VV Extracorporeal Membrane Oxygenation Research Articles

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.

Profiling endogenous adrenal function during veno-venous ECMO support in COVID-19 ARDS: a descriptive analysis.

Prolonged critical illness is often accompanied by an impairment of adrenal function, which has been frequently related to conditions complicating patient management. The presumed connection between hypoxia and the pathogenesis of this critical- illness- related corticosteroid insufficiency (CIRCI) might play an important role in patients with severe acute respiratory distress syndrome (ARDS). Since extracorporeal membrane oxygenation (ECMO) is frequently used in ARDS, but data on CIRCI during this condition are scarce, this study reports the behaviour of adrenal function parameters during oxygenation support with veno-venous (vv)ECMO in coronavirus disease 2019 (COVID-19) ARDS. A total of 11 patients undergoing vvECMO due to COVID-19 ARDS at the Medical University of Vienna, who received no concurrent corticosteroid therapy, were retrospectively included in this study. We analysed the concentrations of cortisol, aldosterone, and angiotensin (Ang) metabolites (Ang I-IV, Ang 1-7, and Ang 1-5) in serum via liquid chromatography/tandem mass spectrometry before, after 1 day, 1 week, and 2 weeks during vvECMO support and conducted correlation analyses between cortisol and parameters of disease severity. Cortisol concentrations appeared to be lowest after initiation of ECMO and progressively increased throughout the study period. Higher concentrations were related to disease severity and correlated markedly with interleukin-6, procalcitonin, pH, base excess, and albumin during the first day of ECMO. Fair correlations during the first day could be observed with calcium, duration of critical illness, and ECMO gas flow. Angiotensin metabolite concentrations were available in a subset of patients and indicated a more homogenous aldosterone response to plasma renin activity after 1 week of ECMO support. Oxygenation support through vvECMO may lead to a partial recovery of adrenal function over time. In homogenous patient collectives, this novel approach might help to further determine the importance of adrenal stress response in ECMO and the influence of oxygenation support on CIRCI.

Calcium Channel Blocker Overdose: What Role Does Extracorporeal Membrane Oxygenation Have in Support? A Systematic Review of the Literature.

Extracorporeal membrane oxygenation (ECMO) has had increasing prevalence and indications in the last decade. Calcium channel blocker overdose (CCBOD) can lead to significant cardiopulmonary dysfunction and has also increased in recent years. CCBOD results in cardiac depression, vasoplegia, and hyperglycemia. Expert consensus recommends 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 associated with use. Electronic literature review identified all relevant studies for CCBOD and ECMO. PRISMA guidelines for systematic review were followed. Three independent authors reviewed abstracts and full texts, and only CCB ingestion without polypharmacy was included. Two authors independently collected data, which included demographics, current medical treatments, ECMO type, and survival. From 314 abstracts, 25 papers were included with a median publication year of 2019. Twenty-six patients were included with an average age of 32.7 years and 42%/58% male/female. Average time on ECMO 4.3 days. VA and VV ECMO use were 92.3% and 7.7%, respectively, and 84.6% of patients survived to hospital discharge. Before ECMO, most patients received 4-5 medical treatments (53.8%). Our systematic review demonstrates ECMO is a newly used, yet valuable therapy for CCBOD when medical treatment fails. Survival to discharge after ECMO for CCBOD is substantially higher than standard VV or VA ECMO. Medical management is still the mainstay therapy for CCBOD, but we show that a persistently unstable patient may benefit from prompt evaluation at an ECMO center for treatment.

