1
|
Erlebach R, Buhlmann A, Andermatt R, Seeliger B, Stahl K, Bode C, Schuepbach R, Wendel-Garcia PD, David S. Carboxyhemoglobin predicts oxygenator performance and imminent oxygenator change in extracorporeal membrane oxygenation. Intensive Care Med Exp 2024; 12:41. [PMID: 38656714 PMCID: PMC11043307 DOI: 10.1186/s40635-024-00626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The continuous exposure of blood to a non-biological surface during extracorporeal membrane oxygenation (ECMO) may lead to progressive thrombus formation in the oxygenator, hemolysis and consequently impaired gas exchange. In most centers oxygenator performance is monitored only on a once daily basis. Carboxyhemoglobin (COHb) is generated upon red cell lysis and is routinely measured with any co-oximetry performed to surveille gas exchange and acid-base homeostasis every couple of hours. This retrospective cohort study aims to evaluate COHb in the arterial blood gas as a novel marker of oxygenator dysfunction and its predictive value for imminent oxygenator change. RESULTS Out of the 484 screened patients on ECMO 89, cumulatively requiring 116 oxygenator changes within 1833 patient days, including 19,692 arterial COHb measurements were analyzed. Higher COHb levels were associated with lower post-oxygenator pO2 (estimate for log(COHb): - 2.176 [95% CI - 2.927, - 1.427], p < 0.0001) and with a shorter time to oxygenator change (estimate for log(COHb): - 67.895 [95% CI - 74.209, - 61.542] hours, p < 0.0001). COHb was predictive of oxygenator change within 6 h (estimate for log(COHb): 5.027 [95% CI 1.670, 15.126], p = 0.004). CONCLUSION COHb correlates with oxygenator performance and can be predictive of imminent oxygenator change. Therefore, longitudinal measurements of COHb in clinical routine might be a cheap and more granular candidate for ECMO surveillance that should be further analyzed in a controlled prospective trial design.
Collapse
Affiliation(s)
- Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Alix Buhlmann
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Rea Andermatt
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Reto Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | | | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
| |
Collapse
|
2
|
Zapletal B, Zimpfer D, Schlöglhofer T, Fritzer-Szekeres M, Szekeres T, Bernardi MH, Geilen J, Schultz MJ, Tschernko EM. Hemolysis Index Correlations with Plasma-Free Hemoglobin and Plasma Lactate Dehydrogenase in Critically Ill Patients under Extracorporeal Membrane Oxygenation or Mechanical Circulatory Support-A Single-Center Study. Diagnostics (Basel) 2024; 14:680. [PMID: 38611592 PMCID: PMC11011733 DOI: 10.3390/diagnostics14070680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
Monitoring for thrombosis and hemolysis is crucial for patients under extracorporeal or mechanical circulatory support, but it can be costly. We investigated correlations between hemolysis index (HI) and plasma-free hemoglobin (PFH) levels on one hand, and between the HI and plasma lactate dehydrogenase (LDH) levels on the other, in critically ill patients with and without extracorporeal or mechanical circulatory support. Additionally, we calculated the cost reductions if monitoring through HI were to replace monitoring through PFH or plasma LDH. In a single-center study, HI was compared with PFH and plasma LDH levels in blood samples taken for routine purposes in critically ill patients with and without extracorporeal or mechanical circulatory support. A cost analysis, restricted to direct costs associated with each measurement, was made for an average 10-bed ICU. This study included 147 patients: 56 patients with extracorporeal or mechanical circulatory support (450 measurements) and 91 patients without extracorporeal or mechanical circulatory support (562 measurements). The HI correlated well with PFH levels (r = 0.96; p < 0.01) and poorly with plasma LDH levels (r = 0.07; p < 0.01) in patients with extracorporeal or mechanical circulatory support. Similarly, HI correlated well with PFH levels (r = 0.97; p < 0.01) and poorly with plasma LDH levels (r = -0.04; p = 0.39) in patients without extracorporeal or mechanical circulatory support. ROC analyses demonstrated a strong performance of HI, with the curve indicating excellent discrimination in the whole cohort (area under the ROC of 0.969) as well as in patients under ECMO or mechanical circulatory support (area under the ROC of 0.988). Although the negative predictive value of HI for predicting PFH levels > 10 mg/dL was high, its positive predictive value was found to be poor at various cutoffs. A simple cost analysis showed substantial cost reduction if HI were to replace PFH or plasma LDH for hemolysis monitoring. In conclusion, in this cohort of critically ill patients with and without extracorporeal or mechanical circulatory support, HI correlated well with PFH levels, but poorly with plasma LDH levels. Given the high correlation and substantial cost reductions, a strategy utilizing HI may be preferable for monitoring for hemolysis compared to monitoring strategies based on PFH or plasma LDH. The PPV of HI, however, is unacceptably low to be used as a diagnostic test.
