Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) severe respiratory failure in Japan

Usefulness of the Yokohama Advanced Cardiopulmonary Help Team in patients with acute respiratory distress syndrome

Aim

To evaluate whether establishing an extracorporeal membrane oxygenation (ECMO) specialist team, termed the Yokohama Advanced Cardiopulmonary Help Team (YACHT), affected the outcomes and centralization of patients requiring ECMO in Yokohama-Yokosuka regions.

Methods

This retrospective observational study included patients aged ≥18 years and treated with venovenous-ECMO for severe acute respiratory distress syndrome (ARDS) from 2014 to 2023. The primary outcome was intensive care unit (ICU) mortality. The secondary outcomes included ICU-, mechanical ventilator-, and ECMO-free days and complications during the first 28 days.

Results

This study included 46 (12 without- and 34 with-YACHT) patients. Among with-YACHT patients, 24 were transferred to our hospital from other hospitals, 14 were assessed by dispatched ECMO physicians, and 9 were transferred after ECMO introduction. No without-YACHT patients were transferred from other hospitals. With-YACHT patients experienced coronavirus disease 2019-associated respiratory failure more frequently (0 vs. 27, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation II scores (19 vs. 24, p = 0.037) and lower Respiratory Extracorporeal Membrane Oxygenation Survival Prediction scores (4 vs. 2, p = 0.021). ICU mortality was not significantly different between the groups (2 vs. 4, p = 0.67). ICU- (14 vs. 9, p = 0.10), ventilator- (11 vs. 5, p = 0.01), and ECMO-free days (20 vs. 14, p = 0.038) were higher before YACHT establishment. The incidences of complications were not significantly different between the groups.

Conclusions

Mortality was not significantly different pre- and post-YACHT establishment; however, it helped promote regionalization and centralization in Yokohama-Yokosuka areas. We will collect more cases to demonstrate YACHT's usefulness.

Emergency and successful management for a case of inferior vena cava perforation caused by cannulation of venovenous extracorporeal membrane oxygenation: A case report

RATIONALE

Vascular complications associated with extracorporeal membrane oxygenation (ECMO) increase the in-hospital mortality. Perforation of the inferior vena cava (IVC) during venovenous extracorporeal membrane oxygenation (V-V ECMO) cannulation and subsequent emergency management prior to vascular surgery has rarely been reported.

PATIENT CONCERNS

A 72-year-old female was diagnosed with IVC perforation caused by venovenous extracorporeal membrane oxygenation cannulation.

DIAGNOSES

Abdominal computed tomography venography with 3D reconstruction confirmed that the cannula tip had perforated the abdominal cavity from the conjunction of the iliac vein and IVC. As a result, the patient was diagnosed with inferior vena cava perforation.

INTERVENTIONS

Attempts to reposition the dislocated cannula using digital subtraction angiography were unsuccessful. However, we found that ECMO could maintain a stable blood flow; therefore, we decided to keep ECMO running, and to minimize blood loss from the puncture site, we ensured adequate blood transfusion while operating V-V ECMO. Subsequently, emergency laparotomy was performed to fix the vascular lesion, and we established a new V-V ECMO circuit through cannulation of the bilateral internal jugular veins.

OUTCOMES

In the case of confirmed V-V ECMO-related vascular perforation of the IVC, it is crucial to continue ECMO device operation to maintain negative pressure in the IVC and position the dislocated catheter to block the perforation site, effectively controlling bleeding. Therefore, emergency laparotomy should be promptly performed for vascular repair. Fortunately, the patient recovered successfully and was subsequently discharged.

LESSONS

This case highlights several important lessons: When advancing a cannula, in this case, it is essential to first identify the guidewire placement to ensure proper guidance; In the event of a confirmed V-V ECMO-related vascular perforation of the IVC, maintaining negative pressure in the IVC through continued ECMO device operation and positioning the dislocated catheter to block the perforation site are crucial steps to control bleeding prior to emergency open vascular repair; After undergoing vascular repair, if ECMO support is still necessary, it is advisable to opt for a catheterization strategy that avoids previously repaired blood vessels.

Extracorporeal Membrane Oxygenation Support for Influenza A: Retrospective Review of the Extracorporeal Life Support Organization Registry Comparing H1N1 With Other Subtypes

Supplemental Digital Content is available in the text.

OBJECTIVES:

Although there is a substantial published experience of extracorporeal membrane oxygenation during the H1N1 pandemic, less is known about the use of extracorporeal membrane oxygenation in patients with other subtypes of the influenza A virus. We hypothesized that the severity of illness and survival of patients supported with extracorporeal membrane oxygenation would differ for those with H1N1 influenza A compared with other subtypes of influenza A.

DESIGN, SETTING, PATIENTS:

Retrospective study of extracorporeal membrane oxygenation–supported adults (> 18 yr) with influenza A viral infection reported to the Extracorporeal Life Support Organization Registry between 2009 and 2019. We describe the frequency and compare characteristics and factors associated with in-hospital survival using a least absolute shrinkage and selection operator regression analysis.