Cardiac Tamponade Complicating Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis

Cardiac tamponade is a potentially life-threatening complication during extracorporeal membrane oxygenation (ECMO). In this study, the authors assessed the incidence, patient characteristics, and risk factors for mortality of cardiac tamponade during ECMO. The authors queried the Extracorporeal Life Support Organization (ELSO) Registry from 1997 to 2021 for all adults with cardiac tamponade as a reported complication during ECMO. Cardiac tamponade was reported in 2,176 (64% men; 53.8 ± 0.33 years) of 84,430 adults (2.6%). Venoarterial ECMO was the main configuration (78%), followed by venovenous ECMO (VV ECMO) (18%), for cardiac (67%), pulmonary (21%) support, and extracorporeal cardiopulmonary resuscitation (ECPR) (12%). Percutaneous cannulation was performed in 51%, with the femoral vein and femoral artery as the most common sites for drainage and return cannulae, with dual-lumen cannulae in 39% of VV ECMO. Hospital survival was lower (35% v 49%; p < 0.01) when compared with that of all adults from the ELSO Registry. In multivariate analysis, age, aortic dissection and/or rupture, COVID-19, ECPR, pre-ECMO renal-replacement therapy, and prone position are associated with hospital mortality, whereas ECMO for pulmonary support is associated with hospital survival. Similarly, renal, cardiovascular, metabolic, neurologic, and pulmonary complications occurred more frequently in nonsurvivors. Cardiac tamponade is a rare complication during ECMO that, despite being potentially reversible, is associated with high hospital mortality. Venoarterial ECMO is the most common configuration. ECMO for pulmonary support was associated with higher survival, and ECPR was associated with higher mortality. In these patients, other ECMO-related complications were frequently reported and associated with hospital mortality.

2420. Analysis of Diagnostic Criteria for ECMO-Associated Pneumonia

Abstract Background Ventilator-associated pneumonia (VAP) is a well-established cause of morbidity and mortality in critically ill patients, but diagnostic criteria exclude patients on extracorporeal membrane oxygenation (ECMO). Despite this, VAP has been used to approximate pneumonia in patients on ECMO for study purposes (Figure 1). An adequate definition to recognize and prevent nosocomial pneumonia in this population is needed. Our institution began looking at a set of diagnostic criteria for EAP (ECMO-Associated Pneumonia, Figure 2). We performed a retrospective analysis to test the validity of VAP and our new EAP definition as diagnostic criteria for pneumonia in ECMO patients.Figure 1.Criteria for Probable VAP. Simplified from NHSN criteria. VAC=ventilator-associated condition. iVAC=infection-related ventilator-associated condition. VAP=ventilator-associated pneumonia.Figure 2.Proposed diagnostic criteria for ECMO-associated pneumonia (EAP) Methods Our center maintains a database of clinical parameters for patients on ECMO, which includes outcomes of interest verified in real time. Patient charts coded as having an outcome of pneumonia from 2018 to 2021 were pulled and independently adjudicated to determine if they met our inclusion criteria (Figure 3). 20 patients were identified as having at least one event. We observed their stay on ECMO up to 30 days. We calculated the established VAP criteria (Figure 1) and our proposed EAP criteria (Figure 2) daily. Dates of clinical pneumonia were time of positive culture and subsequent 5 days.Figure 3.Selection process for study population. BAL=bronchoalveolar lavage Results 85% of patients were on VV ECMO and 50% patients with SARS-CoV-2 (Table 1). In 20 patients with clinically diagnosed, culture confirmed pneumonia, only 1% of patients met criteria for Probable VAP (sensitivity 4%, Table 2). Probable EAP Definition 2 was the most sensitive model for predicting clinical pneumonia (sensitivity 91.1%), followed distantly by the Confirmed EAP model (sensitivity 19.6%). The EAP model had a stronger relationship with clinical pneumonia than the VAP model as demonstrated by the ROC curves (Figure 4). Individual components (flow, sweep, FiO2, PEEP) could not predict onset of clinical pneumonia within 48 to 72 hours.Table 1.Characteristics of study population Table 2. Percentage of days with pneumonia as identified by each set of diagnostic criteria, with sensitivity calculated. Figure 4 ROC curves for comparison. Probable EAP Definition 2 had the highest sensitivity for diagnosing EAP. Conclusion Our study reiterates that VAP criteria should not be used to approximate diagnosis of pneumonia in patients on ECMO. As oxygenation and sepsis triggers adjustment of flow and sweep we found this in combination with infectious parameters, and BAL culture that was more sensitive in predicting clinical pneumonia. These measures require validation in a larger cohort. Disclosures James Kirklin, MD, Data Center for STS Intemacs/Pedimacs Registries: Director, partial salary support|Kirklin Solutions, Inc.: Ownership Interest

ECMO in trauma care: What you need to know.