Collapse
Affiliation(s)
- Bernhard Zapletal
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University Vienna, 1090 Vienna, Austria; (B.Z.); (M.H.B.); (J.G.); (E.M.T.)
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University Vienna, 1090 Vienna, Austria; (D.Z.); (T.S.)
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University Vienna, 1090 Vienna, Austria; (D.Z.); (T.S.)
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, 1090 Vienna, Austria
| | - Monika Fritzer-Szekeres
- Department of Laboratory Medicine, Medical University Vienna, 1090 Vienna, Austria; (M.F.-S.); (T.S.)
| | - Thomas Szekeres
- Department of Laboratory Medicine, Medical University Vienna, 1090 Vienna, Austria; (M.F.-S.); (T.S.)
| | - Martin H. Bernardi
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University Vienna, 1090 Vienna, Austria; (B.Z.); (M.H.B.); (J.G.); (E.M.T.)
| | - Johannes Geilen
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University Vienna, 1090 Vienna, Austria; (B.Z.); (M.H.B.); (J.G.); (E.M.T.)
| | - Marcus J. Schultz
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University Vienna, 1090 Vienna, Austria; (B.Z.); (M.H.B.); (J.G.); (E.M.T.)
- Department of Intensive Care, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Edda M. Tschernko
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Medical University Vienna, 1090 Vienna, Austria; (B.Z.); (M.H.B.); (J.G.); (E.M.T.)
| |
Collapse
|
3
|
Leerson J, Tulloh A, Lopez FT, Gregory S, Buscher H, Rosengarten G. Detecting Oxygenator Thrombosis in ECMO: A Review of Current Techniques and an Exploration of Future Directions. Semin Thromb Hemost 2024; 50:253-270. [PMID: 37640048 DOI: 10.1055/s-0043-1772843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-support technique used to treat cardiac and pulmonary failure, including severe cases of COVID-19 (coronavirus disease 2019) involving acute respiratory distress syndrome. Blood clot formation in the circuit is one of the most common complications in ECMO, having potentially harmful and even fatal consequences. It is therefore essential to regularly monitor for clots within the circuit and take appropriate measures to prevent or treat them. A review of the various methods used by hospital units for detecting blood clots is presented. The benefits and limitations of each method are discussed, specifically concerning detecting blood clots in the oxygenator, as it is concluded that this is the most critical and challenging ECMO component to assess. We investigate the feasibility of solutions proposed in the surrounding literature and explore two areas that hold promise for future research: the analysis of small-scale pressure fluctuations in the circuit, and real-time imaging of the oxygenator. It is concluded that the current methods of detecting blood clots cannot reliably predict clot volume, and their inability to predict clot location puts patients at risk of thromboembolism. It is posited that a more in-depth analysis of pressure readings using machine learning could better provide this information, and that purpose-built imaging could allow for accurate, real-time clotting analysis in ECMO components.