MAIN OUTCOMES AND MEASURES:

Of 2,461 patients supported with extracorporeal membrane oxygenation for influenza A, 445 had H1N1, and 2,004 had other subtypes of influenza A. H1N1 was the predominant subtype between 2009 and 2011. H1N1 patients were younger, with more severe illness at extracorporeal membrane oxygenation cannulation and higher reported extracorporeal membrane oxygenation complications than those with other influenza A subtypes. Patient characteristics including younger age and higher weight and patient management characteristics including longer ventilation duration before extracorporeal membrane oxygenation were associated with worse survival. Extracorporeal membrane oxygenation complications were associated with reduced survival. There was no difference in survival to hospital discharge according to influenza subtype after adjusting for other characteristics.

CONCLUSIONS:

Patients supported with extracorporeal membrane oxygenation for H1N1 were younger, with more severe illness than those supported for other influenza A subtypes. Survival to hospital discharge was associated with patient characteristics, management characteristics, and extracorporeal membrane oxygenation complications but was not impacted by the specific influenza A subtype.

Severe Patients With ARDS With COVID-19 Treated With Extracorporeal Membrane Oxygenation in China: A Retrospective Study

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has become a global health crisis affecting over 200 countries worldwide. Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the management of COVID-19-associated end-stage respiratory failure. However, the exact effect of ECMO in the management of these patients, especially with regards to complications and mortality, is unclear.

Methods: This is the largest retrospective study of ECMO treated COVID-19 patients in China. A total of 50 ECMO-treated COVID-19 patients were recruited. We describe the main characteristics, the clinical features, ventilator parameters, ECMO-related variables and management details, and complications and outcomes of COVID-19 patients with severe acute respiratory distress syndrome (ARDS) that required ECMO support.

Results: For those patients with ECMO support, 21 patients survived and 29 died (mortality rate: 58.0%). Among those who survived, PaO₂ (66.3 mmHg [59.5–74.0 mmHg] and PaO₂/FiO₂ (68.0 mmHg [61.0–76.0 mmHg]) were higher in the survivors than those of non-survivors (PaO₂: 56.8 mmHg (49.0–65.0 mmHg), PaO₂/FiO₂ (58.2 mmHg (49.0–68.0 mmHg), all P < 0.01) prior to ECMO. Patients who achieved negative fluid balance in the early resuscitation phase (within 3 days) had a higher survival rate than those who did not (P = 0.0003).

Conclusions: In this study of 50 cases of ECMO-treated COVID-19 patients, a low PO₂/FIO₂ ratio before ECMO commencement may indicate a poor prognosis. Negative fluid balance in the early resuscitation phase during ECMO treatment was a predictor of increased survival post-ECMO treatment.

Establishment of a Disaster Management-like System for COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation in Japan

The coronavirus disease 2019 (COVID-19) pandemic has increased the number of patients who require extracorporeal membrane oxygenation (ECMO). To manage the demand for ECMO, Japan ECMOnet for COVID-19 was developed as a “disaster management-like system”, utilizing the Cross ICU Searchable Information System (CRISIS) database. This study investigated the effect of the establishment of this disaster management-like system in Japan. This was a nationwide retrospective observational study conducted from 1 February to 31 July in 2020. A total of 187 patients with COVID-19 who received ECMO were included. The median age was 60 years (interquartile range, 53–68), the median length of ventilatory support before ECMO was 3 days (1–5), and the median PaO₂ to FiO₂ ratio at ECMO initiation was 86 (71.3–101.5). During the study period, 165 telephone consultations were conducted, including general questions about ECMO. Among them, 44 concerned patients who were already on ECMO or who ultimately received ECMO. Further coordination, including transport and ECMO physician dispatch, was provided for 23 cases. Overall, 125/187 (66.8%) patients were successfully weaned from ECMO. This study demonstrated that Japan has achieved favorable survival outcomes for patients with COVID-19 who received ECMO with a disaster management-like system. Further research on the causes of these outcomes is needed.

COVID–19呼吸不全に対して3本目のカニューレを用いたVV–V ECMO管理(Role of triple cannulation venovenous extracorporeal membrane oxygenation in patients with coronavirus disease)

A 32–year–old man with dry cough was admitted to a hospital for suspected coronavirus disease–induced pneumonia. The SARS–CoV–2 PCR test showed positive results on day 3 after symptom onset. Mechanical ventilation and venovenous extracorporeal membrane oxygenation (VV ECMO) were initiated for respiratory function deterioration on day 8 after symptom onset. However, ECMO did not maintain adequate oxygenation, and ventilator settings did not allow lung rest. Therefore, secondary ECMO transport was performed, and the patient was transferred to our center via ECMOnet. The reduced oxygenation level was attributed to the use of a small drainage cannula with consequently reduced ECMO circulation. Replacement of the small drainage cannula was unsafe; therefore, an additional drainage cannula was inserted, and the ECMO configuration was switched to VV–V ECMO, which established sufficient ECMO circulation and improved his oxygenation levels, and ventilator settings were modified for lung rest. He was weaned off ECMO on day 14, and retransferred to the previous hospital on day 21 after symptom onset. Selection of a drainage cannula of optimal size is important in patients who receive VV ECMO support. Conversion of a VV ECMO to VV–V ECMO configuration is useful in cases of insufficient ECMO blood flow.

Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.

Use of Venovenous Extracorporeal Membrane Oxygenation in Critically-Ill Patients With COVID-19

Acute respiratory distress syndrome (ARDS) related to Coronavirus disease (COVID-19) is associated with high mortality. It has been suggested that venovenous extracorporeal membrane oxygenation (ECMO) was suitable in this indication, albeit the effects of ECMO on the mechanical respiratory parameters have been scarcely described. In this case-series, we prospectively described the use of venovenous ECMO and its effects on mechanical respiratory parameters in eleven COVID-19 patients with severe ARDS. Implantation of ECMO occurred 6 [3–11] days after the onset of mechanical ventilation. At the time of ECMO implantation, all patients received neuromuscular blocking agents, three (27%) received inhaled nitric oxide and prone positioning was performed in all patients with 4 [3−5] sessions of PP per patient. Under ECMO, the tidal volume was significantly decreased from 6.1 [4.0–6.3] to 3.4 [2.5–3.6] mL/kg of predicted body weight and the positive end-expiratory pressure level was increased by 25 ± 27% whereas the driving pressure and the mechanical power decreased by 33 ± 25% and 71 ± 27%, respectively. The PaO₂/FiO₂ ratio significantly increased from 68 [58–89] to 168 [137–218] and the oxygenation index significantly decreased from 28 [26–35] to 13 [10–15]. The duration of ECMO was 12 [8–25] days. Nine (82%) patients experienced ECMO-related complications and the main complication was major bleeding requiring blood transfusions. Intensive care unit mortality rate was 55% but no patient died from ECMO-related complications. In COVID-19 patients with severe ARDS, venovenous ECMO allowed ultra-protective ventilation, improved oxygenation and should be considered in highly selected patients with the most severe ARDS.

Critical Care Demand and Intensive Care Supply for Patients in Japan with COVID-19 at the Time of the State of Emergency Declaration in April 2020: A Descriptive Analysis

Background and objectives: The coronavirus disease 2019 (COVID-19) pandemic is overwhelming Japan's intensive care capacity. This study aimed to determine the number of patients with COVID-19 who required intensive care and to compare the numbers with Japan's intensive care capacity. Materials and Methods: Publicly available datasets were used to obtain the number of confirmed patients with COVID-19 undergoing mechanical ventilation and extracorporeal membrane oxygenation (ECMO) between 15 February and 19 July 2020 to determine and compare intensive care unit (ICU) and attending bed needs for patients with COVID-19, and to estimate peak ICU demands in Japan. Results: During the epidemic peak in late April, 11,443 patients (1.03/10,000 adults) had been infected, 373 patients (0.034/10,000 adults) were in ICU, 312 patients (0.028/10,000 adults) were receiving mechanical ventilation, and 62 patients (0.0056/10,000 adults) were under ECMO per day. At the peak of the epidemic, the number of infected patients was 651% of designated beds, and the number of patients requiring intensive care was 6.0% of ICU beds, 19.1% of board-certified intensivists, and 106% of designated medical institutions in Japan. Conclusions: The number of critically ill patients with COVID-19 continued to rise during the pandemic, exceeding the number of designated beds but not exceeding ICU capacity.

COVID–19急性呼吸不全への人工呼吸管理とECMO管理：基本的考え方(Mechanical ventilation and extracorporeal membrane oxygenation for acute respiratory failure owing to COVID–19: basic concept)

The pillars of managing critically ill patients with acute respiratory failure owing to coronavirus disease 2019 (COVID–19) are mechanical ventilation and extracorporeal membrane lung oxygenation (ECMO) as supportive therapies for impaired respiratory function. Given the increasing number of patients with COVID–19, a summary of standardized care regarding ECMO that can serve as a reference in clinical practice is proposed as an expert consensus statement. Indications, management practices, and caveats for ECMO management are described, including those in the presence of resource constraints.

Experience with veno-venous ecmo in patients with adult respiratory distress syndrome secondary to viral pneumonia. Case series

Introduction: The use of extracorporeal membrane oxygenation (ECMO) has increased exponentially in recent years and has shown to be effective in treating adult respiratory distress syndrome (ARDS) secondary to H1N1-related pneumonia. However, evidence remains controversial. This study describes a case series of ECMO in ARDS secondary to viral pneumonia. Methods: A search was conducted in the ECMO database of Fundación Cardiovascular de Colombia for the 2013-2017 period. A case series report was written of patients diagnosed with ARDS secondary to confirmed or suspected viral pneumonia. Results: Nineteen patients with ECMO support and ARDS due to viral pneumonia were included in the study. The survival rate upon discharge was 11 patients (58%) and weaning from ECMO support was successful in 13 patients (68%). Hemorrhagic complications were the most frequent: gastrointestinal bleeding, 10 patients (53%); intracranial bleeding, 2 (10%); alveolar hemorrhage, 2 (10%);’ hemothorax requiring thoracostomy with chest tube drainage, 2 (10%); cannulation site bleeding, 9 patients (47%); and surgical site bleeding in 3 patients (25%) who required tracheostomy. Other complications were: pneumothorax, 1 patient (5%); sepsis, 6 patients (32%); and growth of microorganisms in bronchial lavage, 6 patients (32%). Conclusions: This study supports the use of veno-venous ECMO to achieve a higher survival rate than expected in patients with severe ARDS and refractory hypoxemia secondary to viral pneumonia. Early initiation of the therapy should improve overall results.

