Venoarterial Extracorporeal Membrane Oxygenation Treatment Research Articles

ExtraCorporeal Membrane Oxygenation in the therapy for REfractory Septic shock with Cardiac function Under Estimated (ECMO-RESCUE): study protocol for a prospective, multicentre, non-randomised cohort study

IntroductionSevere septic cardiomyopathy (SCM) is one of the main causes of refractory septic shock (RSS), with a high mortality. The application of venoarterial extracorporeal membrane oxygenation (ECMO) to support the...

Venoarterial extracorporeal membrane oxygenation in immunocompromised patients with cardiogenic shock: a cohort study and propensity-weighted analysis.

The outcomes of immunocompromised patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are seldom documented, making ECMO candidacy decisions challenging. This study aims (1) to report outcomes of immunocompromised patients treated with VA-ECMO, (2) to identify pre-ECMO predictors of 90-day mortality, (3) to assess the impact of immunodepression on 90-day mortality, and (4) to describe the main ECMO-related complications. This is a retrospective, propensity-weighted study conducted in two French experienced ECMO centers. From January 2006 to January 2022, 177 critically ill immunocompromised patients (median (interquartile range, IQR) age 49 (32-60) years) received VA-ECMO. The main causes of immunosuppression were long-term corticosteroids/immunosuppressant treatment (29%), hematological malignancy (26%), solid organ transplant (20%), and solid tumor (13%). Overall 90-day and 1-year mortality were 70% (95% confidence interval (CI) 63-77%) and 75% (95% CI 65-79%), respectively. Older age and higher pre-ECMO lactate were independently associated with 90-day mortality. Across immunodepression causes, 1-year mortality ranged from 58% for patients with infection by human immunodeficiency virus (HIV) or asplenia, to 89% for solid organ transplant recipients. Hemorrhagic and infectious complications affected 39% and 54% of patients, while more than half the stay in intensive care unit (ICU) was spent on antibiotics. In a propensity score-weighted model comparing the 177 patients with 942 non-immunocompromised patients experiencing cardiogenic shock on VA-ECMO, immunocompromised status was independently associated with a higher 90-day mortality (odds ratio 2.53, 95% CI 1.72-3.79). Immunocompromised patients undergoing VA-ECMO treatment face an unfavorable prognosis, with higher 90-day mortality compared to non-immunocompromised patients. This underscores the necessity for thorough evaluation and careful selection of ECMO candidates within this frail population.

Prognostic implication of Vasoactive Inotropic Score in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation.

Vasopressors and inotropes are crucial in managing cardiogenic shock (CS) as they enhance microcirculation in patients. Numerous studies have demonstrated the adverse outcomes associated with excessive use of vasoactive drugs and the vasoactive drug scoring system has emerged as a valuable prognostic tool, particularly in pediatric patients. This study aimed to examine the prognostic significance of the Vasoactive Inotropic Score (VIS) in adult patients with CS receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment. This retrospective multi-center study involved 2,453 adult patients who underwent VA-ECMO in China between 2015 and 2021. Among them, 1,742 adult patients with CS following VA-ECMO were finally included. The maximum VIS (VISmax) was determined by considering the highest doses of vasoactive and inotropic drugs administered within the first 6 hours before ECMO initiation. Based on the VISmax, patients were classified into two groups: 0-20 and >20. The primary outcome of this study was in-hospital mortality. A total of 1,146 patients were included in the high VISmax group, while 596 patients were assigned to the low VISmax group. Overall, 882 (50.6%) patients experienced in-hospital mortality, with significantly higher rates observed among those with higher VISmax scores (41.4% for VIS ≤20 versus 68.3% for VIS >20; P<0.001). Similar trends were observed for 30-day mortality (40.7% for VIS ≤20 versus 64.9% for VIS >20; P<0.001). Multivariable regression analysis demonstrated that a VIS score exceeding 20 independently predicted in-hospital mortality [odds ratio (OR) 2.64; 95% confidence interval (CI): 2.10-3.33; P<0.001]. The receiver operating characteristic (ROC) analysis revealed that VIS had an area under the curve (AUC) of 0.65 (95% CI: 0.63-0.68; P<0.001) as a predictor of in-hospital mortality, with an optimal cutoff value of 20.1. Moreover, the VIS exhibited good predictive ability for in-hospital mortality in patients with acute myocarditis (AUC 0.70; 95% CI: 0.63-0.78; P<0.001). Firstly, higher maximum level of VIS within the first 6 hours before ECMO initiation independently predicted poorer clinical outcomes in patients supported with ECMO for CS. Secondly, VIS exceeding 20 was significantly associated with increased risks of in-hospital mortality and 30-day mortality. Thirdly, when categorized by the cause of CS, a high VIS exhibited good predictive ability in patients with acute myocardial infarction, heart failure, and acute myocarditis.