Collapse
Affiliation(s)
- Jack Leerson
- Department is Manufacturing, Materials and Mechatronics Engineering, School of Engineering, RMIT University, Melbourne, Victoria, Australia
- Department of Manufacturing, CSIRO, Research Way, Clayton, Victoria, Australia
| | - Andrew Tulloh
- Department of Manufacturing, CSIRO, Research Way, Clayton, Victoria, Australia
| | - Francisco Tovar Lopez
- Department is Manufacturing, Materials and Mechatronics Engineering, School of Engineering, RMIT University, Melbourne, Victoria, Australia
| | - Shaun Gregory
- Department of Mechanical and Aerospace Engineering, Cardiorespiratory Engineering and Technology Laboratory, Monash University, Melbourne, Victoria, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, Australia
| | - Gary Rosengarten
- Department is Manufacturing, Materials and Mechatronics Engineering, School of Engineering, RMIT University, Melbourne, Victoria, Australia
| |
Collapse
|
4
|
Butt SP, Razzaq N, Saleem Y, Cook B, Abdulaziz S. Improving ECMO therapy: Monitoring oxygenator functionality and identifying key indicators, factors, and considerations for changeout. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2024; 56:20-29. [PMID: 38488715 PMCID: PMC10941833 DOI: 10.1051/ject/2023047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/09/2023] [Indexed: 03/17/2024]
Abstract
INTRODUCTION The optimal timing for extracorporeal membrane oxygenation (ECMO) circuit change-out is crucial for the successful management of patients with severe cardiopulmonary failure. This comprehensive review examines the various factors that influence the timing of oxygenator replacement in the ECMO circuit. By considering these factors, clinicians can make informed decisions to ensure timely and effective change-out, enhancing patient outcomes and optimizing the delivery of ECMO therapy. METHODOLOGY A thorough search of relevant studies on ECMO circuits and oxygenator change-out was conducted using multiple scholarly databases and relevant keywords. Studies published between 2017 and 2023 were included, resulting in 40 studies that met the inclusion criteria. DISCUSSION Thrombosis within the membrane oxygenator and its impact on dysfunction were identified as significant contributors, highlighting the importance of monitoring coagulation parameters and gas exchange. Several factors, including fibrinogen levels, pre and post-membrane blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows and pressures, and anticoagulation strategy, were found to be important considerations when determining the need for an oxygenator or circuit change-out. The involvement of a multidisciplinary team and thorough preparation were also highlighted as crucial aspects of this process. CONCLUSION In conclusion, managing circuit change-outs in ECMO therapy requires considering factors such as fibrinogen levels, blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows, pressures, and anticoagulation strategy. Monitoring these parameters allows for early detection of issues, timely interventions, and optimized ECMO therapy. Standardized protocols, personalized anticoagulation approaches, and non-invasive monitoring techniques can improve the safety and effectiveness of circuit change-outs. Further research and collaboration are needed to advance ECMO management and enhance patient outcomes.
Collapse
Affiliation(s)
- Salman Pervaiz Butt
-
Perfusionist & ECMO Specialist, Heart Vascular and Thoracic Institute, Cleveland Clinic PO BOX: 112412 Abu Dhabi United Arab Emirates
| | - Nabeel Razzaq
-
Perfusion Department, Cleveland Clinic PO BOX: 112412 Abu Dhabi United Arab Emirates
| | - Yasir Saleem
-
Clinical Perfusionist, Department of CTVS, All India Institute of Medical Science Rishikesh
| | - Bill Cook
-
Clinical Perfusionist, Perfusion Department, Glenfield Hospital Leicester UK
| | - Salman Abdulaziz
-
Consultant of Cardiovascular Critical Care, Co-Chair of ECMO Task Force, Department of Health United Arab Emirates
| |
Collapse
|
5
|
Hoffman KR, Diehl A, Paul E, Burrell AJC. The Hematological Effects of Extracorporeal Membrane Oxygenator Exchange. ASAIO J 2023; 69:e308-e314. [PMID: 37146593 PMCID: PMC10298168 DOI: 10.1097/mat.0000000000001976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
Membrane oxygenator failure during venovenous (V-V) extracorporeal membrane oxygenation (ECMO) can lead to life-threatening hypoxia, high replacement costs, and may be associated with a hyperfibrinolytic state and bleeding. The current understanding of the underlying mechanisms that drive this is limited. The primary aim of this study therefore is to investigate the hematological changes that occur before and after membrane oxygenator and circuit exchanges (ECMO circuit exchange) in patients with severe respiratory failure managed on V-V ECMO. We analyzed 100 consecutive V-V ECMO patients using linear mixed-effects modeling to evaluate hematological markers in the 72 hours before and 72 hours after ECMO circuit exchange. A total of 44 ECMO circuit exchanges occurred in 31 of 100 patients. The greatest change from baseline to peak were seen in plasma-free hemoglobin (42-fold increase p < 0.01) and the D-dimer:fibrinogen ratio (1.6-fold increase p = 0.03). Bilirubin, carboxyhemoglobin, D-dimer, fibrinogen, and platelets also showed statistically significant changes ( p < 0.01), whereas lactate dehydrogenase did not ( p = 0.93). Progressively deranged hematological markers normalize more than 72 hours after ECMO circuit exchange, with an associated reduction in membrane oxygenator resistance. This supports the biologic plausibility that ECMO circuit exchange may prevent further complications such as hyperfibrinolysis, membrane failure, and clinical bleeding.
