the two groups. <h3>Conclusion</h3> These findings suggest that central VA-ECMO without anticoagulation is a safe alternative to traditional cardiopulmonary bypass during lung transplantation. While use of VA-ECMO increased operative time, it did not result in increased rate of blood transfusions or lengthen overall hospital stay. We believe this approach could improve outcomes associated with mechanical life support for lung transplant.

Mechanical Circulatory Support During Lung Transplantation: Choices, Outcomes and Impact of Duration

<h3>Purpose</h3> Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) has recently replaced cardiopulmonary bypass (CPB) as the method of choice for mechanical circulatory support during lung transplantation (LTx). The aim of this study was to compare the outcomes of using ECMO versus CPB and examine the impact of its duration in a contemporary LTx cohort. <h3>Methods</h3> Between January 2017, and January 2020, 379 LTx were performed at our center. CPB was utilized in 111 and VA ECMO in 33 cases (unmatched cohort). After exclusion of patients who underwent concomitant cardiac procedures or retransplantation (all were in CPB group), the 33 VA ECMO patients were matched to CPB patients with a 1:2 ratio based on primary diagnosis, LTx type (bilateral or single), age, lung allocation score, body mass index, donor type (brain death or cardiac death), and duration of mechanical circulatory support. <h3>Results</h3> In the unmatched cohort, CPB group had a significantly higher incidence of re-exploration for bleeding and hospital mortality compared to ECMO group (15.3% vs 3.0%, <b>p = .047</b>; 10.8% vs 0%, <b>p = .038</b>, respectively). There were no statistically significant differences between CPB and ECMO groups in ICU stay, hospital stay, incidence of primary graft dysfunction (PGD) at 72 hours, postoperative tracheostomy, post-transplant ECMO use, re-admission, or 1-year survival. In the matched cohort, the differences between CPB and ECMO groups in both incidence of re-exploration for bleeding or hospital mortality were found to be statistically insignificant (13.6% vs 3.0%, <i>p</i> = .092; 7.6% vs 0%, <i>p</i> = .125, respectively). The differences between both groups in the other outcome endpoints remained insignificant. In the CPB group, patients with higher grades of PGD at 72 hours had significantly longer duration of CPB (PGD 0, 1, 2, 3 median 217, 209, 250, 289 minutes, <b>p = .014</b>, respectively). In the ECMO group, there were no differences in duration of ECMO between patients with different PGD grades. <h3>Conclusion</h3> Despite having a significantly higher incidence of re-exploration for bleeding and hospital mortality in CPB group in the unmatched cohort, there were no statistically significant differences between the two groups in the studied outcomes in the matched cohort, although there were strong trends. Notably, longer CPB time was associated with higher PGD grades whereas time on ECMO was not associated with PGD grades.

Mobilized Pediatric Patients on Veno-Arterial ECMO Have Improved Outcomes

<h3>Purpose</h3> There is increasing evidence that active rehabilitation and ambulation have a survival benefit for patients supported with veno-venous extracorporeal membrane oxygenation (ECMO). However, there are limited data describing the frequency and distribution, or evaluating the impact of mobilization, on pediatric patients supported with veno-arterial (VA) ECMO. <h3>Methods</h3> This retrospective cohort study identified all patients from the ELSO database from January 2018 through July 2021 supported with cardiac VA ECMO. Patients aged 8-18y with mobilization scores were included. Mobilization was divided into two categories; non-mobile (NM) and mobile (M). M includes patients with any degree of mobility, ranging from sitting up in bed through ambulation without support. Primary outcomes included heart transplant and survival to hospital discharge. <h3>Results</h3> A total of 689 patients were identified with a median age of 13.6y (8.0, 17.9) and median support time of 4.8 days (0, 257.9). 10.1% of patients (N=70) were in the mobility cohort (M). When comparing M to NM, there was no difference in the median age (14.9 [8.00, 17.9] vs 13.6 [8.00, 17.9] <i>p=0.076)</i> or duration of ECMO support (6.7d [1.6, 257.9] vs 4.6d [0, 75], <i>p=0.079</i>). M had a lower incidence of history of cardiac arrest prior to ECMO (18.6% vs 36.2%, <i>p=0.014).</i> M was more likely to be extubated (7.1% vs 1.0%, <i>p=0.006)</i> and had a higher incidence of heart transplant (22.9% vs 9.7%, <i>p=0.002).</i> Survival to discharge was far superior in the mobility cohort (82.9%) compared the non-mobility group (65.1%), <i>p=0.003.</i> <b>Figure</b> <h3>Conclusion</h3> One out of ten pediatric VA ECMO patients achieve some measure of mobility. These patients are more likely to be extubated, have higher rates of heart transplant and improved survival to hospital discharge. Further study is needed understand the potential positive effects of mobilization on pediatric VA ECMO patients, and whether this may be an effective and safe way to improve outcomes in a high-risk cohort.