Over the past 10 years, extracorporeal membrane oxygenation (ECMO) use in trauma patients has increased significantly. This includes adult and pediatric trauma patients and even combat casualties. Most ECMO applications are in a venovenous (VV ECMO) configuration for acute hypoxemic respiratory failure or anatomic injuries that require pneumonectomy or extreme lung rest in a patient with insufficient respiratory reserve. In this narrative review, we summarize the most common indications for VV ECMO and other forms of ECMO support used in critically injured patients, underscore the importance of early ECMO consultation or regional referral, review the technical aspects of ECMO cannulation and management, and examine the expected outcomes for these patients. In addition, we evaluate the data where it exists to try to debunk some common myths surrounding ECMO management.

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.

P94: Successful Extracorporeal Membrane Oxygenation Course in an Acquired Immune Deficiency Syndrome (AIDS) Patient with Acute Respiratory Distress Syndrome (ARDS) Complicated by Pneumocystis jirovecii Pneumonia and COVID-19: A Unique Case

Background: The use of extracorporeal membrane oxygenation (ECMO) in patients who have acute respiratory distress syndrome has been shown to have very good outcomes. However, there is limited data to support the initiation of ECMO in patients who have human immunodeficiency virus infection with or without acquired immune deficiency syndrome. We review the current literature and case reports of patients placed on Venous-Venous ECMO support for HIV and AIDS, with confection with Pneumocystis pneumonia and covid-19 pneumonia. Methods: We present a unique and challenging case of a 30 year old male, with no known past medical history, unvaccinated against covid-19, who presented with one week of progressive shortness of breath. On admission he was found with moderate bilateral infiltrates and was diagnosed with covid-19 pneumonia. Despite appropriate medical therapy, patient developed worsening hypoxic respiratory failure. Found to have elevated (1-3)-β-d-glucan and tested positive for HIV. CD4 count 11, HIV viral load 70,000. The patient remained severely hypoxemic despite mechanical ventilation, sedation, paralytics and proning. Venous venous extracorporeal membrane oxygenation was initiated. Considering his non improvement with variety of antivirals and antibiotics and with elevated (1-3)-β-d-glucan in the setting of AIDS he was treated for presumed Pneumocystis pneumonia. The patient tolerated proning while on VV ECMO and his course was complicated with bilateral pneumothorax necessitating chest tube placement. Results: The patient successfully completed 64 days on VV ECMO, where he was treated for PCP pneumonia, covid pneumonia, CMV viremia and tolerated initiation of anti-retroviral therapy. Patient was successfully decannulated, and ultimately discharged from the hospital. Conclusion: VV-ECMO can be a beneficial intervention with successful outcomes in severely immunocomprimised patients with AIDS. This case highlights the importance of minimizing sedation and early mobilization on ECMO support.Figure 1. CT Chest with contrast approximately 40 days on VV ECMO