Collapse
Affiliation(s)
- Kenneth R. Hoffman
- From the Alfred Hospital, Intensive Care Unit, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Arne Diehl
- From the Alfred Hospital, Intensive Care Unit, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Aidan J. C. Burrell
- From the Alfred Hospital, Intensive Care Unit, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Bünger V, Hunsicker O, Krannich A, Balzer F, Spies CD, Kuebler WM, Weber-Carstens S, Menk M, Graw JA. Potential of cell-free hemoglobin and haptoglobin as prognostic markers in patients with ARDS and treatment with veno-venous ECMO. J Intensive Care 2023; 11:15. [PMID: 37081577 PMCID: PMC10116665 DOI: 10.1186/s40560-023-00664-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Hemolysis is associated with increased mortality in patients with sepsis, ARDS, or therapy with extracorporeal membrane oxygenation (ECMO). To quantify a critical threshold of hemolysis in patients with ARDS and treatment with veno-venous ECMO, we aimed to identify cutoff values for cell-free hemoglobin (CFH) and haptoglobin (Hp) plasma concentrations associated with a significant increase in ICU mortality. METHODS Patients with ARDS admitted to a tertiary ARDS referral center between 01/2007 and 12/2018 and treatment with veno-venous ECMO were included. Cutoff values for mean CFH (mCFH) and mean Hp (mHp) plasma concentrations dividing the cohort into groups with significantly different ICU mortalities were calculated and patient characteristics were compared. A multiple logistic regression model with stepwise backward variable selection was included. In addition, cutoff values for vulnerable relative timespans for the respective CFH and Hp concentrations were calculated. RESULTS A quantitative cutoff value of 11 mg/dl for mCFH separated the cohort (n = 442) regarding ICU mortality (mCFH ≤ 11 mg/dl: 38%, [95%-CI: 32.22-43.93] (n = 277) vs. mCFH > 11 mg/dl: 70%, [61.99-76.47] (n = 165), p < 0.001). Analogously, a mHp cutoff value ≤ 0.39 g/l was associated with a significant increase in ICU mortality (mHp ≤ 0.39 g/l: 68.7%, [60.91-75.61] (n = 163) vs. mHp > 0.39 g/l: 38.7%, [33.01-44.72] (n = 279), p < 0.001). The independent association of ICU mortality with CFH and Hp cutoff values was confirmed by logistic regression adjusting for confounders (CFH Grouping: OR 3.77, [2.51-5.72], p < 0.001; Hp Grouping: OR 0.29, [0.19-0.43], p < 0.001). A significant increase in ICU mortality was observed when CFH plasma concentration exceeded the limit of 11 mg/dl on 13.3% of therapy days (≤ 13.3% of days with CFH > 11 mg/dl: 33%; [26.81-40.54] (n = 192) vs. > 13.3% of days with CFH > 11 mg/dl: 62%; [56.05-68.36] (n = 250), p < 0.001). Analogously, a mortality increase was detected when Hp plasma concentration remained ≤ 0.39 g/l for > 18.2% of therapy days (≤ 18.2% days with Hp ≤ 0.39 g/l: 27%; [19.80-35.14] (n = 138) vs. > 18.2% days with Hp ≤ 0.39 g/l: 60%; [54.43-65.70] (n = 304), p < 0.001). CONCLUSIONS Moderate hemolysis with mCFH-levels as low as 11 mg/dl impacts mortality in patients with ARDS and therapy with veno-venous ECMO. Furthermore, a cumulative dose effect should be considered indicated by the relative therapy days with CFH-concentrations > 11 mg/dl. In addition, also Hp plasma concentrations need consideration when the injurious effect of elevated CFH is evaluated.