Extracorporeal Life Support in Pregnancy: A Systematic Review

Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.

ECMO use in COVID-19: lessons from past respiratory virus outbreaks-a narrative review

The spread of coronavirus disease 2019 (COVID-19) continues to grow exponentially in most countries, posing an unprecedented burden on the healthcare sector and the world economy. Previous respiratory virus outbreaks, such as severe acute respiratory syndrome (SARS), pandemic H1N1 and Middle East respiratory syndrome (MERS), have provided significant insights into preparation and provision of intensive care support including extracorporeal membrane oxygenation (ECMO). Many patients have already been supported with ECMO during the current COVID-19 pandemic, and it is likely that many more may receive ECMO support, although, at this point, the role of ECMO in COVID-19-related cardiopulmonary failure is unclear. Here, we review the experience with the use of ECMO in the past respiratory virus outbreaks and discuss potential role for ECMO in COVID-19.

Japan ECMOnet for COVID-19: telephone consultations for cases with severe respiratory failure caused by COVID-19

Recently, the novel coronavirus disease 2019 (COVID-19) started spreading in Japan. Therefore, the number of patients with severe COVID-19 requiring extracorporeal membranous oxygenation (ECMO) is expected to increase. A working group has been formed to provide telephone consultation services for cases with severe respiratory failure caused by COVID-19 in Japan. During the first 13 days of the service, there were 12 consultations. For each consultation, we advised the patient on the initiation of ECMO and arranged transportation for patients with ECMO. Based on experience from the H1N1 influenza pandemic, transporting patients to experienced facilities is essential to obtain better outcomes.

Epidemiology and volume-outcome relationship of extracorporeal membrane oxygenation for respiratory failure in Japan: A retrospective observational study using a national administrative database

Aim

To describe the epidemiology of patients on extracorporeal membrane oxygenation (ECMO) and investigate the possible association between outcomes for respiratory ECMO patients and hospital volume of ECMO treatment for any indications.

Methods

Using data from the Diagnosis Procedure Combination database, a nationwide Japanese inpatient database, between 1 July 2010 and 31 March 2018, we identified inpatients aged ≥18 years who underwent ECMO. Institutional case volume was defined as the mean annual number of ECMO cases; eligible patients were categorized into institutional case volume tertile groups. The primary outcome was in-hospital mortality. For ECMO patients with respiratory failure, the association between institutional case volume group and in-hospital mortality rate was analyzed using a multilevel logistic regression model including multiple imputation.

Results

Extracorporeal membrane oxygenation was carried out on 25,384 patients during the study period; of those, 1,227 cases were for respiratory failure. Respiratory cases were categorized into low- (<8 cases/year), medium- (8-16 cases/year), and high-volume groups (≥17 cases/year). The overall in-hospital mortality rate for respiratory ECMO was 62.5% in low-, 54.7% in medium-, and 50.4% in high-volume institutions. With reference to low-volume institutions, the adjusted odds ratios (95% confidence interval) of the medium- and high-volume institutions for in-hospital mortality were 0.72 (0.50-1.04; P = 0.082) and 0.65 (0.45-0.95; P = 0.024), respectively.

Conclusions

The present study showed that accumulating the experience of using ECMO for any indications could positively affect the outcome of ECMO treatment for respiratory failure, which suggests the effectiveness of consolidating ECMO cases in high-volume centers in Japan.

Azithromycin, a 15-membered macrolide antibiotic, inhibits influenza A(H1N1)pdm09 virus infection by interfering with virus internalization process

The pandemic influenza 2009 (A(H1N1)pdm09) virus currently causes seasonal and annual epidemic outbreaks. The widespread use of anti-influenza drugs such as neuraminidase and matrix protein 2 (M2) channel inhibitors has resulted in the emergence of drug-resistant influenza viruses. In this study, we aimed to determine the anti-influenza A(H1N1)pdm09 virus activity of azithromycin, a re-positioned macrolide antibiotic with potential as a new anti-influenza candidate, and to elucidate its underlying mechanisms of action. We performed in vitro and in vivo studies to address this. Our in vitro approaches indicated that progeny virus replication was remarkably inhibited by treating viruses with azithromycin before infection; however, azithromycin administration after infection did not affect this process. We next investigated the steps inhibited by azithromycin during virus invasion. Azithromycin did not affect attachment of viruses onto the cell surface, but blocked internalization into host cells during the early phase of infection. We further demonstrated that azithromycin targeted newly budded progeny virus from the host cells and inactivated their endocytic activity. This unique inhibitory mechanism has not been observed for other anti-influenza drugs, indicating the potential activity of azithromycin before and after influenza virus infection. Considering these in vitro observations, we administered azithromycin intranasally to mice infected with A(H1N1)pdm09 virus. Single intranasal azithromycin treatment successfully reduced viral load in the lungs and relieved hypothermia, which was induced by infection. Our findings indicate the possibility that azithromycin could be an effective macrolide for the treatment of human influenza.