Left-ventricular unloading with Impella during refractory cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation - A systematic review and meta-analysis

Abstract Background Extracorporeal cardio-pulmonary resuscitation (ECPR) is the implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") during ECPR is unlear. Purpose This is the first systematic review and meta-analysis to characterise patients receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO treatment during ECPR. Methods A systematic review and meta-analysis was performed according to the PRISMA checklist on clinical studies with adult patients with refractory cardiac arrest treated with ECMELLA or VA-ECMO as part of ECPR. The meta-analysis was performed by using a random-effects model. Risk of bias was assessed with Cochrane ROBINS-I tool, heterogeneity with Cochrane Q test and publication bias with funnel plots. Results Altogether, 13 study records from 32 tertiary care centers with a total of 1,037 adult patients with ECPR were included, out of which 785 patients (75.7%) received VA-ECMO and 252 (24.3%) ECMELLA support. Compared to VA-ECMO, the ECMELLA group was comprised of more male patients (71.4% vs. 57.3%), more patients with initial shockable ECG rhythms (55.2% vs. 40.3%), lower pre-ECPR pH (7.07 vs. 7.11) and higher lactate levels (10.9 vs. 10.1 mmol/L), as well as higher rates of acute myocardial infarction (75.0% vs. 41.9%) and percutaneous coronary interventions (71.8% vs. 35.4%) (Table). Age, rate of out-of-hospital cardiac arrest and low-flow times were similar between both treatment groups. Compared to ECMELLA, VA-ECMO alone was more frequently used in pulmonary embolism (6.4% vs. 0.4%) and miscellaneous causes of cardiac arrest (19.0% vs. 4.4%). ECMELLA support was associated with a 47% reduced mortality risk [95% Confidence Interval 0.31-0.93] compared to VA-ECMO alone: 123 (48.8%) vs. 539 (68.7%) patients (P=0.026). Patients with ECMELLA had a longer hospital length of stay (18.7 days vs. 10.6 days). Results remained robust in sensitivity analyses after exclusion of smaller studies and gray literature. Conclusions ECMELLA support was predominantly utilised in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism and miscellaneous causes of cardiac arrest across institutions. Indications and frequency of ECMELLA use varied strongly between institutions. ECMELLA support during ECPR was associated with improved survival across studies and might be considered in well selected patients with refractory cardiac arrest. Further scientific evidence is urgently required to elaborate standardised guidelines for the use of LV unloading during ECPR.

Abstract 381: Simultaneous Use of VA-ECMO and Impella (ECPELLA) Improves Mid-Term Mortality in Patients With Refractory Cardiac Arrest or Cardiac Shock Who Required VA-ECMO

