Capabilities of a mobile extracorporeal membrane oxygenation service for severe respiratory failure delivered by intensive care specialists

Primary neonatal and pediatric ECMO transport: First experience in Spain

INTRODUCTION

The organization of primary Extracorporeal membrane oxygenation (ECMO) transport is highly variable.

METHODS

To present the experience of the first mobile pediatric ECMO program in Spain, we designed a prospective descriptive study of all primary neonatal and pediatric (0-16 years) ECMO transports carried out over 10 years. The main variables recorded include demographic information, patient background, clinical data, ECMO indications, adverse events, and main outcomes.

RESULTS

39 primary ECMO transports were carried out with a 66.7% survival to hospital discharge. The median age was 1.24 months[IQR: 0.09-96]. Cannulation was mostly peripheral venoarterial (33/39). The mean response time from the call from the sending center to the departure of the ECMO team was 4 h[2.2-8]. The median inotropic score at the time of cannulation was 70[17.2-206.5], with a median oxygenation index of 40.5[29-65]. In 10% of the cases, ECMO-CPR was performed. Adverse events occurred in 56.4%, mostly related to the means of transport (40% overall). On arrival at the ECMO center, 44% of the patients underwent interventions. The median PICU stay was 20.5 days[11-32]. 5 patients developed neurological sequels. Statistically significant differences between survivors and deceased patients were not found.

CONCLUSIONS

A good survival rate, with a low prevalence of serious adverse events, suggests a clear benefit of primary ECMO transport when conventional therapeutic measures are exhausted and the patient is too unstable to undergo conventional transport. A nationwide primary ECMO-transport program must therefore be offered to all patients regardless of their location.

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.

Clinical impact of screening computed tomography in extracorporeal membrane oxygenation: a retrospective cohort study

BACKGROUND

Data on the prevalence and clinical impact of extrapulmonary findings at screening computed tomography (CT) on initiation of veno-venous extracorporeal membrane oxygenation (V-V ECMO) are limited. We aimed to identify the prevalence of extrapulmonary findings on screening CT following V-V ECMO initiation. We hypothesized that extrapulmonary findings would influence clinical management and outcome.

METHODS

Retrospective analysis (2011-2021) of admission screening CT including head, abdomen and pelvis with contrast of consecutive patients on initiation of V-V ECMO. CT findings identified by the attending consultant radiologist were extracted. Demographics, admission physiological and laboratory data, clinical decision-making following CT and ECMO ICU mortality were recorded from the electronic medical record. We used multivariable logistic regression and Kaplan-Meier curves to evaluate associations between extrapulmonary findings and ECMO ICU mortality.

RESULTS

Of the 833 patients receiving V-V ECMO, 761 underwent routine admission CT (91.4%). ECMO ICU length of stay was 19 days (IQR 12-23); ICU mortality at the ECMO centre was 18.9%. An incidental extrapulmonary finding was reported in 227 patients (29.8%), leading to an invasive procedure in 12/227 cases (5.3%) and a change in medical management (mainly in anticoagulation strategy) in 119/227 (52.4%). Extrapulmonary findings associated with mortality were intracranial haemorrhage (OR 2.34 (95% CI 1.31-4.12), cerebral infarction (OR 3.59 (95% CI 1.26-9.86) and colitis (OR 2.80 (95% CI 1.35-5.67).

CONCLUSIONS

Screening CT frequently identifies extrapulmonary findings of clinical significance. Newly detected intracranial haemorrhage, cerebral infarction and colitis were associated with increased ICU mortality.

Prevalence and Indications for Oxygenator Circuit Replacement in Patients Receiving Venovenous Extracorporeal Membrane Oxygenation