Comparison of extracorporeal membrane oxygenation outcome for influenza-associated acute respiratory failure in Japan between 2009 and 2016

Background

Since the 2009 pandemic influenza, we have nationally established a committee of the extracorporeal membrane oxygenation (ECMO) project. This project involves adequate respiratory management for severe respiratory failure using ECMO. This study aimed to investigate the correlations between changes in respiratory management using ECMO in Japan and outcomes of patients with influenza-associated acute respiratory failure between 2009 and 2016.

Methods

We investigated the incidence, severity, characteristics, and prognosis of influenza-associated acute respiratory failure in 2016 by web-based surveillance. The correlations between clinical characteristics, ventilator settings, ECMO settings, and prognosis were evaluated.

Results

A total of 14 patients were managed with ECMO in 2016. There were no significant differences in age, sex, and the acute physiology and chronic health evaluation II score between 2009 and 2016. The maximum sequential organ failure assessment score and highest positive end-expiratory pressure were lower in 2016 than in 2009 (p = 0.03 and p = 0.015, respectively). Baseline and lowest partial pressure of arterial oxygen (PaO₂)/fraction of inspiratory oxygen (F_IO₂) ratios were higher in 2016 than in 2009 (p = 0.009 and p = 0.002, respectively). The types of consoles, circuits, oxygenators, centrifugal pumps, and cannulas were significantly changed between 2016 and 2009 (p = 0.006, p = 0.003, p = 0.004, p < 0.001, respectively). Duration of the use of each circuit was significantly longer in 2016 than in 2009 (8.5 vs. 4.0 days; p = 0.0001). Multivariate analysis showed that the use of ECMO in 2016 was an independent predictor of better overall survival in patients with influenza-associated acute respiratory failure (hazard ratio, 7.25; 95% confidence interval, 1.35–33.3; p = 0.021).

Conclusions

Respiratory management for influenza-associated acute respiratory failure using ECMO was significantly changed in 2016 compared with 2009 in Japan. The outcome of ECMO use had improved in 2016 compared with the outcome in 2009 in patients with influenza-associated acute respiratory failure.

Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus

Background

Middle East respiratory syndrome (MERS) is caused by a coronavirus (MERS‐CoV) and is characterized by hypoxemic respiratory failure. The objective of this study is to compare the outcomes of MERS-CoV patients before and after the availability of extracorporeal membrane oxygenation (ECMO) as a rescue therapy in severely hypoxemic patients who failed conventional strategies.

Methods

We collected data retrospectively on MERS-CoV patients with refractory respiratory failure from April 2014 to December 2015 in 5 intensive care units (ICUs) in Saudi Arabia. Patients were classified into two groups: ECMO versus conventional therapy. Our primary outcome was in-hospital mortality; secondary outcomes included ICU and hospital length of stay.

Results

Thirty-five patients were included; 17 received ECMO and 18 received conventional therapy. Both groups had similar baseline characteristics. The ECMO group had lower in-hospital mortality (65 vs. 100%, P = 0.02), longer ICU stay (median 25 vs. 8 days, respectively, P < 0.01), and similar hospital stay (median 41 vs. 31 days, P = 0.421). In addition, patients in the ECMO group had better PaO2/FiO2 at days 7 and 14 of admission to the ICU (124 vs. 63, and 138 vs. 36, P < 0.05), and less use of norepinephrine at days 1 and 14 (29 vs. 80%; and 36 vs. 93%, P < 0.05).

Conclusions

ECMO use, as a rescue therapy, was associated with lower mortality in MERS patients with refractory hypoxemia. The results of this, largest to date, support the use of ECMO as a rescue therapy in patients with severe MERS-CoV.

Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus

BACKGROUND

Middle East respiratory syndrome (MERS) is caused by a coronavirus (MERS-CoV) and is characterized by hypoxemic respiratory failure. The objective of this study is to compare the outcomes of MERS-CoV patients before and after the availability of extracorporeal membrane oxygenation (ECMO) as a rescue therapy in severely hypoxemic patients who failed conventional strategies.

METHODS

We collected data retrospectively on MERS-CoV patients with refractory respiratory failure from April 2014 to December 2015 in 5 intensive care units (ICUs) in Saudi Arabia. Patients were classified into two groups: ECMO versus conventional therapy. Our primary outcome was in-hospital mortality; secondary outcomes included ICU and hospital length of stay.

RESULTS

Thirty-five patients were included; 17 received ECMO and 18 received conventional therapy. Both groups had similar baseline characteristics. The ECMO group had lower in-hospital mortality (65 vs. 100%, P = 0.02), longer ICU stay (median 25 vs. 8 days, respectively, P < 0.01), and similar hospital stay (median 41 vs. 31 days, P = 0.421). In addition, patients in the ECMO group had better PaO2/FiO2 at days 7 and 14 of admission to the ICU (124 vs. 63, and 138 vs. 36, P < 0.05), and less use of norepinephrine at days 1 and 14 (29 vs. 80%; and 36 vs. 93%, P < 0.05).