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is an effective therapy to rescue patients with refractory cardiogenic shock, including cardiac arrest. VA-ECMO increase damaged left ventricular (LV) afterload. The intra-aortic balloon pump (IABP) has been often used as the additional circulatory support for LV unloading. However, the effectiveness of combining VA-ECMO with IABP has not been definitively established. The Impella , a percutaneous micro-axial pump, can reduce damaged LV preload with circulatory support, which may have significant effect on clinical outcome by concomitant use of VA-ECMO and Impella (ECPELLA). Objective: This single-site cohort study aimed to assess the impact of ECPELLA compared to VA-ECMO with or without IABP in patients with refractory cardiogenic shock who received VA-ECMO treatment. Methods: We retrospectively reviewed 275 consecutive patients who received VA-ECMO from January 2012 through December 2022 in our institute. The patients were divided into two groups, ECEPLLA (n = 81) and VA-ECMO with or without IABP (n = 194). The primary outcome of this study was the 180-day all-cause mortality rate. Results: There were no significant differences in age, gender ratio, prevalence of coronary risk factors, serum lactate levels at the emergency room (ER), the rate of extracorporeal cardiopulmonary resuscitation (E-CPR), and instances of out-of-hospital cardiac arrest between the groups. The ECPELLA groups had a significantly higher rate of acute coronary syndrome and a lower prevalence of chronic kidney disease. Kaplan-Meier analysis demonstrated that the 180-day all-cause mortality was significantly lower in the ECPELLA group compared to the VA-ECMO group (p &lt; 0.001). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.27 [10 years increase]; 95% confidence interval [CI], 1.13-1.42, p &lt; 0.001), E-CPR (HR 1.43; 95% CI 1.02-2.00, p = 0.04), lactate level at ER (HR 1.07; 95% CI 1.04-1.10, p &lt; 0.001), and ECPELLA (HR, 0.55, 95% CI, 0.40-0.76, p &lt; 0.001) were significantly associated with the 180-day all-cause mortality. Conclusion: ECPELLA was associated with improvement of mid-term mortality in patients with refractory cardiogenic shock who received VA-ECMO.

Comparation of the outcomes between ProGlide based post-closure technique and arteriotomy repair for veno-arterial extracorporeal membrane oxygenation decannulation

PurposeTo compare outcomes between post-closure technique based on ProGlide and arteriotomy repair for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation in this study. Materials and methodsPatients who received VA-ECMO treatment and successfully removed from its support in Changhai Hospital from January 2018 to December 2021 were included in this study. Patients was divided into post-closure group and surgical repair group according to the artery access closure method used. Clinical data of these patients were retrospectively collected and analyzed. ResultsA total of 58 patients were eventually enrolled in this study, including 26 (44.83%) patients in post-closure group and 32 (55.17%) patients in surgical repair group. Post-closure group had shorter procedure time, less minor bleeding events, estimated blood loss and packed cells transfused compared with the surgical repair group. The intensive care unit (ICU) length of stay after decannulation and the hospital length of stay after ICU in post-closure group were both shorter than surgical repair group. Nine patients (15.52%) died of multiple system organ failure after decannulation in this cohort and there were no significant differences between two groups. ConclusionsOur study showed the post-closure technique based on ProGlide for VA-ECMO decannulation is feasible, safe and effective.

Expert consensus on prevention and treatment of lower limb ischemia during transfemoral veno-arterial extracorporeal membrane oxygenation therapy in adults in China (2023)

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important technique for the treatment of patients with severe circulatory failure, and is used in a wider range. Canulation through the femoral artery is simple and convenient, which has become the most commonly used canulation method of VA-ECMO for adults. Lower limb ischemia is a common complication in transfemoral VA-ECMO therapy, which will seriously affect the prognosis and quality of life of patients. In order to standardize the lower limb ischemia management during VA-ECMO treatment and reduce disability and mortality, Extracorporeal Life Support Professional Committee of Chinese Medical Doctor Association and Extracorporeal Life Support Professional Committee of Shandong Physician Association organized multidisciplinary medical experts with ECMO proficiency from China to develop the Expert consensus on prevention and treatment of lower limb ischemia during transfemoral veno-arterial extracorporeal membrane oxygenation therapy in adults in China (2023), based on literature review and their clinical practice experience. This consensus is expected to provide valuable reference for the prevention, monitoring and treatment of lower limb ischemia during femoral artery VA-ECMO treatment.

Ultrasound vector flow imaging during veno-arterial extracorporeal membrane oxygenation in a thoracic aorta model.

In veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment, the mixing zone is a key hemodynamic factor that determines the efficacy of the treatment. This study aimed to evaluate the applicability of a novel ultrasound technique called vector flow imaging (VFI) for visualizing complex flow patterns in an aorta phantom under VA-ECMO settings. VFI experiments were performed to image aortic hemodynamics under VA-ECMO treatment simulated in an anthropomorphic thoracic aorta phantom using a pulsatile pump (cardiac output: 2.7 L/min) and an ECMO pump with two different flow rates, 0.35 L/min and 1.0 L/min. The cardiac cycle of hemodynamics in the ascending aorta, aortic arch, and descending aorta was visualized, and the spatio-temporal dynamics of flow vectors were analyzed. VFI successfully visualized dynamic flow patterns in the aorta phantom. When the flow rate of the ECMO pump increased, ECMO flow was more dominant than cardiac output in the diastole phase, and the speed of cardiac output was suppressed in the systole phase. Vortex flow patterns were also detected in the ascending aorta and the arch under both ECMO flow rate conditions. The VFI technique may provide new insights into aortic hemodynamics and facilitates effective and safe VA-ECMO treatment.