Collapse
Affiliation(s)
- Victoria Bünger
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Oliver Hunsicker
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Krannich
- Clinical Trial Office, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department Analytics, TCC GmbH, Hamburg, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Jan A Graw
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Ulm, Ulm University, Ulm, Germany
| |
Collapse
|
7
|
Costantini S, Belliato M, Ferrari F, Gazzaniga G, Ravasi M, Manera M, De Piero ME, Curcelli A, Cardinale A, Lorusso R. A retrospective analysis of the hemolysis occurrence during extracorporeal membrane oxygenation in a single center. Perfusion 2023; 38:609-621. [PMID: 35225087 DOI: 10.1177/02676591211073768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO)-associated hemolysis still represents a serious complication. The present study aimed to investigate those predictive factors, such as flow rates, the use of anticoagulants, and circuit connected dialysis, that might play a pivotal role in hemolysis in adult patients. METHODS This is a retrospective single-center case series of 35 consecutive adult patients undergoing veno-venous ECMO support at our center between April 2014 and February 2020. Daily plasma-free hemoglobin (pfHb) and haptoglobin (Hpt) levels were chosen as hemolysis markers and they were analyzed along with patients' characteristics, daily laboratory findings, and corresponding ECMO system variables, as well as continuous renal replacement therapy (CRRT) when administered, looking for factors influencing their trends over time. RESULTS Among the many settings related to the ECMO support, the presence of CRRT connected to the ECMO circuit has been found associated with both higher daily pfHb levels and lower Hpt levels. After correction for potential confounders, hemolysis was ascribable to circuit-related variables, in particular the membrane oxygenation dead space was associated with an Hpt reduction (B = -215.307, p = 0.004). Moreover, a reduction of ECMO blood flow by 1 L/min has been associated with a daily Hpt consumption of 93.371 mg/dL (p = 0.001). CONCLUSIONS Technical-induced hemolysis during ECMO should be monitored not only when suspected but also during quotidian management and check-ups. While considering the clinical complexity of patients on ECMO support, clinicians should not only be aware of and anticipate possible circuitry malfunctions or inadequate flow settings, but they should also take into account the effects of an ECMO circuit-connected CRRT, as an equally important key factor triggering hemolysis.
Collapse
Affiliation(s)
- Silvia Costantini
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Mirko Belliato
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Fiorenza Ferrari
- UOC Anestesia e Rianimazione I, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Gazzaniga
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Marta Ravasi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Miriam Manera
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Antonio Curcelli
- Cardiac Anesthesia and Intensive Care ICLAS Rapallo, 18591GVM Care & Res, Rapallo, Italy
| | - Alessandra Cardinale
- Department of Statistical Sciences, 9311Sapienza University of Rome, Rome, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,118066Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherland
| |
Collapse
|
8
|
Wickramarachchi A, Khamooshi M, Burrell A, Pellegrino VA, Kaye DM, Gregory SD. The effect of drainage cannula tip position on risk of thrombosis during venoarterial extracorporeal membrane oxygenation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 231:107407. [PMID: 36764061 DOI: 10.1016/j.cmpb.2023.107407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/01/2023] [Accepted: 02/04/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Venoarterial extracorporeal membrane oxygenation (VA ECMO) is able to support critically ill patients undergoing refractory cardiopulmonary failure. It relies on drainage cannulae to extract venous blood from the patient, but cannula features and tip position may impact flow dynamics and thrombosis risk. Therefore, this study aimed to investigate the effect of tip position of single-stage (SS) and multi-stage (MS) VA ECMO drainage cannulae on the risk of thrombosis. METHODS Computational fluid dynamics was used to model flow dynamics within patient-specific geometry of the venous vasculature. The tip of the SS and MS cannula was placed in the superior vena cava (SVC), SVC-Right atrium (RA) junction, mid-RA, inferior vena cava (IVC)-RA junction, and IVC. The risk of thrombosis was assessed by measuring several factors. Blood residence time was measured via an Eulerian approach through the use of a scalar source term. Regions of stagnant volume were recognised by identifying regions of low fluid velocity and shear rate. Rate of blood washout was calculated by patching the domain with a scalar value and measuring the rate of fluid displacement. Lastly, wall shear stress values were determined to provide a qualitative understanding of potential blood trauma. RESULTS Thrombosis risk varied substantially with position changes of the SS cannula, which was less evident with the MS cannula. The SS cannula showed reduced thrombosis risk arising from stagnant regions when placed in the SVC or SVC-RA junction, whereas an MS cannula was predicted to create stagnant regions during all tip positions. When positioned in the IVC-RA junction or IVC, the risk of thrombosis was higher in the SS cannula than in the MS cannula due to both high and low shear flow. CONCLUSION Tip position of the drainage cannula impacts cannula flow dynamics and, subsequently, the risk of thrombosis. The use of MS cannulae can reduce high shear-related thrombosis, but SS cannulae can eliminate stagnant regions when advanced into the SVC. Therefore, the choice of cannula design and tip position should be carefully considered during cannulation.