CONCLUSIONS

ECMO use, as a rescue therapy, was associated with lower mortality in MERS patients with refractory hypoxemia. The results of this, largest to date, support the use of ECMO as a rescue therapy in patients with severe MERS-CoV.

Extracorporeal membrane oxygenation in acute respiratory distress syndrome due to influenza A (H1N1)pdm09 pneumonia. A single-center experience during the 2013-2014 season

Objective

This report aimed to describe the outcomes of the patients with severe H1N1 associated acute respiratory distress syndrome who were treated with extracorporeal membrane oxygenation therapy.

Methods

This retrospective review analyzed a single-center cohort of adult patients with H1N1-related acute respiratory distress syndrome who were managed with veno-venous extracorporeal membrane oxygenation during the winter of 2013/2014.

Results

A total of 10 patients received veno-venous extracorporeal membrane oxygenation for H1N1 influenza between January 2013 and March 2014. Seven patients were transferred to our center for extracorporeal membrane oxygenation consideration (all within 72 hours of initiating mechanical ventilation). The median patient age was forty years, and 30% were female. The median arterial oxygen partial pressure to fraction of inspired oxygen ratio was 62.5, and the median RESP score was 6. Three patients received inhaled nitric oxide, and four patients were proned as rescue therapy before extracorporeal membrane oxygenation was initiated. The median duration of mechanical ventilation was twenty-two days (range, 14 - 32). The median length of stay in the intensive care unit was twenty-seven days (range, 14 - 39). The median hospital length of stay was 29.1 days (range, 16.0 - 46.9). Minor bleeding complications occurred in 6 of 10 patients. Eight of the ten patients survived to hospital discharge.

Conclusion

The survivors were relatively young and discharged with good functional status (i.e., enhancing quality-adjusted life-years-saved). Our experience shows that even a relatively new extracorporeal membrane oxygenation program can play an important role in that capacity and provide excellent outcomes for the sickest patients.

Novel temporary left ventricular assist system with hydrodynamically levitated bearing pump for bridge to decision: initial preclinical assessment in a goat model

The management of heart failure patients presenting in a moribund state remains challenging, despite significant advances in the field of ventricular assist systems. Bridge to decision involves using temporary devices to stabilize the hemodynamic state of such patients while further assessment is performed and a decision can be made regarding patient management. We developed a new temporary left ventricular assist system employing a disposable centrifugal pump with a hydrodynamically levitated bearing. We used three adult goats (body weight, 58-68 kg) to investigate the 30-day performance and hemocompatibility of the newly developed left ventricular assist system, which included the pump, inflow and outflow cannulas, the extracorporeal circuit, and connectors. Hemodynamic, hematologic, and blood chemistry measurements were investigated as well as end-organ effect on necropsy. All goats survived for 30 days in good general condition. The blood pump was operated at a rotational speed of 3000-4500 rpm and a mean pump flow of 3.2 ± 0.6 L min. Excess hemolysis, observed in one goat, was due to the inadequate increase in pump rotational speed in response to drainage insufficiency caused by continuous contact of the inflow cannula tip with the left ventricular septal wall in the early days after surgery. At necropsy, no thrombus was noted in the pump, and no damage caused by mechanical contact was found on the bearing. The newly developed temporary left ventricular assist system using a disposable centrifugal pump with hydrodynamic bearing demonstrated consistent and satisfactory hemodynamic performance and hemocompatibility in the goat model.

Extracorporeal Life Support: Four Decades and Counting

Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a form of heart lung bypass that is used to support neonates, pediatrics, and adult patients with cardiorespiratory failure for days or weeks till organ recovery or transplantation. Venoarterial (VA) and venovenous (VV) ECLS are the most common modes of support. ECLS circuit components and monitoring have been evolving over the last 40 years. The technology is safer, simpler, and more durable with fewer complications. The use of neonatal respiratory ECLS use has been declining over the last two decades, while adult respiratory ECLS is growing especially since the H1N1 influenza pandemic in 2009. This review provides an overview of ECLS evolution over the last four decades, its use in neonatal, pediatric and adults, description of basic principles, circuit components, complications, and outcomes as well as a quick look into the future.

Extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: A systematic review and meta-analysis

Introduction:

Extracorporeal membrane oxygenation (ECMO) has been extensively used for potentially reversible acute respiratory failure associated with severe influenza A (H1N1) pneumonia; however, it remains an expensive, resource-intensive therapy, with a high associated mortality. This systematic review and meta-analysis aims to summarize and pool outcomes data available in the published literature to guide clinical decision-making and further research.

Methods:

We conducted a systematic search of MEDLINE (1966 to April 15, 2015), EMBASE (1980 to April 15, 2015), CENTRAL, and Google Scholar for patients with severe H1N1 pneumonia and respiratory failure who received ECMO. The study validity was appraised by Newcastle–Ottawa Scale. The primary outcome was all-cause mortality. The secondary outcomes were duration of ECMO therapy, mechanical ventilation, and Intensive Care Unit (ICU) length of stay.