Combination Therapy with Ceftazidime-Avibactam and Amikacin for Multidrug-Resistant Pseudomonas aeruginosa Infection with Fulminant Myocarditis in a Younger Patient: A Case Report and Literature Review

Introduction: Fulminant myocarditis is a life-threatening disease among young patients. Pseudomonas aeruginosa is distributed in nature and is often spread as an opportunistic pathogen to cause hospital-acquired infections in patients with underlying diseases and low immunity. Case Presentation: This report presented a case of a 28-year-old woman with fulminant myocarditis followed by P. aeruginosa infection. After hospitalization, she received veno-arterial extracorporeal membrane oxygenation (ECMO) and continuous renal replacement treatment (CRRT). Initially, piperacillin sodium tazobactam combined with amikacin was used for anti-infection therapy, which had a poor clinical effect. Subsequently, it was recommended to use ceftazidime-avibactam and amikacin for treatment. Finally, the infection index of the patient returned to normal. Conclusions: It is necessary to select correct and effective drugs according to etiology, considering the influence of ECMO and CRRT on the patient’s antimicrobial pharmacokinetics/pharmacodynamics (PK/PD). This case could provide a reference for safe and rational drug use in clinical practice.

Veno-arterial extracorporeal membrane oxygenation versus standard medical management for massive pulmonary embolism.

There is limited research on the use and outcomes of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment for massive pulmonary embolism (PE). This study compared VA-ECMO treatment for massive PE versus patients treated medically. Patients diagnosed with massive PE at one hospital system were reviewed. VA-ECMO and non-ECMO groups were compared by t test and Chi-square. Mortality risk factors were identified by logistic regression. Survival was assessed by Kaplan Meier and propensity matching of groups. Ninety-two patients were included (22 VA-ECMO and 70 non-ECMO). Age (OR 1.08, 95% CI 1.03-1.13), arterial SBP (OR 0.97, 95% CI 0.94-0.99), albumin (OR 0.3, 95% CI 0.1-0.8), and phosphorus (OR 2.0, 95% CI 1.4-3.17) were independently associated with 30-day mortality. Alkaline phosphate (OR 1.03, 95% CI 1.01-1.05) and SOFA score (OR 1.3, 95% CI 1.06-1.51) were associated with 1-year mortality. Propensity matching showed no difference in 30-day (59% VA-ECMO versus 72% non-ECMO, p = 0.363) or 1-year survival (50% VA-ECMO versus 64% non-ECMO, p = 0.355). Patients treated with VA-ECMO for massive PE and medically treated patients have similar short- and long-term survival. Further research is needed to define clinical recommendations and benefits of intensive therapy such as VA-ECMO in this critically ill population.

Lung ultrasound to evaluate pulmonary changes in patients with cardiogenic shock undergoing extracorporeal membrane oxygenation: a retrospective study

PurposeThe aim of the study was to evaluate the value of lung ultrasound (LUS) in patients with cardiogenic shock treated by venoarterial extracorporeal membrane oxygenation (VA-ECMO).MethodsA retrospective study was conducted in Xuzhou Central Hospital from September 2015 to April 2022. Patients with cardiogenic shock who received VA-ECMO treatment were enrolled in this study. The LUS score was obtained at the different time points of ECMO.ResultsTwenty-two patients were divided into a survival group (n = 16) and a nonsurvival group (n = 6). The intensive care unit (ICU) mortality was 27.3% (6/22). The LUS scores in the nonsurvival group were significantly higher than those in the survival group after 72 h (P < 0.05). There was a significant negative correlation between LUS scores and PaO2/FiO2 and LUS scores and pulmonary dynamic compliance(Cdyn) after 72 h of ECMO treatment (P < 0.001). ROC curve analysis showed that the area under the ROC curve (AUC) of T72-LUS was 0.964 (95% CI 0.887 ~ 1.000, P < 0.01).ConclusionLUS is a promising tool for evaluating pulmonary changes in patients with cardiogenic shock undergoing VA-ECMO.Trial registrationThe study had been registered in the Chinese Clinical Trial Registry(NO.ChiCTR2200062130 and 24/07/2022).