Arterial Carbon Dioxide and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation.

Acute brain injury (ABI) occurs frequently in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We examined the association between peri-cannulation arterial carbon dioxide tension (PaCO 2 ) and ABI with granular blood gas data. We retrospectively analyzed adult patients who underwent VA-ECMO at a tertiary care center with standardized neuromonitoring. Pre- and post-cannulation PaCO 2 were defined as the mean of all PaCO 2 values in the 12 hours before and after cannulation, respectively. Peri-cannulation PaCO 2 drop (∆PaCO 2 ) equaled pre- minus post-cannulation PaCO 2 . ABI included intracranial hemorrhage (ICH), ischemic stroke, hypoxic-ischemic brain injury, cerebral edema, seizure, and brain death. Univariable logistic regression analysis was performed for the presence of ABI. Out of 129 VA-ECMO patients (median age = 60, 63% male), 43 (33%) patients experienced ABI. Patients had a median of 11 (interquartile range: 8-14) peri-cannulation PaCO 2 values. Comparing patients with and without ABI, pre-cannulation (39 vs. 42 mm Hg; p = 0.38) and post-cannulation (37 vs. 36 mm Hg; p = 0.82) PaCO 2 were not different. However, higher pre-cannulation PaCO 2 (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.10-4.00; p = 0.02) and larger ∆PaCO 2 (OR = 2.69; 95% CI = 1.18-6.13; p = 0.02) were associated with ICH. In conclusion, in a cohort with granular arterial blood gas (ABG) data and a standardized neuromonitoring protocol, higher pre-cannulation PaCO 2 and larger ∆PaCO 2 were associated with increased prevalence of ICH.

Intracranial haemorrhage in adult patients on venoarterial extracorporeal membrane oxygenation.

Intracranial haemorrhage (ICH) is one of the most serious complications of adult patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and is associated with increased morbidity and mortality. However, the prevalence and risk factors of ICH in this cohort are still insufficiently understood. We hypothesized that a considerable proportion of patients undergoing VA-ECMO support suffer from ICH and that specific risk factors are associated with the occurrence of ICH. Therefore, the purpose of this study was to further investigate the prevalence and associated mortality as well as to identify risk factors for ICH in VA-ECMO patients. We conducted a retrospective multicentre study including adult patients (≥18 years) treated with VA-ECMO in cardiac intensive care units (ICUs) at five German clinical sites between January 2016 and March 2020, excluding patients with ICH upon admission. Differences in baseline characteristics and clinical outcome between VA-ECMO patients with and without ICH were analysed and risk factors for ICH were identified. Among the 598 patients included, 70/598 (12%) developed ICH during VA-ECMO treatment. In-hospital mortality in patients with ICH was 57/70 (81%) and 1-month mortality 60/70 (86%), compared to 332/528 (63%) (P = 0.002) and 340/528 (64%) (P < 0.001), respectively, in patients without ICH. Intracranial haemorrhage was positively associated with diabetes mellitus [odds ratio (OR) 2, 95% confidence interval (CI) 1.11-3.56; P = 0.020] and lactate (per mmol/L) (OR 1.06, 95% CI 1.01-1.11; P = 0.020), and negatively associated with platelet count (per 100 G/L) (OR 0.32, 95% CI 0.15-0.59; P = 0.001) and fibrinogen (per 100 mg/dL) (OR 0.64, 95% CI 0.49-0.83; P < 0.001). Intracranial haemorrhage was associated with a significantly higher mortality rate. Diabetes mellitus and lactate were positively, platelet count, and fibrinogen level negatively associated with the occurrence of ICH. Thus, platelet count and fibrinogen level were revealed as potentially modifiable, independent risk factors for ICH. The findings address an area with limited data, provide information about risk factors and the epidemiology of ICH, and may be a starting point for further investigations to develop effective strategies to prevent and treat ICH.

Mild hypothermia and neurologic outcomes in patients undergoing venoarterial extracorporeal membrane oxygenation.

Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 h post-ECMO on neurological outcomes in VA-ECMO patients. This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 h post-ECMO. The primary outcome was a good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 h of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 h while 18 of those 88 patients (14.2%) had a mean temperature <36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.04-1.31, p = .01) after adjusting for age, the severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-h PaO2 . Neither duration of mild hypothermia (OR = 0.93, CI = 0.84-1.03, p = .17) nor mean temperature (OR = 0.78, CI = 0.29-2.08, p = .62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p = .47) and mean 24-h temperature (p = .76) were not significantly associated with the frequency of systemic hemorrhages. In this single-center study, a longer duration of mild hypothermia during the first 24 h of ECMO support was significantly associated with improved neurological outcomes. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.

Cardiovascular critical care nursing procedures in patients on venoarterial extracorporeal membrane oxygenation

Objectives: This study aims to evaluate nursing care procedures and outcomes in patients with post-cardiotomy cardiogenic shock (PCCS) requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). Patients and methods: Between June 2016 and June 2017, a total of five patients (1 male, 4 females; mean age 67.2 years; range, 55 to 81 years) who received VA-ECMO for PCCS in our clinic were retrospectively analyzed. The ECMO device was implanted in the operating room or in the cardiovascular intensive care unit CICU by an experienced cardiovascular surgeon. Air and thrombus formation and blood flow were monitored by the perfusionists. Daily nursing care included monitorization, control of bleeding, sedation management, pain control, nutrition, control of skin integrity and infection, sponge bath, changing the position of endotracheal tube, dressing replacement, decubitus control, changing sheets, and back hygiene. Results: Two patients who were successfully weaned off VA-ECMO survived to hospital discharge. The median duration of daily nursing care was 62 (range, 45 to 65) min. The longest steps in daily nursing were sponge bath and elevation of the patient. None of the patients suffered from decannulation or displacement of the VA-ECMO cannulas during nursing. Conclusion: We conclude that nurses are fundamental in the care of VA-ECMO patients for the early diagnosis and intervention of procedure-related complications.

Single-center surgical site infection rate after peripheral ECMO decannulation and surgical repair.

Objective:Extracorporeal membrane oxygenation (ECMO) is used to provide heart–lung bypass support in cases of acute respiratory and cardiac failure. The two main classifications of ECMO are venoarterial (VA) and venovenous (VV). After the patient recovers from an acute state, ECMO decannulation from the groin often requires femoral exploration and vessel repair. This study was performed to quantify the rate of surgical site infection (SSI) after ECMO decannulation.Methods:Retrospective single-institutional review of patients requiring ECMO from January 2016 to October 2019 was conducted. The study examined incidence of SSI. We evaluated preoperative risk factors, VA versus VV ECMO, Szilagyi infection score, and postoperative management.Results:Initial search began with 176 ECMO cases, of which 106 patients were deceased before development of any infection. Eighteen were eliminated because of central ECMO access, and four were lost to chart privacy. Of the 154 patients requiring femoral ECMO, 48 (31%) survived, with 22 VA and 26 VV ECMO. Twelve patients were classified as infected, resulting in an overall SSI rate of 25%. Surgical repair of the femoral arterial cannulation site was required in the 22 VA ECMO patients, and 10 of these became infected, resulting in an infection rate of 45%. The remaining two infected were VV ECMO and did not require surgery. The VV ECMO SSI rate was 7.7%. The infected group of VA ECMO consisted of eight primary surgical repairs and two patch repairs. Eight of the patients required multiple reoperations and two required antibiotics and wound care alone. There was no instance of limb loss. Statistical analysis showed intraoperative transfusion of >250 ml and blood loss of >300 ml as the only predictive factors of infection. The Szilagyi score was found to be worse in patients requiring patch angioplasty.Conclusion:Surgical repair of ECMO arterial cannulation sites had postoperative SSIs in nearly half of the patients (45%). The VV ECMO SSI rate was found to be 7.7%. Severity of infection was worse in more complicated repairs. Overall ECMO mortality was high at 69%. Although we found no clear correlation with common risk factors, transfusions >250 ml and blood loss >300 ml were found to be predictive. Vascular surgeons should be aware of high risk of SSI with repair of femoral ECMO cannulation sites.

Platelet Transfusion and In-Hospital Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation Patients.