In this retrospective observational cohort study, we aimed to describe the rate of extracorporeal membrane oxygenation (ECMO) circuit change, the associated risk factors and its relationship with patient characteristics and outcome in patients receiving venovenous (VV) ECMO at our center between January 2015 and November 2017. Twenty-seven percent of the patients receiving VV ECMO (n = 224) had at least one circuit change, which was associated with lower ICU survival (68% vs 82% p=0.032) and longer ICU stay (30 vs . 17 days p < 0.001). Circuit duration was similar when stratified by gender, clinical severity, or prior circuit change. Hematological abnormalities and increased transmembrane lung pressure (TMLP) were the most frequent indication for circuit change. The change in transmembrane lung resistance (Δ TMLR) gave better prediction of circuit change than TMLP, TMLR, or ΔTMLP. Low postoxygenator PO 2 was indicated as a reason for one-third of the circuit changes. However, the ECMO oxygen transfer was significantly higher in cases of circuit change with documented "low postoxygenator PO 2 " than those without (244 ± 62 vs. 200 ± 57 ml/min; p = 0.009). The results suggest that circuit change in VV ECMO is associated with worse outcomes, that the Δ TMLR is a better predictor of circuit change than TMLP, and that the postoxygenator PO 2 is an unreliable proxy for the oxygenator function.

Extracorporeal Life Support Organization Guideline for Transport and Retrieval of Adult and Pediatric Patients with ECMO Support

DISCLAIMER

This guideline for the preparation for and undertaking of transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) is intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgement, knowledge and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

Prediction of readiness to decannulation from venovenous extracorporeal membrane oxygenation

OBJECTIVE

The criteria and process for liberation from extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome are not standardized. The predictive accuracy of the oxygen challenge test as a diagnostic test in determining weaning and decannulation from venovenous extracorporeal membrane oxygenation was tested.

DESIGN

A single-centre, retrospective, observational cohort study.

SETTING

Tertiary referral severe respiratory failure centre in a university hospital in the United Kingdom.

PATIENTS

253 adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Patients had median age: 43 years (interquartile range: 32-52) years, extracorporeal membrane oxygenation days: 9 (interquartile range: 6-14) and acute physiology and chronic health evaluation II score 17.5 (interquartile range: 15-20). Oxygen challenge test value (PaO_2-OCT) with best prediction was 31 kPa (232 mmHg; sensitivity 0.74; specificity 0.70; area under curve 0.77 (confidence interval: 0.73-0.81)). PaO_2-OCT did not perform well as a prospective test to identify readiness to decannulation. Only 24 patients (10%) were decannulated 48 hours after their first positive oxygen challenge test (true positive) and 73.4% patients were false positives (positive oxygen challenge test but not decannulated). True positives had higher tidal volume (541 ± 218 vs 368 mL ± 210; p < 0.05) and minute ventilation (9.34 ± 5.36 vs 6.33 L/min ± 4.43; p < 0.05). Blood flow (3.17 ± 0.23 vs 3.53 L/min ± 0.56; p < 0.05), sweep gas flow (1.42 ±1.83 vs 3.74 L/min ± 2.43; p < 0.05) and extracorporeal membrane oxygenation minute volume at time of first positive oxygen challenge test was lower in true positives (1.66 ± 2.26 vs 4.82 ± 3.43 L/min). This was a strong predictor for decannulation within 48 hours (area under curve: 0.88, confidence interval: 0.88-0.89).

CONCLUSIONS

In severe acute respiratory distress syndrome requiring venovenous extracorporeal membrane oxygenation, the PaO_2-OCT is a poor predictor of readiness to decannulate from extracorporeal membrane oxygenation. Additional factors involved in the control of respiratory drive and carbon dioxide clearance, particularly native lung dead space and total minute ventilation, should be assessed.

Mobile Extracorporeal Membrane Oxygenation

To review our experience with mobile extracorporeal membrane oxygenation (ECMO). Mobile ECMO team included: ECMO-trained surgeon and intensivist, specialist nurse, and perfusionist. Patients were cannulated for venous-arterial (V-A) or venous-venous (V-V) ECMO, depending on clinical indication. Mobile transfers were carried out utilizing a Levitronics Centrimag centrifugal pump and Hico Variotherm 555 heater cooler. From October 2009 to May 2019, 571 patients, 185 (32%) neonates, 95 (17%) pediatric, and 291 (51%) adults, underwent mobile ECMO transfer. Four hundred fifty-three (79%) transfers were completed by road, 76 (13%) by air, and 42 (8%) by road/air combination. Road was the travel mode of choice for journeys with expected duration up to 3 hours one way. Nevertheless, road transfers up to 6 hours duration were performed safely. Average duration of mobile ECMO transfer was 5.5 hours (2-18 hours). Two patients died before arrival of mobile ECMO team, four patients were cannulated during cardio-pulmonary resuscitation, and one of them died of uncontrollable hemorrhage in the right hemithorax. One patient had cardiac arrest after V-V cannulation and required conversion to V-A. Mobile ECMO is safe and reliable to transfer the sickest of patients. Fully trained team with all equipment and disposables is indispensable for reliable mobile ECMO service.

Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team

INTRODUCTION

The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients.

MATERIALS AND METHODS

We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth.

RESULTS

The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451 miles (median air transport distance = 1,328 miles, median ground transport distance = 16 miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%.

CONCLUSIONS

Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.

Patient Safety during ECMO Transportation: Single Center Experience and Literature Review

Background

Extracorporeal membrane oxygenation (ECMO) has been proven to support in lifesaving rescue therapy. The best outcomes can be achieved in high-volume ECMO centers with dedicated emergency transport teams.

Aim

The aim of this study was to analyze the safety of ECMO support during medical transfer on the basis of our experience developed on innovation cooperation and review of literature.

Methods

A retrospective analysis of our experience of all ECMO-supported patients transferred from regional hospital of the referential ECMO center between 2015 and 2020 was carried out. Special attention was paid to transportation-related mortality and morbidity. Moreover, a systematic review of the Medline, Embase, Cochrane, and Google Scholar databases was performed. It included the original papers published before the end of 2019.

Results

Twelve (5 women and 7 men) critically ill ECMO-supported patients with the median age of 33 years (2-63 years) were transferred to our ECMO center. In 92% (n = 11) of the cases venovenous and in 1 case, venoarterial supports were applied. The median transfer length was 45 km (5-200). There was no mortality during transfer and no serious adverse events occurred. Of note, the first ECMO-supported transfer had been proceeded by high-fidelity simulations. For our systematic review, 68 articles were found and 22 of them satisfied the search criteria. A total number of 2647 transfers were reported, mainly primary (90%) and as ground transportations (91.6%). A rate of adverse events ranged from 1% through 20% but notably only major complications were mentioned. The 4 deaths occurred during transport (mortality 0.15%).

Conclusions

Our experiences and literature review showed that transportation for ECMO patients done by experienced staff was associated with low mortality rate but life-threatening adverse events might occur. Translational simulation is an excellent probing technique to improve transportation safety.

Assessment of Right Ventricular Function With CT and Echocardiography in Patients With Severe Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation

Supplemental Digital Content is available in the text.

Changes in right ventricular size and function are frequently observed in patients with severe acute respiratory distress syndrome. The majority of patients who receive venovenous extracorporeal membrane oxygenation undergo chest CT and transthoracic echocardiography. The aims of this study were to compare the use of CT and transthoracic echocardiography to evaluate the right ventricular function and to determine the prevalence of acute cor pulmonale in this patient population.

Veno-venous extracorporeal membrane oxygenation in coronavirus disease 2019: a case series

Background

The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in severe hypoxaemic respiratory failure from coronavirus disease 2019 (COVID-19) has been described, but reported utilisation and outcomes are variable, and detailed information on patient characteristics is lacking. We aim to report clinical characteristics, management and outcomes of COVID-19 patients requiring VV-ECMO, admitted over 2 months to a high-volume centre in the UK.

Methods

Patient information, including baseline characteristics and clinical parameters, was collected retrospectively from electronic health records for COVID-19 VV-ECMO admissions between 3 March and 2 May 2020. Clinical management is described. Data are reported for survivors and nonsurvivors.

Results

We describe 43 consecutive patients with COVID-19 who received VV-ECMO. Median age was 46 years (interquartile range 35.5–52.5) and 76.7% were male. Median time from symptom onset to VV-ECMO was 14 days (interquartile range 11–17.5). All patients underwent computed tomography imaging, revealing extensive pulmonary consolidation in 95.3%, and pulmonary embolus in 27.9%. Overall, 79.1% received immunomodulation with methylprednisolone for persistent maladaptive hyperinflammatory state. Vasopressors were used in 86%, and 44.2% received renal replacement therapy. Median duration on VV-ECMO was 13 days (interquartile range 8–20). 14 patients died (32.6%) and 29 survived (67.4%) to hospital discharge. Nonsurvivors had significantly higher d-dimer (38.2 versus 9.5 mg·L⁻¹, fibrinogen equivalent units; p=0.035) and creatinine (169 versus 73 μmol·L⁻¹; p=0.022) at commencement of VV-ECMO.