Results:

Of 698 abstracts screened and 142 full-text articles reviewed, we included 13 studies with a total of 494 patients receiving ECMO in our final review and meta-analysis. The study validity was satisfactory. The overall mortality was 37.1% (95% confidence interval: 30–45%) limited by underlying heterogeneity (I² = 65%, P value of Q statistic = 0.006). The median duration for ECMO was 10 days, mechanical ventilation was 19 days, and ICU length of stay was 33 days. Exploratory meta-regression did not identify any statistically significant moderator of mortality (P < 0.05), except for the duration of pre-ECMO mechanical ventilation in days (coefficient 0.19, standard error: 0.09, Z = 2.01, P < 0.04, R² = 0.16). The visual inspection of funnel plots did not suggest the presence of publication bias.

Conclusions:

ECMO therapy may be used as an adjunct or salvage therapy for severe H1N1 pneumonia with respiratory failure. It is associated with a prolonged duration of ventilator support, ICU length of stay, and high mortality. Initiating ECMO early once the patient has been instituted on mechanical ventilation may result in improved survival.

Associations between ventilator settings during extracorporeal membrane oxygenation for refractory hypoxemia and outcome in patients with acute respiratory distress syndrome: a pooled individual patient data analysis : Mechanical ventilation during ECMO

Purpose

Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for patients with acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate associations between ventilatory settings during ECMO for refractory hypoxemia and outcome in ARDS patients.

Methods

In this individual patient data meta-analysis of observational studies in adult ARDS patients receiving ECMO for refractory hypoxemia, a time-dependent frailty model was used to determine which ventilator settings in the first 3 days of ECMO had an independent association with in-hospital mortality.

Results

Nine studies including 545 patients were included. Initiation of ECMO was accompanied by significant decreases in tidal volume size, positive end-expiratory pressure (PEEP), plateau pressure, and driving pressure (plateau pressure − PEEP) levels, and respiratory rate and minute ventilation, and resulted in higher PaO₂/FiO₂, higher arterial pH and lower PaCO₂ levels. Higher age, male gender and lower body mass index were independently associated with mortality. Driving pressure was the only ventilatory parameter during ECMO that showed an independent association with in-hospital mortality [adjusted HR, 1.06 (95 % CI, 1.03–1.10)].

Conclusion

In this series of ARDS patients receiving ECMO for refractory hypoxemia, driving pressure during ECMO was the only ventilator setting that showed an independent association with in-hospital mortality.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4507-0) contains supplementary material, which is available to authorized users.

[A Case of Acute Respiratory Distress Syndrome (ARDS) Accompanied with Influenza (H1N1) 2009 Successfully Treated with Polymyxin B-immobilized Fiber Column-direct Hemoperfusion (PMX-DHP)]

A 51-year-old man was admitted to our hospital because of fever and diarrhea. Chest X-ray revealed consolidation in the left lower lung field. Ceftriaxone and minocycline were given empirically, under the suspicion of bacterial or atypical pneumonia. In spite of treatment with antibiotics, the disease rapidly progressed to systemic inflammatory response syndrome. The diagnosis of acute respiratory distress syndrome (ARDS) accompanied with influenza (H1N1) 2009 was made because of positive findings of real-time polymerase chain reaction. While multidisciplinary treatment was performed, his condition was further deteriorated suggesting the excessive pro-inflammatory mediators. To remove them, we conducted polymyxin-B immobilized column-direct hemoperfusion (PMX-DHP), and his general condition recovered successfully. PMX-DHP may be a useful treatment choice for ARDS accompanied with influenza.

Extracorporeal membrane oxygenation for acute respiratory distress syndrome

Extracorporeal membrane oxygenation (ECMO) can be a lifesaving therapy in patients with refractory severe respiratory failure or cardiac failure. Severe acute respiratory distress syndrome (ARDS) still has a high-mortality rate, but ECMO may be able to improve the outcome. Use of ECMO for respiratory failure has been increasing since 2009. Initiation of ECMO for adult ARDS should be considered when conventional therapy cannot maintain adequate oxygenation. ECMO can stabilize gas exchange and haemodynamic compromise, consequently preventing further hypoxic organ damage. ECMO is not a treatment for the underlying cause of ARDS. Because ARDS has multiple causes, the diagnosis should be investigated and treatment should be commenced during ECMO. Since ECMO is a complicated and high-risk therapy, adequate training in its performance and creation of a referring hospital network are essential. ECMO transport may be an effective method of transferring patients with severe ARDS.