PULM14: Long-haul ECMO as Bridge to Transplant in COVID-19 ARDS

Background: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LT) is an established treatment modality for refractory acute respiratory distress syndrome (ARDS). Per the Scientific Registry of Transplant Recipients (SRTR) database, 215 patients supported on ECMO due to the Coronavirus disease of 2019 (COVID-19) related ARDS underwent LT between August 2020 and June 2022. The COVID-19 pandemic limited donor availability and increased duration of ECMO support in ECMO-dependent patients listed for LT. Outcomes of long-term ECMO as bridge to transplant (BTT) in this population remain unclear, and no cases of VV ECMO greater than 200 days has been documented in the literature. Methods: A single-center review was conducted to identify patients cannulated for VV-ECMO to treat COVID-19 associated ARDS between January 1, 2021 and January 1, 2022. Patients were selected who were supported by VV-ECMO for ARDS secondary to COVID-19 for greater than 200 days before receiving a lung transplant. Detailed analysis was performed for the outcomes and characteristics of all patients who received a lung transplant for post-COVID-19 ARDS after >200 days of VV-ECMO support. Results: Three patients were identified as long-term ECMO as BTT recipients (>200 days) for COVID-19-associated ARDS. Average age was 38 years (22,52), BMI 32.9 (31.6,34) and no patients had any known relevant respiratory medical history. One patient had a history of daily e-cigarette use. All patients were unvaccinated at the time of first positive COVID-19 test. All were successfully bridged to bilateral lung transplant (BLT) off of VV-ECMO. None required VV-ECMO post-operatively. One patient required VA-ECMO post-operatively for elevated pulmonary arterial pressures related to incidentally discovered septal defects. Average ECMO duration was 278 days (250, 324). Two patients were cannulated as bridge to recovery, and one as bridge to decision. Patients remained ambulant on ECMO support until they were able to undergo the transplant procedure. Cannulation strategies included double lumen right internal jugular (RIJ), RIJ to right femoral vein, and bifemoral venous cannulation. Complications on ECMO included sepsis, hemorrhage, stroke, reconfiguration, and atrial fibrillation. Two were discharged to home and one to inpatient rehabilitation. Average length of stay after transplant was 27 days (16,37). All 3 patients have continued to do well. Conclusion: We present three patients with the longest documented VV-ECMO support for COVID-19 ARDS a bridge to lung transplant. Our findings suggest long-term VV-ECMO support is a feasible bridge to LT for patients with COVID-19-related ARDS when used in the long-term (>200 days). The duration of ECMO support remains associated with known ECMO-related complications. Post-transplant survival to-date suggests that survival in long-term ECMO support as a BTT may be comparable to short-term ECMO in patients with COVID-19-related ARDS.

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.

Extracorporeal Membrane Oxygenation in Intoxication and Overdoses: A Systematic Review.

Extracorporeal membrane oxygenation (ECMO) has been increasingly applied over recent decades to treat severe cardiogenic shock and acute lung failure and cardiac arrest of various causes. Acute intoxication with therapeutic substances or other chemical substances can cause severe cardiogenic shock or even cardiac arrest. The purpose of this study was to conduct a qualitative systematic review of ECMO use in intoxication and poisoning. We searched the PubMed, Medline, and Web of Science databases from January 1971 to December 2021 and selected appropriate studies according to our inclusion and exclusion criteria to evaluate the role of ECMO in intoxication and poisoning systematically. Survival at hospital discharge was examined to describe the outcome. The search resulted in 365 publications after removing duplicates. In total, 190 full-text articles were assessed for eligibility. A total of 145 articles from 1985 to 2021 were examined in our final qualitative analysis. A total of 539 (100%) patients were included (mean age: 30.9 ± 16.6 years), with a distribution of n = 64 (11.9%) cases with venovenous (vv) ECMO, n = 218 (40.4%) cases with venoarterial (va) ECMO, and n = 257 (47.7%) cases with cardiac arrest and extracorporeal cardiopulmonary resuscitation. Survival at hospital discharge was 61.0% for all patients, 68.8% for vaECMO, 75% for vvECMO, and 50.9% for extracorporeal cardiopulmonary resuscitation. When used and reported, ECMO seems to be a valid tool for adult and pediatric patients suffering intoxication from various pharmaceutical and nonpharmaceutical substances due to a high survival rate at hospital discharge.

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.