Conclusions

Our data support the use of VV-ECMO in selected COVID-19 patients. The cohort was characterised by high degree of alveolar consolidation, systemic inflammation and intravascular thrombosis.

VV-ECMO, when offered to #COVID19 patients in refractory respiratory failure, can be associated with favourable outcomes. This is a detailed case series of 43 COVID-19 patients requiring VV-ECMO from a UK centre. 67.4% survived to hospital discharge.https://bit.ly/3ko9Ucu

Extra-corporeal membrane oxygenation for severe respiratory failure in the UK

An overview of the current system for referrals and management of severe respiratory failure in the United Kingdom. We outline the history of severe respiratory failure centres, the process of retrieving a patient for veno-venous extra corporeal membrane oxygenation and highlight some common difficulties and pitfalls when referring these critically unwell patients.

Lung Recruitability in Severe Acute Respiratory Distress Syndrome Requiring Extracorporeal Membrane Oxygenation

OBJECTIVES

Quantification of potential for lung recruitment may guide the ventilatory strategy in acute respiratory distress syndrome. However, there are no quantitative data on recruitability in patients with severe acute respiratory distress syndrome who require extracorporeal membrane oxygenation. We sought to quantify potential for lung recruitment and its relationship with outcomes in this cohort of patients.

DESIGN

A single-center, retrospective, observational cohort study.

SETTING

Tertiary referral severe respiratory failure center in a university hospital in the United Kingdom.

PATIENTS

Forty-seven adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

In patients with severe acute respiratory distress syndrome-mainly of pulmonary origin (86%)-the potential for lung recruitment and the weight of nonaerated, poorly aerated, normally aerated, and hyperaerated lung tissue were assessed at low (5 cmH2O) and high (45 cmH2O) airway pressures. Patients were categorized as high or low potential for lung recruitment based on the median potential for lung recruitment value of the study population. The median potential for lung recruitment was 24.3% (interquartile range = 11.4-37%) ranging from -2% to 76.3% of the total lung weight. Patients with potential for lung recruitment above the median had significantly shorter extracorporeal membrane oxygenation duration (8 vs 13 d; p = 0.013) and shorter ICU stay (15 vs 22 d; p = 0.028), but mortality was not statistically different (24% vs 46%; p = 0.159).

CONCLUSIONS

We observed significant variability in potential for lung recruitment in patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation. Patients with high potential for lung recruitment had a shorter ICU stay and shorter extracorporeal membrane oxygenation duration.

Screening pulmonary angiogram and the effect on anticoagulation strategies in severe respiratory failure patients on venovenous extracorporeal membrane oxygenation

BACKGROUND

Venovenous extracorporeal membrane oxygenation in the treatment of severe respiratory failure in adults continues to increase with survival improving; however, it remains associated with serious complications.

OBJECTIVE

The aim of this study was to evaluate the prevalence of pulmonary embolism (PE) in patients with severe respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV ECMO) and in those managed with conventional mechanical ventilation.

METHODS

A single-center, observational cohort, retrospective study was undertaken of patients with severe respiratory failure managed with conventional ventilation or requiring ECMO in a tertiary referral university teaching hospital.

RESULTS

We identified 343 patients with severe respiratory failure between January 2014 and December 2017. VV ECMO was used to support 290 patients and 53 were managed by conventional mechanical ventilation. The prevalence of PE was 9.6% (33/343), of which those supported with VV ECMO was 10% (29/290) and conventional ventilation 7.5% (4/53). There was no difference in survival rates between cohorts with PE versus no PE (ECMO survival to discharge P = .56; conventional ventilation survival to discharge P = .21).

CONCLUSIONS

The prevalence of pulmonary embolism in severe respiratory failure has important clinical implications for both short and long-term anticoagulation strategies. Routine screening pulmonary angiogram is warranted in this cohort.

Mobile extracorporeal membrane oxygenation service for severe acute respiratory failure - A review of five years of experience

Provision of extracorporeal membrane oxygenation as part of support escalation in severe refractory acute respiratory failure in England is provided by five specialist centres that operate within a well-defined quality and safety framework. We conducted a qualitative study of the extracorporeal membrane oxygenation retrieval service provided by one of the five centres. We analysed 176 consecutive debrief reports written between October 2013 and April 2018 by the consultant. Main identified issues were short delays in retrieval predominantly due to insufficient communication or equipment failure. All issues were addressed in subsequent practice. Our results suggest a need for improved communication between the referring intensive care unit and retrieving team. Our findings highlight the value of regular reflection-based evaluation to ensure continued provision of safe and efficient service.