Collapse
Affiliation(s)
- Avishka Wickramarachchi
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia.
| | - Mehrdad Khamooshi
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| | - Aidan Burrell
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | | | - David M Kaye
- The Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Shaun D Gregory
- Cardio-Respiratory Engineering and Technology Laboratory (CREATElab), Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
9
|
Balthazar T, Bennett J, Adriaenssens T. Hemolysis during short-term mechanical circulatory support: from pathophysiology to diagnosis and treatment. Expert Rev Med Devices 2022; 19:477-488. [PMID: 35912874 DOI: 10.1080/17434440.2022.2108319] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Despite advances in heart failure therapies and percutaneous coronary interventions, survival for cardiogenic shock remains poor. Percutaneous ventricular assist devices (pVAD) are increasingly used, but current evidence remains conflicting. The Impella is an example of such a device, based on a catheter mounted micro-axial continuous flow pump, that has been rapidly adopted in routine practice. An important aspect in the post implantation care is the prevention of complications. Hemolysis is one of the more frequent complications seen with this device. AREAS COVERED In this review we discuss the pathophysiology, diagnosis and treatment of hemolysis in patients supported with a pVAD. A practical algorithm for rapid identification of hemolysis and the underlying cause is presented, allowing for early treatment and prevention of further complications. EXPERT OPINION Hemolysis remains a threat to patients supported with any mechanical circulatory support device. Prevention as well as treatment demands for sufficient knowledge about the device, the optimal position and hemodynamics. Future studies should try to clarify some of the elements that are still unclear such as optimal anticoagulation, the place of pentoxyfilline or extracorporeal removal of free hemoglobin. This could help to optimize outcomes in clinical practice as well as future studies.
Collapse
Affiliation(s)
- Tim Balthazar
- University Hospitals Brussel, Department of Cardiology, Jette, Belgium
| | - Johan Bennett
- University Hospitals Leuven, Department of Cardiovascular Medicine, Leuven, Belgium.,Katholieke Universiteit Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Tom Adriaenssens
- University Hospitals Leuven, Department of Cardiovascular Medicine, Leuven, Belgium.,Katholieke Universiteit Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| |
Collapse
|
10
|
Cousin VL, Giraud R, Assouline B, Silva IN, Bendjelid K. Use of Carboxyhemoglobin as an Early Sign of Oxygenator Dysfunction in Patients Supported by Extracorporeal Membrane Oxygenation. Front Med (Lausanne) 2022; 9:893642. [PMID: 35572967 PMCID: PMC9106404 DOI: 10.3389/fmed.2022.893642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/11/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Plasma free hemoglobin is the gold standard for monitoring hemolysis in extracorporeal membrane oxygenation (ECMO) but its routine use has some limitations. Carboxyhemoglobin (HbCO) is also a marker of intravascular hemolysis. We aimed to investigate HbCO as a marker of both hemolysis and oxygenator dysfunction in patients supported by ECMO. Methods Retrospective analysis of patients on ECMO in an adult ICU in a tertiary hospital. HbCO was recorded every 6 h in the 48 h before and after oxygenator change in adult patients on ECMO support with an oxygenator dysfunction and replacement. Results The investigation of 27 oxygenators replacements in 19 patients demonstrated that HbCO values progressively increased over time and then significantly decreased after oxygenator change. Median oxygenator lifespan was 14 days [interquartile range (IQR) 8–21] and there was no correlation between HbCO and oxygenator lifespan [Spearman coefficient 0.23 (p = 0.23)]. HbCO values at oxygenator change [HbCO median 2.7 (IQR 2.5–3.5)] were significantly higher than the HbCO values 1 week before [HbCO median 2.07 (IQR 1.86–2.8)] (p value < 0.001). Conclusion Our data highlight the potential role of HbCO as a novel marker for ECMO oxygenator dysfunction.