Thrombocytopenia is common during extracorporeal membrane oxygenation (ECMO), and platelets are sometimes transfused to meet arbitrary goals. We performed a retrospective cohort study of veno-arterial (VA) ECMO patients from a single academic medical center and explored the relationship between platelet transfusion and in-hospital mortality using multivariable logistic regression. One hundred eighty-eight VA ECMO patients were included in the study. Ninety-one patients (48.4%) were transfused platelets during ECMO. Patients who received platelet transfusion had more coronary artery disease, lower platelet counts at cannulation, higher predicted mortality, lower nadir platelet counts, more ECMO days, and more red blood cell (RBC) and plasma transfusion. Mortality was 19.6% for patients who received no platelets, 40.8% for patients who received 1-3 platelets, and 78.6% for patients who received 4 or more platelets ( P &lt; 0.001). After controlling for confounding variables including baseline severity of illness, central cannulation, postcardiotomy status, RBC and plasma transfusion, major bleeding, and total ECMO days, transfusion of 4 or more platelets remained associated with in-hospital mortality; OR = 4.68 (95% CI = 1.18-27.28), P = 0.03. Our findings highlight the need for randomized controlled trials that compare different platelet transfusion triggers, so that providers can better understand when platelet transfusion is indicated in VA ECMO patients.

Opioid and sedative requirements in extracorporeal membrane oxygenation patients on hydromorphone versus fentanyl.

The extracorporeal membrane oxygenation (ECMO) circuit causes pharmacokinetic alterations of medications which impact drug selection and dosing. Although hydromorphone has a favorable pharmacokinetic profile, it is unclear whether hydromorphone provides better patient-centered benefits compared to fentanyl. The objective of this study is to compare opioid and sedative requirements in ECMO patients started on a fentanyl- versus hydromorphone-based analgesia regimen. This was a non-interventional retrospective cohort study. It was conducted at a single center in the cardiovascular intensive care units and cardiac intensive care units. We included venovenous (VV) or venoarterial ECMO patients. Patients who were started on a fentanyl continuous infusion within 24h of cannulation were compared to patients started on a hydromorphone continuous infusion. A linear mixed effects model was performed to compare doses of opioid, sedative, and propofol between groups over time. We included 28 hydromorphone patients and 53 fentanyl patients, with 85% on VV ECMO. There were no differences between hydromorphone and fentanyl groups in opioid or sedative (including propofol and benzodiazepine) doses for any ECMO day (p value for interaction .63 and .83, respectively). Propofol doses alone, however, were significantly higher in the fentanyl group on ECMO days three, four, and five. There appear to be no major differences in opioid or sedative requirements whether ECMO patients are initiated on a hydromorphone- or fentanyl-based regimen.

Endotoxin Activity in Patients With Extracorporeal Membrane Oxygenation Life Support: An Observational Pilot Study.

Background: Extracorporeal membrane oxygenation (ECMO) life support has become an integral part of intensive care. The endotoxin activity assay (EAA) is a useful test to measure endotoxemia severity in whole blood. To date, no information is available regarding the EAA levels and their effect on clinical outcomes in critically ill patients with ECMO support.Methods: This prospective observational pilot study enrolled adult critically ill patients with ECMO support from August 2019 to December 2020. The EAA levels were measured within 24 h (T1), and at 25–48 (T2), 49–72 (T3), and 73–96 h (T4) after ECMO initiation. This study primarily aimed to investigate the incidence of high EAA levels (≥0.6) at each time point. Subsequent exploratory analyses were conducted to compare the EAA levels of venoarterial ECMO (VA-ECMO) patients between 30-day survivors and non-survivors. Post-hoc analysis was performed to compare the clinical outcomes of VA-ECMO patients with elevated EAA levels at T3 (vs. T1) and those without elevated EAA levels.Results: A total of 39 VA-ECMO patients and 15 venovenous ECMO (VV-ECMO) patients were enrolled. At T1, the incidence of high EAA level (≥0.6) was 42% in VV-ECMO patients and 9% in VA-ECMO patients (P = 0.02). At T2, the incidence of high EAA level was 40% in VV-ECMO patients and 5% in VA-ECMO patients (P = 0.005). In VA-ECMO patients, EAA levels at T3 were significantly higher in 30-day non-survivors than in survivors (median [interquartile range]: 0.49 [0.37–0.93] vs. 0.31 [0.19–0.51], median difference 0.16 [95% confidence interval [CI], 0.02–0.31]; P = 0.024). Moreover, VA-ECMO patients with elevated EAA levels at T3 (vs. T1) had lower 30-day survival than patients without elevated EAA levels (39 vs. 83%, P = 0.026) and fewer ECMO free days by day 30 (median: 3 vs. 23 days, median difference 12 days [95% CI, 0–22]; P = 0.028).Conclusions: A certain proportion of patients experienced high EAA levels (≥0.6) after VV-ECMO or VA-ECMO initiation. VA-ECMO patients with an elevated EAA level at 49–72 h were associated with poor clinical outcomes.