Diagnosis of death using neurological criteria in adult patients on extracorporeal membrane oxygenation: Development of UK guidance

The diagnosis of death using neurological criteria is an important legal method of establishing death in the UK. The safety of the diagnosis lies in the exclusion of conditions which may mask the diagnosis and the testing of the fundamental reflexes of the brainstem including the apnoea reflex. Extracorporeal membrane oxygenation for cardiac or respiratory support can impact upon these tests, both through drug sequestration in the circuit and also through the ability to undertake the apnoea test. Until recently, there has been no nationally accepted guidance regarding the conduct of the tests to undertake the diagnosis of death using neurological criteria for a patient on extracorporeal membrane oxygenation. This article considers both the background to and the process of guideline development.

Interhospital Transport on Extracorporeal Membrane Oxygenation of Neonates-Perspective for the Future

In recent years the number of extracorporeal membrane oxygenation (ECMO) cases in neonates has been relatively constant. Future expansion lays in new indications for treatment. Regionalization to high-volume ECMO centers allows for optimal utilization of resources, reduction in costs, morbidity, and mortality. Mobile ECMO services available "24-7" are needed to provide effective logistics and reliable infrastructure for patient safety. ECMO transports are usually high-risk and complex. To reduce complications during ECMO transport communication using time-out, checklists, and ECMO A-B-C are paramount in any size mobile program. Team members' education, clinical training, and experience are important. For continuing education, regular wet-lab training, and simulation practices in teams increase performance and confidence. In the future the artificial placenta for the extremely premature infant (23-28 gestational weeks) will be introduced. This will enforce the development and adaptation of ECMO devices and materials for increased biocompatibility to manage the high-risk prem-ECMO (28-34 weeks) patients. These methods will likely first be introduced at a few high-volume neonatal ECMO centers. The ECMO team brings bedside competence for assessment, cannulation, and commencement of therapy, followed by a safe transport to an experienced ECMO center. How transport algorithms for the artificial placentae will affect mobile ECMO is unclear. ECMO transport services in the newborn should firstly be an out-reach service led and provided by ELSO member centers that continuously report transport data to an expansion of the ELSO Registry to include transport quality follow-up and research. For future development and improvement follow-up and sharing of data are important.

The use of extracorporeal membrane oxygenation in HIV-positive patients with severe respiratory failure: a retrospective observational case series

The objective is to describe the outcomes of patients with human immunodeficiency virus (HIV) infection who received extracorporeal membrane oxygenation (ECMO) for severe respiratory failure (SRF). The design and setting was a single centre retrospective observational case series, from January 2012 to June 2017, at a tertiary university hospital and regional referral centre for ECMO in the United Kingdom. The participants were all patients referred with SRF and HIV infection. The main outcome measure was patient 90-day survival. Twenty-four patients were referred, of whom nine received ECMO. Six out of nine (67%) of patients were alive at 90 days. Median duration of ECMO was 18 days. There were no identified differences between survivors and non-survivors. ECMO can be used successfully in selected patients with HIV and SRF, including those with poor HIV control and high illness severity. HIV status alone should not exclude patients from treatment with extracorporeal therapy.

Veno-arterio-venous ECMO for septic cardiomyopathy: a single-centre experience

INTRODUCTION

The role of extracorporeal support for patients with septic shock remains unclear.

METHODS

We conducted a retrospective analysis of our single-centre experience with veno-arterio-venous extracorporeal membrane oxygenation (VAV ECMO) in adult patients with severe respiratory failure and septic cardiomyopathy. Clinical data was extracted from electronic medical records including a dedicated ECMO referral and follow-up database.