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Meta-analysis of extracorporeal membrane oxygenation in combination with intra-aortic balloon pump vs. extracorporeal membrane oxygenation only in patients with cardiogenic shock due to acute myocardial infarction.

Incidence and mortality of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) remain high despite substantial therapy improvements in acute percutaneous coronary intervention over the last decades. Unloading the left ventricle in patients with Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be performed by using an intra-aortic balloon pumps' (IABP) afterload reduction, which might be especially beneficial in AMI patients with CS. The objective of this meta-analysis was to assess the effect of VA-ECMO + IABP vs. VA-ECMO treatment on the mortality of patients with CS due to AMI. A systematic literature search was performed using EMBASE, COCHRANE, and MEDLINE databases. Studies comparing the effect of VA-ECMO + IABP vs. VA-ECMO on mortality of patients with AMI were included. Meta-analyses were performed to analyze the effect of the chosen treatment on 30-day/in-hospital mortality. Twelve studies were identified by the literature search, including a total of 5,063 patients, 81.5% were male and the mean age was 65.9 years. One thousand one hundred and thirty-six patients received treatment with VA-ECMO in combination with IABP and 2,964 patients received VA-ECMO treatment only. The performed meta-analysis showed decreased mortality at 30-days/in-hospital after VA-ECMO + IABP compared to VA-ECMO only for patients with cardiogenic shock after AMI (OR 0.36, 95% CI 0.30-0.44, P≤0.001). Combination of VA-ECMO + IABP was associated with higher rates of weaning success (OR 0.29, 95% CI 0.16-0.53, P < 0.001) without an increase of vascular access complications (OR 0.85, 95% CI 0.35-2.08, P = 0.72). In this meta-analysis, combination therapy of VA-ECMO + IABP was superior to VA-ECMO only therapy in patients with CS due to AMI. In the absence of randomized data, these results are hypothesis generating only.

Outcomes of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation

Primary graft dysfunction (PGD) is the leading cause of death in the first 30 days after lung transplantation and is also associated with worse long-term outcomes. Outcomes of patients with PGD grade 3 requiring extracorporeal membrane oxygenation (ECMO) support after lung transplantation have yet to be well described. We sought to describe short- and long-term outcomes for patients with PGD grade 3 who required ECMO support. This is a single-center retrospective cohort study of patients undergoing lung transplantation. We stratified patients with PGD grade 3 into non-ECMO, venoarterial (VA) ECMO, and venovenous (VV) ECMO groups after transplantation. We then compared the outcomes between the groups. Of 773 lung transplant recipients, PGD grade 3 developed in 204 (26%) at any time in the first 72 hours after lung transplantation. Of these, 13 (5%) required VA ECMO and 25 (10%) required VV ECMO support. The 30-day, 1-year, and 5-year survival in the VA ECMO group was 62%, 54%, and 43% compared with 96%, 84%, and 65% in the VV ECMO group and 99%, 94%, and 71% in the non-ECMO group. Multivariable Cox regression analysis showed that VA ECMO was associated with increased mortality (hazard ratio, 2.37; 95% CI, 1.06-5.28; P= .04). Patients who required VA ECMO support for PGD grade 3 have significantly worse survival compared with those who did not require ECMO and those who required VV ECMO support. This suggests that VA ECMO treatment of patients with PGD grade 3 after lung transplantation can be a predictable risk factor for mortality.