Extracorporeal life support: experience with 2,000 patients

This is a review of the University of Michigan experience with extracorporeal life support (ECLS) also known as extracorporeal membrane oxygenation (ECMO). Two thousand patients were managed with ECMO from 1973 to 2010. The first 1,000 patients were reported previously. Of the 2,000 patients, 74% were weaned from ECLS, and 64% survived to hospital discharge. In patients with respiratory failure, survival to hospital discharge was 84% in 799 neonates, 76% in 239 children, and 50% in 353 adults. Survival in patients with cardiac failure was 45% in 361 children and 38% in 119 adults. ECLS during extracorporeal cardiopulmonary resuscitation was performed in 129 patients, with 41% surviving to discharge. Survival decreased from 74 to 55% between the first and second 1,000 patients. The most common complication was bleeding at sites other than the head, with an incidence of 39%, and the least frequent complication was pump malfunction, with a 2% incidence. Intracranial bleeding or infarction occurred in 8% of patients, with a 43% survival rate. This is the largest series of ECLS at one institution reported in the world to date. Our experience has shown that ECLS saves lives of moribund patients with acute pulmonary and cardiac failure in all age groups.

Extracorporeal gas exchange for acute respiratory failure in adult patients: a systematic review

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Successful use of extracorporeal membrane oxygenation for respiratory failure caused by mediastinal precursor T lymphoblastic lymphoma

Precursor T lymphoblastic lymphoma (T-LBL) often manifests as a mediastinal mass sometimes compressing vital structures like vessels or large airways. This case was a 40-year-old male who developed T-LBL presenting as respiratory failure caused by mediastinal T-LBL. He presented with persistent life threatening hypoxia despite tracheal intubation. We successfully managed this respiratory failure using venovenous (VV) ECMO. Induction chemotherapy was started after stabilizing oxygenation and the mediastinal lesion shrank rapidly. Respiratory failure caused by compression of the central airway by tumor is an oncologic emergency. VV ECMO may be an effective way to manage this type of respiratory failure as a bridge to chemotherapy.

Leucomycin A3, a 16-membered macrolide antibiotic, inhibits influenza A virus infection and disease progression

Severe respiratory disease arising from influenza virus infection has a high fatality rate. Neutrophil myeloperoxidase (MPO) has been implicated in the pathogenesis of severe influenza-induced pneumonia because extracellularly released MPO mediates the production of hypochlorous acid, a potent tissue injury factor. To search for candidate anti-influenza compounds, we screened leucomycin A3 (LM-A3), spiramycin (SPM), an erythromycin derivative (EM900, in which anti-bacterial activity has been eliminated), and clarithromycin (CAM), by analyzing their ability to inhibit MPO release in neutrophils from mice and humans. When each candidate was injected into mice infected with a lethal dose of A/H1N1 influenza virus (PR-8), LM-A3 produced the highest survival rate (80.9%). We found that LM-A3 induced beneficial effects on lung pathology and viral proliferation involved in the regulatory activity of MPO release, pro-inflammatory cytokines and interferon-α production in the lung. SPM and EM900 also induced positive survival effects in the infected mice, whereas CAM did not. We further found that these compounds inhibit virus proliferation in human pneumonia epithelial A549 cells in vitro. LM-A3 showed effective action against influenza A virus infection with high anti-viral activity in human host cells, indicating the possibility that LM-A3 is a prospective lead compound for the development of a drug for human influenza. The positive survival effect induced by EM900 suggests that pharmacological architectures between anti-bacterial and anti-influenza virus activities can be dissociated in macrolide derivatives. These observations provide valuable evidence for the potential development of novel macrolide derivatives that have strong anti-viral but no anti-bacterial activity.

Successful use of extracorporeal membrane oxygenation in the reversal of cardiorespiratory failure induced by atonic uterine bleeding: a case report

Introduction

Although extracorporeal membrane oxygenation has made sufficient progress to be considered for the management of life-threatening cardiac and respiratory failure, the risk of hemorrhagic complications may outweigh the benefits for patients with bleeding tendencies. We report, to the best of our knowledge, the first case of successful treatment by extracorporeal membrane oxygenation, without any hemorrhagic complications, of postpartum cardiorespiratory failure after massive uterine bleeding.

Case presentation

A 25-year-old Japanese woman experienced massive atonic bleeding after delivering her second baby. Recovery from hemorrhagic shock was managed by conservative treatments, but she developed decompensated heart failure and refractory hypoxia. Because we could not obtain hemodynamic stability and proper oxygenation even with high doses of catecholamines and maximal ventilator settings, we administered venoarterial extracorporeal membrane oxygenation, whereupon her hemodynamic status immediately stabilized. After 72 hours of support without major bleeding, extracorporeal membrane oxygenation was successfully withdrawn.

Conclusion

Even in cases of obstetric bleeding, if clotting status is stringently monitored, extracorporeal membrane oxygenation can be considered as an ultimate means of life support.

Ventilatory Strategy Used for Management of Acute Respiratory Failure Due to Novel Influenza A(H1N1) Infection

The first cases of the novel influenza A(H1N1) virus were reported in April 2009, especially in Mexico and the United States [1, 2]. The disease spread rapidly, becoming a pandemic by June 2009. On August 21, 2009, a total of 177 reported cases of novel influenza 182.166 A(H1N1) infection, of which 1,799 were fatal [2]. It has been observed in animal studies that the novel influenza virus A has a high replication rate in lung tissue, with a great capacity to invade the lower respiratory tract in humans, causing especially acute fulminant respiratory failure.