RESULTS

Twelve patients were commenced on VAV ECMO for septic cardiomyopathy for a median of four days (IQR 3.0 to 5.3) between 01/2014 and 12/2017. Five patients (41.7%) had a cardiac arrest prior to initiation of ECMO support. At baseline, median left ventricular ejection fraction was 16.25% (IQR 13.13 to 17.5) and median PaO₂/FiO₂ ratio was 9 kPa (IQR 6.5 to 12.0) [67.50 mmHg (IQR 48.75 to 90.00)]. The survival rate to hospital discharge for VAV ECMO was 75% in this cohort. None of the surviving patients died within the follow-up period (median six month).

CONCLUSION

VAV ECMO is a feasible rescue strategy for a small proportion of patients with combined respiratory and cardiac failure secondary to septic shock with septic cardiomyopathy. We provide a detailed report of our experience with this technique. Further research is required comparing the different extracorporeal strategies directly to conventional resuscitation and against each other.

A novel risk score for severe ARDS patients undergoing ECMO after retrieval from peripheral hospitals

BACKGROUND

Extracorporeal Membrane Oxygenation in severe ARDS unresponsive to conventional protective ventilation is associated with elevated costs, resource and complications, and appropriate risk stratification of candidate patients could be useful to recognize those more likely to benefit from ECMO. We aimed to derive a new outcome prediction score for patients retrieved by our ECMO team from peripheral centers, including systematic echocardiographic evaluation before ECMO start.

METHODS

Sixty-nine consecutive patients with refractory ARDS requiring ECMO transferred from peripheral centers to our ICU (a tertiary ECMO referral center), from 1 October 2009 to 31 December 2015, were assessed.

RESULTS

All patients were transported on ECMO (distance, median 77, range 4-456 km) The mortality rate was 41% (28/69). Our new risk score included age ≥ 42 years, BMI < 31 kg/m² , RV dilatation, and pH < 7.35. The proposed cut off (Youden's index method) of nine had a sensitivity of 96% and a specificity of 30% (AUC-ROC: 0.85, 95% CI: 0.76-0.94, P < 0.001). When assessing the discriminatory ability of our risk score in the population of local patients, survivors had a mean value of 15.4 ± 8.6, whereas non-survivors showed a mean value of 20.1 ± 7.4 (P < 0.001).

CONCLUSIONS

Our new risk score shows good discriminatory ability both in patients retrieved from peripheral centers and in those implanted at our center. This score includes variables easily available at bedside, and, for the first time, a pathophysiologic element, RV dilatation.

Severe Respiratory Failure, Extracorporeal Membrane Oxygenation, and Intracranial Hemorrhage

OBJECTIVES

For patients supported with veno-venous extracorporeal membrane oxygenation, the occurrence of intracranial hemorrhage is associated with a high mortality. It is unclear whether intracranial hemorrhage is a consequence of the extracorporeal intervention or of the underlying severe respiratory pathology. In a cohort of patients transferred to a regional severe respiratory failure center that routinely employs admission brain imaging, we sought 1) the prevalence of intracranial hemorrhage; 2) survival and neurologic outcomes; and 3) factors associated with intracranial hemorrhage.

DESIGN

A single-center, retrospective, observational cohort study.

SETTING

Tertiary referral severe respiratory failure center, university teaching hospital.

PATIENTS

Patients admitted between December 2011 and February 2016.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Three hundred forty-two patients were identified: 250 managed with extracorporeal support and 92 managed using conventional ventilation. The prevalence of intracranial hemorrhage was 16.4% in extracorporeal membrane oxygenation patients and 7.6% in conventionally managed patients (p = 0.04). Multivariate analysis revealed factors independently associated with intracranial hemorrhage to be duration of ventilation (d) (odds ratio, 1.13 [95% CI, 1.03-1.23]; p = 0.011) and admission fibrinogen (g/L) (odds ratio, 0.73 [0.57-0.91]; p = 0.009); extracorporeal membrane oxygenation was not an independent risk factor (odds ratio, 3.29 [0.96-15.99]; p = 0.088). In patients who received veno-venous extracorporeal membrane oxygenation, there was no significant difference in 6-month survival between patients with and without intracranial hemorrhage (68.3% vs 76.0%; p = 0.350). Good neurologic function was observed in 92%.

CONCLUSIONS

We report a higher prevalence of intracranial hemorrhage than has previously been described with high level of neurologically intact survival. Duration of mechanical ventilation and admission fibrinogen, but not exposure to extracorporeal support, are independently associated with intracranial hemorrhage.