Interleukin-10: A Potential Pre-Cannulation Marker for Development of Acute Kidney Injury in Patients Receiving Veno-Arterial Extracorporeal Membrane Oxygenation

Introduction: Acute kidney injury (AKI) in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is associated with high mortality. The objective of this study was to investigate whether cytokine levels before the initiation of ECMO treatment could predict AKI. We also aimed to investigate the impact of AKI on 30-day and 1-year mortality. Methods: Serum cytokine levels were analyzed in 100 consecutive VA-ECMO-treated patients at pre-cannulation, at 48 h post-cannulation, and at 8 days. Clinical data to establish the incidence and outcome of AKI after the start of ECMO was retrieved from the local ECMO registry. Setting: The study was conducted at tertiary care, university hospital. Participants included 100 patients treated with VA-ECMO. Interventions: The blood samples for cytokine analysis were collected before VA-ECMO treatment, at 48 h after VA-ECMO treatment was started, and at 8 days. Results: Pre-cannulation serum IL-10 levels were significantly higher in patients who developed AKI (212 [38.9, 620.7]) versus those who did not (49.0 [11.9, 102.2]; p = 0.007), and the development of AKI can be predicted by pre-cannulation IL-10 levels (p = 0.025, OR = 1.2 [1.02–1.32]). The development of AKI during ECMO treatment is associated with increased 30-day mortality (p = 0.049) compared to patients who did not develop AKI and had a pre-cannulation estimated glomerular filtration rate ≥ 45 mL/min. The 1-year survival rate for patients with AKI who survived the first 30 days of ECMO treatment is comparable to that of patients without AKI. Conclusion: Increased pre-cannulation IL-10 levels are associated with the development of AKI during VA-ECMO support. AKI is associated with increased 30-day mortality compared to patients with no AKI and better renal function. However, patients with AKI who survive the first 30 days have a 1-year survival rate similar to those without AKI.

Analysis of 24-hour Death Risk Factors in Circulatory Failure Patients Treated with Venoarterial Extracorporeal Membrane Oxygenation.

To explore the factors affecting short-term prognosis of circulatory failure patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) treatment. A total of 136 patients undergoing VA-ECMO were enrolled in this study and subsequently divided into the death group (n=35) and the survival group (n=101) based on whether death occurred during hospitalisation. Extracorporeal membrane oxygenation (ECMO) running time, length of intensive care unit stay, length of hospital stay, costs, and ECMO complications were then compared between the two groups. The average age of all patients undergoing ECMO was 47.64±16.78 years (53.2±16.20 years in the death group and 45.713±16.62 years in the survival group) (P=0.022). Patients in the survival group exhibited a clear downward trend in lactic acid value following ECMO treatment compared to those in the death group. Total hospitalisation stay was longer in the survival group (35 days) than in the death group (15.5 days) (P<0.001). In the analysis of ECMO complications, the incidence of neurological complications, renal failure, limb complications, and infection were higher in the death group than in the survival group (P<0.05 for all). Specifically, as a risk factor for patient survival and discharge, the occurrence of infection will lead to increased hospitalisation stays and costs (P<0.05 for both). Complications such as kidney failure and infection are associated with in-hospital death, and ECMO-related complications should be actively prevented to improve the survival rate of VA-ECMO treatment.

Characterization and prognostic relevance of neuron specific enolase after cardiopulmonary resuscitation with extracorporeal circulation (e-CPR)