132: ANTI THE ANTICOAGULATION IN ECMO? A SURVEY OF PRACTICES IN ADULT ECMO PATIENTS

Introduction: Two of the major risks associated with extracorporeal membrane oxygenation (ECMO) are bleeding and thromboembolism. Due to concerns for thrombosis, particularly of the circuit and oxygenator, the Extracorporeal Life Support Organization (ELSO) recommends that ECMO patients be systemically anticoagulated. However, several recent trials have called into question the preferred anticoagulant with direct thrombin inhibitors (DTIs) potentially supplanting unfractionated heparin (UFH) due to their more favorable pharmacokinetic profile and potential superiority. There is also increasing evidence in VV ECMO to suggest lower therapeutic ranges, or even no anticoagulation, are safe and effective strategies. The purpose of this survey was to assess and describe anticoagulation prescribing patterns at adult ECMO centers. Methods: An electronic survey was distributed to respondents through the ELSO newsletter and discussion board. The primary objective was to identify the primary anticoagulant utilized by respondent institutions. Secondary objectives included identifying anticoagulation monitoring methods, rationale for switching from UFH, and VV ECMO anticoagulation practices. Institutional demographics, standard anticoagulant and monitoring method, rationale for switching from UFH, and anticoagulation practices in VV ECMO patients were all assessed. Results: Eighteen centers completed the survey, with 17 of the 18 (94%) being ELSO designated centers. Most respondents (67%) were pharmacists at their respective institutions. UFH was identified as the primary anticoagulant at most centers (78%) with activated partial thromboplastin time (aPTT) (64%) and anti-Xa (21%) being the most common monitoring methods. The main reason for switching from UFH to a DTI was heparin-induced thrombocytopenia (HIT) (93%). There was variability with regards to anticoagulation practices for VV ECMO patients with 44% of centers anticoagulating all patients, 39% anticoagulating depending on patient specific factors, and 17% not anticoagulating at all. Conclusions: While UFH remains the anticoagulant of choice at most centers despite recent evidence, variability still exists with monitoring methods and anticoagulation practices for VV ECMO patients. Further research is necessary to standardize anticoagulation practices.

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.

809: ANTICOAGULATION IN ADULT ECMO: PERCENTAGE OF TIME IN THERAPEUTIC RANGE WITH HEPARIN OR BIVALIRUDIN

Introduction: There is debate regarding optimal anticoagulation strategies in adults receiving extracorporeal membrane oxygenation (ECMO). While unfractionated heparin (UFH) is most utilized, there is increasing use of alternate anticoagulants. This investigation examined the efficacy and safety of UFH versus bivalirudin. Methods: This retrospective, observational study examined adult (age >= 18 years) ECMO patients who received UFH or bivalirudin for systemic anticoagulation in a health system between January 1, 2015 and November 30, 2020. Demographics, lab values, ECMO type, anticoagulation strategy, and clinical outcomes were collected. The primary outcome was percentage of time spent in the therapeutic range, defined by coagulation labs. Secondary outcomes included time to reach therapeutic goal and clinical events. Univariable and multivariable comparisons, controlling for ECMO type and admission period, were performed. Impact of admission period between 2015-2017 and 2018-2020 was analyzed due to changes in anticoagulation practices. Results: There were 118 patients, of whom 39% (n=46) received UFH and 61% (n=72) received bivalirudin. Demographics were similar between groups. More VV ECMO patients were in the bivalirudin group (65%) than in the UFH group (24%) (p< 0.001). Bivalirudin treated patients reached therapeutic range sooner than UFH treated patients (median time 9.3 vs. 16.5 hours, p= 0.0236) although this difference was not significant when controlling for ECMO type and admission period. Bivalirudin treated patients spent a greater percentage of time in therapeutic range compared to UFH treated patients (median 80% vs 24%, p < .0001), an effect that persisted after controlling for ECMO type and admission period (66% vs 39%, p=0.0002). There were no differences between groups in length of stay, days on ECMO, safety outcomes, or inpatient mortality. In multivariable modeling, UFH treated patients received more red blood cell transfusions per ECMO day compared to bivalirudin treated patients (1.40 vs 0.90, p=0.048). Conclusions: A bivalirudin strategy offered more time spent in therapeutic range and fewer blood product transfusions compared to UFH in adult ECMO patients and had similar clinical and safety outcomes. Bivalirudin is a viable anticoagulant for adult patients receiving ECMO.

