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Kalra A, Kang JK, Khanduja S, Menta AK, Ahmad SA, Liu O, Rodriguez E, Spann M, Hernandez AV, Brodie D, Whitman GJR, Cho SM. Long-Term Neuropsychiatric, Neurocognitive, and Functional Outcomes of Patients Receiving ECMO: A Systematic Review and Meta-Analysis. Neurology 2024; 102:e208081. [PMID: 38181313 PMCID: PMC11023037 DOI: 10.1212/wnl.0000000000208081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/26/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the common occurrence of neurologic complications during extracorporeal membrane oxygenation (ECMO) support, data on long-term neuropsychiatric, neurocognitive, and functional outcomes are sparse. We aimed to determine the prevalence of long-term neuropsychiatric symptoms, neurocognitive and functional impairment, and favorable neurologic outcomes in adult patients who receive ECMO. METHODS PubMed, Embase, Cochrane, Web of Science, and Scopus were searched for text related to ECMO and neuropsychiatric, neurocognitive, and functional outcomes from inception to May 3, 2023. Our primary outcome was the prevalence of neuropsychiatric symptoms (pain/discomfort, anxiety, depression, posttraumatic stress disorder [PTSD], and sleep disturbance) at long-term (≥6 months) follow-up. Our secondary outcomes were the prevalence of neurocognitive impairment (memory, attention, and reasoning), functional impairment (daily activities, physical activity/mobility, and personal/self-care), and favorable neurologic outcomes (Cerebral Performance Category ≤2, modified Rankin scale ≤3, or Glasgow Outcome Scale ≥4). This study was registered in PROSPERO (CRD42023420565). RESULTS We included 59 studies with 3,280 patients (median age 54 years, 69% male). The cohort consisted of 86% venoarterial (VA)-ECMO (n = 2,819) and 14% venovenous (VV)-ECMO (n = 461) patients. More than 10 tools were used to assess neuropsychiatric and neurocognitive outcomes, indicating a lack of standardization in assessment methodologies. The overall prevalence of neuropsychiatric symptoms was 41% (95% CI 33%-49%): pain/discomfort (52%, 95% CI 42%-63%), sleep disturbance (37%, 95% CI 0%-98%), anxiety (36%, 95% CI 27%-46%), depression (31%, 95% CI 22%-40%), and PTSD (18%, 95% CI 9%-29%). The prevalence of neurocognitive impairment was 38% (95% CI 13%-65%). The prevalence of functional impairment was 52% (95% CI 40%-64%): daily activities (54%, 95% CI 41%-66%), mobility (41%, 95% CI 28%-54%), and self-care (21%, 95% CI 13%-31%). The prevalence of neuropsychiatric symptoms in VV-ECMO patients was higher than that in VA-ECMO patients (55% [95% CI 34%-75%] vs 32% [95% CI 23%-41%], p = 0.01), though the prevalence of neurocognitive and functional impairment was not different between the groups. The prevalence of favorable neurologic outcomes was not different at various follow-ups: 3 months (23%, 95% CI 12%-36%), 6 months (25%, 95% CI 16%-35%), and ≥1 year (28%, 95% CI 21%-36%, p = 0.68). DISCUSSION A substantial proportion of ECMO patients seemed to experience neuropsychiatric symptoms and neurocognitive and functional impairments at long-term follow-up. Considerable heterogeneity in methodology for gauging these outcomes exists, warranting the need for standardization. Multicenter prospective observational studies are indicated to further investigate risk factors for these outcomes in ECMO-supported patients.
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Affiliation(s)
- Andrew Kalra
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin Kook Kang
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shivalika Khanduja
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arjun K Menta
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Syed A Ahmad
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Olivia Liu
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily Rodriguez
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Spann
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adrian V Hernandez
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Brodie
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- From the Division of Cardiac Surgery (A.K., J.K.K., S.K., A.K.M., E.R., G.J.R.W.), Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Sidney Kimmel Medical College (A.K.), Thomas Jefferson University, Philadelphia, PA; Division of Neurosciences Critical Care (S.A.A., O.L., S.-M.C.), Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital; Informationist Services (M.S.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Pharmacy Practice (A.V.H.), University of Connecticut School of Pharmacy, Storrs; Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET) (A.V.H.), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru; and Division of Pulmonary and Critical Care Medicine (D.B.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Higa KC, Mayer K, Quinn C, Jubina L, Suarez-Pierre A, Colborn K, Jolley SE, Enfield K, Zwischenberger J, Sevin CM, Rove JY. Sounding the Alarm: What Clinicians Need to Know about Physical, Emotional, and Cognitive Recovery After Venoarterial Extracorporeal Membrane Oxygenation. Crit Care Med 2023; 51:1234-1245. [PMID: 37163480 PMCID: PMC11210608 DOI: 10.1097/ccm.0000000000005900] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE We summarize the existing data on the occurrence of physical, emotional, and cognitive dysfunction associated with postintensive care syndrome (PICS) in adult survivors of venoarterial extracorporeal membrane oxygenation (VA-ECMO). DATA SOURCES MEDLINE, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched. STUDY SELECTION Peer-reviewed studies of adults receiving VA-ECMO for any reason with at least one measure of health-related quality of life outcomes or PICS at long-term follow-up of at least 6 months were included. DATA EXTRACTION The participant demographics and baseline characteristics, in-hospital outcomes, long-term health outcomes, quality of life outcome measures, and prevalence of PICS were extracted. DATA SYNTHESIS Twenty-seven studies met inclusion criteria encompassing 3,271 patients who were treated with VA-ECMO. The studies were limited to single- or two-center studies. Outcomes variables and follow-up time points evaluated were widely heterogeneous which limits comprehensive analysis of PICS after VA-ECMO. In general, the longer-term PICS-related outcomes of survivors of VA-ECMO were worse than the general population, and approaching that of patients with chronic disease. Available studies identified high rates of abnormal 6-minute walk distance, depression, anxiety, and posttraumatic stress disorder that persisted for years. Half or fewer survivors return to work years after discharge. Only 2 of 27 studies examined cognitive outcomes and no studies evaluated cognitive dysfunction within the first year of recovery. No studies evaluated the impact of targeted interventions on these outcomes. CONCLUSIONS Survivors of VA-ECMO represent a population of critically ill patients at high risk for deficits in physical, emotional, and cognitive function related to PICS. This systematic review highlights the alarming reality that PICS and in particular, neurocognitive outcomes, in survivors of VA-ECMO are understudied, underrecognized, and thus likely undertreated. These results underscore the imperative that we look beyond survival to focus on understanding the burden of survivorship with the goal of optimizing recovery and outcomes after these life-saving interventions. Future prospective, multicenter, longitudinal studies in recovery after VA-ECMO are justified.
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Affiliation(s)
- Kelly C Higa
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA
| | - Kirby Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, KY
| | - Christopher Quinn
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Lindsey Jubina
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, KY
| | | | - Kathryn Colborn
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Sarah E Jolley
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Kyle Enfield
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA
| | - Joseph Zwischenberger
- Division of Cardiothoracic Surgery, Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY
| | - Carla M Sevin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, TN
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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