Intracardiac Right-to-Left Shunt Impeding Liberation From Veno-Venous Extracorporeal Membrane Oxygenation: Two Case Studies

OBJECTIVES

Veno-venous extracorporeal membrane oxygenation is an increasingly used form of advanced respiratory support, but its effects on the physiology of the right heart are incompletely understood. We seek to illustrate the impact of veno-venous extracorporeal membrane oxygenation return blood flow upon the right atrium by considering the physiologic effects during interatrial shunting.

PATIENTS

Two veno-venous extracorporeal membrane oxygenation patients in whom an extracorporeal membrane oxygenation induced right-to-left interatrial shunt appears to have created a barrier to liberation from extracorporeal support.

CONCLUSIONS

Veno-venous extracorporeal membrane oxygenation return flow generates a high-pressure jet that has potential to exert focal pressure upon the intra-atrial septum. In patients with potential for interatrial flow, this may lead to a right-to-left shunt, which becomes physiologically apparent only when sweep gas flow is ceased.

Transportation of patients on extracorporeal membrane oxygenation: a tertiary medical center experience and systematic review of the literature

Background

Utilization of extracorporeal membrane oxygenation (ECMO) has increased worldwide, but its use remains restricted to severely ill patients, and few referral centers are properly structured to offer this support. Inter-hospital transfer of patients on ECMO support can be life-threatening. In this study, we report a single-center experience and a systematic review of the available published data on complications and mortality associated with ECMO transportation.

Methods

We reported single-center data regarding complications and mortality associated with the transportation of patients on ECMO support. Additionally, we searched multiple databases for case series, observational studies, and randomized controlled trials regarding mortality of patients transferred on ECMO support. Results were analyzed independently for pediatric (under 12 years old) and adult populations. We pooled mortality rates using a random-effects model. Complications and transportation data were also described.

Results

A total of 38 manuscripts, including our series, were included in the final analysis, totaling 1481 patients transported on ECMO support. A total of 951 patients survived to hospital discharge. The pooled survival rates for adult and pediatric patients were 62% (95% CI 57–68) and 68% (95% CI 60–75), respectively. Two deaths occurred during patient transportation. No other complication resulting in adverse outcome was reported.

Conclusion

Using the available pooled data, we found that patient transfer to a referral institution while on ECMO support seems to be safe and adds no significant risk of mortality to ECMO patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0232-7) contains supplementary material, which is available to authorized users.

Successful 2,000-Kilometer International Transfer of an Infant Receiving Extracorporeal Membrane Oxygenation for Severe Respiratory Failure

There is minimal reported experience with long-range retrieval of pediatric patients receiving extracorporeal membrane oxygenation (ECMO) support. We report the case of a 10-month old boy with necrotizing staphylococcal pneumonia complicated by a bronchopleural fistula, who was successfully retrieved and transported while receiving ECMO to our unit in Sydney, Australia, from a referring hospital 2,000 kilometers away in the Pacific Islands. He was successfully weaned from ECMO to receive single-lung ventilation after 13 days, and he underwent surgical repair of his bronchopleural fistula through a thoracotomy 3 days after decannulation. He has made a full recovery.

Transportation of Critically Ill Patients on Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) may be a life-saving procedure for patients with severe reversible pulmonary or cardiac failure or for patients in need for a bridge to transplantation. ECMO is provided by specialized centers, but patients in need of ECMO are frequently taken care of at other centers. Conventional transports to an ECMO center can be hazardous and deaths have been described. For this reason, many ECMO centers have developed transport programs with mobile ECMO. After request, the mobile team including all necessary equipment to initiate ECMO is sent to the referring hospital, where the patient is cannulated and ECMO commenced. The patient is then transported on ECMO to the ECMO facility by road, helicopter, or fixed-wing aircraft depending on distance, weather conditions, etc. Eight publications have reported series of more than 50 transports on ECMO of which the largest included over 700. Together, these papers report on more than 1400 patient transports on ECMO. Two deaths during transport have occurred. A number of other adverse events are described, but without effect on patient outcome. Survival of patients transported on ECMO is equivalent to that of non-transported ECMO patients. It is concluded that long-, short-distance interhospital transports on ECMO can be performed safely. The staff should be experienced and highly competent in intensive care, ECMO cannulation, ECMO treatment, intensive care transport, and air transport medicine.