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.

Diagnosis and treatment of right ventricular dysfunction in patients with COVID-19 on veno-venous extra-corporeal membrane oxygenation

BackgroundVeno-venous (VV) extracorporeal membrane oxygenation (ECMO) is an effective, but highly resource intensive salvage treatment option in COVID patients with acute respiratory distress syndrome (ARDS). Right ventricular (RV) dysfunction is a known sequelae of COVID-19 induced ARDS, yet there is a paucity of data on the incidence and determinants of RV dysfunction on VV ECMO. We retrospectively examined the determining factors leading to RV failure and means of early identification of this phenomenon in patients on VV ECMO.MethodsThe data was extracted from March 2020 to March 2021 from the regional University of Washington Extracorporeal Life Support database. The inclusion criteria included patients > 18 years of age with diagnosis of COVID-19. All had already been intubated and mechanically ventilated prior to VV ECMO deployment. Univariate analysis was performed to identify risk factors and surrogate markers for RV dysfunction. In addition, we compared outcomes between those with and without RV dysfunction.ResultsOf the 33 patients that met inclusion criteria, 14 (42%) had echocardiographic evidence of RV dysfunction, 3 of whom were placed on right ventricular assist device support. Chronic lung disease was an independent risk factor for RV dysfunction (p = 0.0002). RV dysfunction was associated with a six-fold increase in troponin I (0.07 ng/ml vs. 0.44 ng/ml, p = 0.039) and four-fold increase in brain natriuretic peptide (BNP) (158 pg/ml vs. 662 pg/ml, p = 0.037). Deep vein thrombosis (DVT, 21% vs. 43%, p = 0.005) and pulmonary embolism (PE, 11% vs. 21%, p = 0.045) were found to be nearly twice as common in the RV dysfunction group. Total survival rate to hospital discharge was 39%. Data trended towards shorter duration of hospital stay (47 vs. 65.6 days, p = 0.15), shorter duration of ECMO support (21 days vs. 36 days, p = 0.06) and improved survival rate to hospital discharge (42.1% vs. 35.7%, p = 0.47) for those with intact RV function compared to the RV dysfunction group.ConclusionsRV dysfunction in critically ill patients with COVID-19 pneumonia in common. Trends of troponin I and BNP may be important surrogates for monitoring RV function in patients on VV ECMO. We recommend echocardiographic assessment of the RV on such patients.

Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 Patients

ObjectivesA paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19.DesignSingle-center retrospective cohort study.SettingThe study took place in the intensive care unit of an academic tertiary center.ParticipantsThe authors included 107 patients with confirmed SARS-CoV-2 infection who underwent bedside venovenous ECMO (VV ECMO) cannulation under TEE guidance between May 2020 and June 2021.InterventionsTEE-guided bedside VV ECMO cannulation.MeasurementsPatient characteristics, physiologic and ventilatory parameters, and echocardiographic findings were analyzed. The primary outcome was the number of successful TEE-guided bedside cannulations without complications. The secondary outcomes were cannulation complications, frequency of cannula repositioning, and TEE-related complications.Main ResultsTEE-guided cannulation was successful in 99% of the patients. Initial cannula position was adequate in all but 1 patient. Fourteen patients (13%) required cannula repositioning during ECMO support. Forty-five patients (42%) had right ventricular systolic dysfunction, and 9 (8%) had left ventricular systolic dysfunction. Twelve patients (11%) had intracardiac thrombi. One superficial arterial injury and 1 pneumothorax occurred. No pericardial tamponade, hemothorax or intraabdominal bleeding occurred in the authors’ cohort. No TEE-related complications or COVID-19 infection of healthcare providers were reported during this study.ConclusionsBedside TEE guidance for VV ECMO cannulation is safe in patients with severe respiratory failure due to COVID-19. No tamponade or hemothorax, nor TEE-related complications were observed in the authors’ cohort.