Abstract Background The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is recommended in the current resuscitation guidelines of the European Resuscitation Council as a rescue attempt for selected patients for whom extended resuscitation measures do not lead to the establishment of a spontaneous circulation (ROSC). We aim to characterize and investigate the value of neuron specific enolase (NSE) for assessing the neurological prognosis after cardiopulmonary resuscitation (CPR) as these have so far only been evaluated in resuscitated patients without extracorporeal circulatory support. Methods We retrospectively analyzed the records of patients, who received a VA-ECMO under ongoing CPR between 2004 and 2021 and were treated in a cardiac intensive care unit (ICU) of a university, tertiary care center. Outcome will be measured clinically by using the Glasgow Outcome Score (GOS) four weeks after ICU discharge. Neurological prognosis will be estimated by serum concentration of NSE (baseline until 96h). Serum free hemoglobin (fHb, baseline until 96h) serves as a marker for identifying a potential confounding effect of relevant parallel hemolysis. Results 190 patients were included in our study (baseline characteristics, Figure 1). 154 patients (84.5%) died within 4 weeks after ICU admission or remained unconscious (GOS 1+2), 29 survived (15.5%) with a residual slight to severe neurological deficit (GOS 3–5). Mean duration of VA-ECMO treatment was 103.4±112.1 h. In a wake-up attempt 48–96 h after CPR, patients with GOS 3–5 showed significantly more frequent adequate responses to speech (84% vs. 30.3%; p&amp;lt;0.001). Starting 24h after CPR, NSE was significantly lower and continued to decrease in patients with GOS 3–5 compared to the group with an unfavorable outcome of GOS 1+2 (24h: 34.9±35.9 ng/ml vs. 84.9±90.9 // 48h: 26.5±10.8 vs. 103.1±170.3 // 72h: 30.6±39.3 vs. 96.9±149.1 // 96h: 25.8±20.2 vs. 74.4±97.1; p&amp;lt;0.05; Figure 2). In addition, when evaluating on the basis of receiver operating characteristic curves (ROC) relevant and stable area under the curve (AUC) values for NSE could be calculated (48h: 0.87 // 72h: 0.86 // 96h: 0.84; p&amp;lt;0.001; Figure 2) highlighting the level of discrimination between both outcome groups. On the basis of a binary logistic regression model, relevant odds ratios for the NSE values were found even after adjusting for fHb. The respective adjusted AUCs of the combined predictive probabilities were significant (48h: 0.79 // 72h: 0.77 // 96h: 0.76; p=0.01; Figure 2). Conclusion The neuroprotein NSE makes an early, neurological, prognostic assessment of resuscitated patients possible even during VA-ECMO treatment and could be used in sedated patients as a biomarker for evaluation of treatment decision in acute heart failure such as therapy continuation, eligibility for heart transplantation or LVAD implantation. Funding Acknowledgement Type of funding sources: None.

Femoral artery variation was found during V-A ECMO catheterization

BackgroundHigh bifurcation of the deep femoral artery (DFA) is rare in clinical practice, and patients with this variation are less likely to receive venoarterial extracorporeal membrane oxygenation (V-A ECMO) treatment. Therefore, the method by which V-A ECMO is introduced in patients with vascular variation is very important.Case presentationA 52-year-old male patient had ST elevation myocardial infarction due to coronary heart disease. Angiography showed tripartite coronary artery lesions, and coronary artery stenting supported by V-A ECMO was needed. Vascular evaluation before ECMO catheterization revealed high bifurcation of the bilateral DFA located at the inguinal ligament. After discussion, the perfusion cannula was placed in the left superficial femoral artery (SFA) towards the heart, and the distal perfusion catheter (DPC) was placed in the left SFA towards the distal end. Nevertheless, after the patient's heart recovered, necrosis of the toe of the left lower limb still occurred.ConclusionCommon femoral artery assessment must be performed before V-A ECMO for patients with high bifurcation of the DFA. Incision catheterization and DPC placement are recommended. After decannulation, arterial repair under direct visualisation is recommended, and rigorous distal vascular assessment and management are needed.

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.

Clinical analysis of 6 critically ill children with acute chlorine poisoning

Objective: To analyze the clinical characteristics and treatment of critically ill children with acute chlorine poisoning and explore the risk factors and effective strategies. Methods: This retrospective study collected the clinical data, including general state, clinical characteristics, treatment and follow-up(till 1 year and 6 months after discharge), of 6 critically ill children who were hospitalized in the Pediatric Intensive Care Unit of Beijing Children's Hospital due to acute chlorine poisoning in August 2019. Results: There were 6 children characterized by severe dyspnea in this accident, among whom 4 were boys and two girls, aged 4-12 years. When the accident occurred, they were within 5 m of the chlorine source. These patients underwent tracheal intubation and mechanical ventilation in 3.5-7.0 h after poisoning. The child who was the closest to the chlorine source (1.5 m) and took the longest time (5 min) to evacuate was the most severe one. He suffered hypoxia which could not be corrected by conventional mechanical ventilation and severe shock, then had veno-arterial extracorporeal membrane oxygenation(ECMO) treatment started 10 h after the accident. All the 6 children in this study survived. Following-up found no growth and developmental abnormality. The pulmonary function tests were normal except for one case with increased small airway resistance due to previous suspected asthma, and the lung CT, electhoencephalogram, and brain magnetic resonance imaging were all normal. Conclusions: Severe chlorine poisoning is mainly characterized by respiratory failure. Mechanical ventilation is often required within a few hours after poisoning. When conventional mechanical ventilation is ineffective, ECMO could save live. Timely treatment could improve prognosis.