Collapse
Affiliation(s)
- Vladimir L. Cousin
- Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
- Geneva Hemodynamic Research Group, Geneva University, Geneva, Switzerland
- *Correspondence: Vladimir L. Cousin,
| | - Raphaël Giraud
- Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
- Geneva Hemodynamic Research Group, Geneva University, Geneva, Switzerland
| | - Benjamin Assouline
- Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
- Geneva Hemodynamic Research Group, Geneva University, Geneva, Switzerland
| | - Ivo Neto Silva
- Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
- Geneva Hemodynamic Research Group, Geneva University, Geneva, Switzerland
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
- Geneva Hemodynamic Research Group, Geneva University, Geneva, Switzerland
| |
Collapse
|
11
|
Chu JH, Sarathy S, Ramesh S, Rudolph K, Raghavan ML, Badheka A. Risk factors for hemolysis with centrifugal pumps in pediatric extracorporeal membrane oxygenation: Is pump replacement an answer? Perfusion 2022; 38:771-780. [PMID: 35354417 DOI: 10.1177/02676591221082499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Hemolysis during pediatric extracorporeal membrane oxygenation (ECMO) is associated with increased risk for renal failure and mortality. OBJECTIVES We aim to describe risk factors for hemolysis in pediatric ECMO supported by centrifugal pumps. METHODS We conducted an analysis of retrospective data collected at an academic children's hospital from January 2017 to December 2019. MEASUREMENTS AND RESULTS Plasma-free hemoglobin (PFH) levels were measured daily, and hemolysis was defined as PFH>50 mg/dL. Of 46 ECMO runs over 528 ECMO days, hemolysis occurred in 23 (58%) patients over a total of 40 (8%) ECMO days. In multivariable logistic regression models, VA-ECMO (aOR=4.69, 95% CI: 1.01-21.83) and higher hemoglobin (aOR = 1.38, 95% CI: 1.06-1.81) were independently associated with hemolysis. There were also non-significant trends toward increased risk for hemolysis with higher rotational pump speed (aOR=2.39, 95% CI: 0.75-7.65), higher packed red blood cell transfusions (aOR=1.15, 95% CI: 0.99-1.34), and higher cryoprecipitate transfusions (aOR=2.01, 95% CI: 0.83-4.86). Isolated pump exchanges that were performed in 12 patients with hemolysis led to significant decreases in PFH levels within 24 h (89 vs 11 mg/dL, p<0.01). CONCLUSIONS Hemolysis is common in pediatric ECMO using centrifugal pumps. Avoidance of high pump speeds and conservative administration of blood products may help to mitigate the risk for hemolysis. Furthermore, pump exchange may be an effective first-line treatment for hemolysis.
Collapse
Affiliation(s)
- Jian H Chu
- 2468University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,Department of Internal Medicine, 20512Rush University Medical Center, Chicago, IL, USA
| | - Srivats Sarathy
- 4083University of Iowa Seamans Center for the Engineering Arts and Sciences, Iowa City, IA 52242, USA
| | - Sonali Ramesh
- Division of Pediatric Critical Care, Department of Pediatrics, 21827University of Iowa Stead Family Children's Hospital, Iowa City, IA 52242, USA
| | - Kristina Rudolph
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Madhavan L Raghavan
- 4083University of Iowa Seamans Center for the Engineering Arts and Sciences, Iowa City, IA 52242, USA
| | - Aditya Badheka
- Division of Pediatric Critical Care, Department of Pediatrics, 21827University of Iowa Stead Family Children's Hospital, Iowa City, IA 52242, USA
| |
Collapse
|
12
|
Hesselmann F, Arnemann D, Bongartz P, Wessling M, Cornelissen C, Schmitz-Rode T, Steinseifer U, Jansen SV, Arens J. Three-dimensional membranes for artificial lungs: Comparison of flow-induced hemolysis. Artif Organs 2021; 46:412-426. [PMID: 34606117 DOI: 10.1111/aor.14081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/11/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Membranes based on triply periodic minimal surfaces (TPMS) have proven a superior gas transfer compared to the contemporary hollow fiber membrane (HFM) design in artificial lungs. The improved oxygen transfer is attributed to disrupting the laminar boundary layer adjacent to the membrane surface known as main limiting factor to mass transport. However, it requires experimental proof that this improvement is not at the expense of greater damage to the blood. Hence, the aim of this work is a valid statement regarding the structure-dependent hemolytic behavior of TPMS structures compared to the current HFM design. METHODS Hemolysis tests were performed on structure samples of three different kind of TPMS-based designs (Schwarz-P, Schwarz-D and Schoen's Gyroid) in direct comparison to a hollow fiber structure as reference. RESULTS The results of this study suggest that the difference in hemolysis between TPMS membranes compared to HFMs is small although slightly increased for the TPMS membranes. There is no significant difference between the TPMS structures and the hollow fiber design. Nevertheless, the ratio between the achieved additional oxygen transfer and the additional hemolysis favors the TPMS-based membrane shapes. CONCLUSION TPMS-shaped membranes offer a safe way to improve gas transfer in artificial lungs.