COVID–19によるARDSを来した短頚の高度肥満女性に対し両側大腿静脈カニュレーションによるECMOを用いて救命した1例(A case of extracorporeal membrane oxygenation with bilateral femoral vein cannulation in a morbidly obese woman with a short neck who had acute respiratory distress syndrome due to coronavirus disease 2019)

ABSTRACTWe present a case of a morbidly obese 44–year–old woman with a short neck who had nasal discharge 3 days prior to admission. She was diagnosed with acute respiratory distress syndrome due to coronavirus disease 2019 (COVID–19) using severe acute respiratory syndrome–coronavirus–2 polymerase chain reaction test and was admitted to our hospital the following day. Her respiratory condition gradually worsened. On day 9 of hospitalization, she was intubated and transferred to our department. On day 4 after admission to the intensive care unit (ICU), her P/F ratio was 82.6. Therefore, extracorporeal membrane oxygenation (ECMO) was warranted. Since she had a short neck, the cannula could not be inserted through the jugular vein. Therefore, veno–venous ECMO was initiated through the left and right femoral veins. On day 30, the patient was weaned off ECMO. On day 36, she was extubated, and on day 47, she was discharged from the ICU. Finally, on day 55, she was discharged from the hospital. In morbidly obese patients with short necks, VV–ECMO with bilateral femoral venipuncture may be a treatment option. Thus, it is important to understand its advantages and disadvantages to ensure proper management.

Heparin-free after 3000 IU heparin loaded in veno-venous ECMO supported acute respiratory failure patients with hemorrhage risk: a novel anti-coagulation strategy

BackgroundThe anti-coagulation protocol of patients with hemorrhage risk primary disease who need extracorporeal membrane oxygenation (ECMO) supported is controversial. This study evaluated the feasibility of a new anti-coagulation strategy, that is heparin-free after 3000 IU heparin loaded in veno-venous ECMO (VV ECMO) supported acute respiratory failure patients with hemorrhage risk.MethodsA retrospective study was performed in a series of hemorrhage risk patients supported with VV ECMO at the First Affiliated Hospital of Zhengzhou University, between June 2012 to Sept 2020. A total of 70 patients received a low heparin bolus of 3000 units for cannulation but without subsequent, ongoing heparin administration. Patients were divided into survival (n = 25) and non-survival group (n = 45). Data of coagulation, hemolysis and membrane lung function were calculated and analyzed. The complications of patients were recorded. Finally, the binary Logistic regression was conducted.ResultsThe longest heparin-free time was 216 h, and the mean heparin-free time was 102 h. Compared with survivors, the non-survivors were showed higher baseline SOFA score and lower platelet counts in 0.5 h, 24 h, 48 h and 96 h after ECMO applied. However, there was no significant differences between survivors and non-survivors in ACT, APTT, INR, D-dimer, fibrinogen, LDH, blood flow rate, Δp and Ppost-MLO2 (all p < 0.05) of all different time point. Moreover, only the baseline SOFA score was significantly associated with mortality (p < 0.001, OR(95%CI): 2.754 (1.486–5.103)) while the baseline levels of ACT, APTT, INR, platelet, D-dimer, fibrinogen and LDH have no association with mortality. The percentage of thrombosis complications was 54.3% (38/70) including 3 oxygenator changed but there was no significant difference of complications in survival and non-survival groups (p > 0.05).ConclusionsThe anticoagulation protocol that no heparin after a 3000 units heparin bolus in VV ECMO supported acute respiratory failure patients with hemorrhage risk is feasible.