Life impact of VA-ECMO due to primary graft dysfunction in patients after orthotopic heart transplantation.

AimsPrimary graft dysfunction (PGD) is a feared complication after heart transplantation (HTX). HTX patients frequently receive veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) until graft recovery. Long‐term mortality of patients weaned from VA‐ECMO after HTX is comparable with non‐ECMO patients. However, impact on quality of life is unknown. This study investigated days alive and out of hospital (DAOH) as patient‐centred outcome in HTX patients at 1 year after surgery.Methods and resultsThis retrospective single‐centre cohort study included patients who underwent HTX at the University Hospital Düsseldorf, Germany, from 2010 to 2020. Main exposure was VA‐ECMO due to PGD. VA‐ECMO and non‐VA‐ECMO patients were compared regarding the primary endpoint DAOH at 1 year after HTX. Subgroup analysis for patients weaned from VA‐ECMO was performed. In total, 144 patients were included into analysis; 1 year mortality was significantly lower in non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO 34.8% (16/46), adjusted hazard ratio: 0.32, 95% confidence interval: 0.15–0.74; P = 0.002]. Mortality did not differ significantly between patients weaned from VA‐ECMO and non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO (weaned) 18.9% (7/37), adjusted hazard ratio: 0.72, 95% confidence interval: 0.27–1.90; P = 0.48]. DAOH were significantly higher in non‐ECMO patients compared with VA‐ECMO patients and patients weaned from VA‐ECMO [non‐ECMO vs. VA‐ECMO: median 310 (inter‐quartile range 277–327) days vs. 243 (0–288) days; P < 0.0001; non‐ECMO vs. VA‐ECMO (weaned): 310 (277–327) days vs. 253 (208–299) days; P < 0.0001]. These results were still significant after multivariable adjustment with forced entry of predefined covariables.ConclusionsDespite similar survival rates, VA‐ECMO due to PGD has a relevant life impact as defined by DAOH in the first year after HTX. As a more patient‐centred endpoint, DAOH may contribute to a more comprehensive assessment of outcome in HTX patients.

Extracellular Vesicles Are Associated With Outcome in Veno-Arterial Extracorporeal Membrane Oxygenation and Myocardial Infarction

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is being increasingly applied in patients with circulatory failure, but mortality remains high. An inflammatory response syndrome initiated by activation of blood components in the extracorporeal circuit may be an important contributing factor. Patients with ST-elevation myocardial infarction (STEMI) may also experience a systemic inflammatory response syndrome and are at risk of developing cardiogenic shock and cardiac arrest, both indications for VA-ECMO. Extracellular vesicles (EV) are released by activated cells as mediators of intercellular communication and may serve as prognostic biomarkers. Cardiomyocyte EV, released upon myocardial ischemia, hold strong potential for this purpose. The aim of this study was to assess the EV-profile in VA-ECMO and STEMI patients and the association with outcome.Methods: In this prospective observational study, blood was sampled on day 1 after VA-ECMO initiation or myocardial reperfusion (STEMI patients). EV were isolated by differential centrifugation. Leukocyte, platelet, endothelial, erythrocyte and cardiomyocyte (caveolin-3+) Annexin V+ EV were identified by flow cytometry. EV were assessed in survivors vs. non-survivors of VA-ECMO and in STEMI patients with normal-lightly vs. moderately-severely reduced left ventricular function. Logistic regression was conducted to determine the predictive accuracy of EV. Pearson correlation analysis of EV with clinical parameters was performed.Results: Eighteen VA-ECMO and 19 STEMI patients were recruited. Total Annexin V+, cardiomyocyte and erythrocyte EV concentrations were lower (p ≤ 0.005) while the percentage of platelet EV was increased in VA-ECMO compared to STEMI patients (p = 0.002). Total Annexin V+ EV were increased in non-survivors of VA-ECMO (p = 0.01), and higher levels were predictive of mortality (AUC = 0.79, p = 0.05). Cardiomyocyte EV were increased in STEMI patients with moderately-severely reduced left ventricular function (p = 0.03), correlated with CK-MBmax (r = 0.57, p = 0.02) and time from reperfusion to blood sampling (r = 0.58, p = 0.01). Leukocyte EV correlated with the number of coronary stents placed (r = 0.60, p = 0.02).Conclusions: Elevated total Annexin V+ EV on day 1 of VA-ECMO are predictive of mortality. Increased cardiomyocyte EV on day 1 after STEMI correlate with infarct size and are associated with poor outcome. These EV may aid in the early identification of patients at risk of poor outcome, helping to guide clinical management.