Collapse
Affiliation(s)
- Felix Hesselmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Daniel Arnemann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Patrick Bongartz
- Chair of Chemical Process Engineering, RWTH Aachen University, Aachen, Germany
| | - Matthias Wessling
- Chair of Chemical Process Engineering, RWTH Aachen University, Aachen, Germany.,DWI-Leibniz Institute for Interactive Materials, RWTH Aachen University, Aachen, Germany
| | - Christian Cornelissen
- Department of Pneumology and Internal Intensive Care Medicine, Medical Clinic V, RWTH Aachen University Hospital, Aachen, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Sebastian Victor Jansen
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Jutta Arens
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany.,Chair of Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering, Technology University of Twente, Twente, The Netherlands
| |
Collapse
|
13
|
Shah NS, Sokolovic M. Carboxyhemoglobin Elevation, a Marker for Hemolysis, Is Common in Veno-venous Extracorporeal Membrane Oxygenation. ASAIO J 2021; 67:e116. [PMID: 34033586 DOI: 10.1097/mat.0000000000001481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Nimesh S Shah
- From the MedStar Heart and Vascular Institute, Baltimore, Maryland
| | - Mladen Sokolovic
- Department of Critical Care, St David's Round Rock Medical Center, Round Rock, Texas
| |
Collapse
|
14
|
Malfertheiner MV, Broman LM, Vercaemst L, Belliato M, Aliberti A, Di Nardo M, Swol J, Barrett N, Pappalardo F, Bělohlávek J, Taccone FS, Millar JE, Crawford L, Lorusso R, Suen JY, Fraser JF. Ex vivo models for research in extracorporeal membrane oxygenation: a systematic review of the literature. Perfusion 2021; 35:38-49. [PMID: 32397884 DOI: 10.1177/0267659120907439] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With ongoing progress of components of extracorporeal membrane oxygenation including improvements of oxygenators, pumps, and coating materials, extracorporeal membrane oxygenation became increasingly accepted in the clinical practice. A suitable testing in an adequate setup is essential for the development of new technical aspects. Relevant tests can be conducted in ex vivo models specifically designed to test certain aspects. Different setups have been used in the past for specific research questions. We conducted a systematic literature review of ex vivo models of extracorporeal membrane oxygenation components. MEDLINE and Embase were searched between January 1996 and October 2017. The inclusion criteria were ex vivo models including features of extracorporeal membrane oxygenation technology. The exclusion criteria were clinical studies, abstracts, studies in which the model of extracorporeal membrane oxygenation has been reported previously, and studies not reporting on extracorporeal membrane oxygenation components. A total of 50 studies reporting on different ex vivo extracorporeal membrane oxygenation models have been identified from the literature search. Models have been grouped according to the specific research question they were designed to test for. The groups are focused on oxygenator performance, pump performance, hemostasis, and pharmacokinetics. Pre-clinical testing including use of ex vivo models is an important step in the development and improvement of extracorporeal membrane oxygenation components and materials. Furthermore, ex vivo models offer valuable insights for clinicians to better understand the consequences of choice of components, setup, and management of an extracorporeal membrane oxygenation circuit in any given condition. There is a need to standardize the reporting of pre-clinical studies in this area and to develop best practice in their design.
Collapse
Affiliation(s)
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Leen Vercaemst
- Perfusion Department, University Hospital Gasthuisberg, Louvain, Belgium
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Aliberti
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Nicholas Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Jan Bělohlávek
- Second Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Lachlan Crawford
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Hospital (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jacky Y Suen
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| |
Collapse
|
15
|
A Systematic Literature Review of Packed Red Cell Transfusion Usage in Adult Extracorporeal Membrane Oxygenation. MEMBRANES 2021; 11:membranes11040251. [PMID: 33808419 PMCID: PMC8065680 DOI: 10.3390/membranes11040251] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 01/28/2023]
Abstract
Background: Blood product administration plays a major role in the management of patients treated with extracorporeal membrane oxygenation (ECMO) and may be a contributor to morbidity and mortality. Methods: We performed a systematic review of the published literature to determine the current usage of packed red cell transfusions. Predefined search criteria were used to identify journal articles reporting transfusion practice in ECMO by interrogating EMBASE and Medline databases and following the PRISMA statement. Results: Out of 1579 abstracts screened, articles reporting ECMO usage in a minimum of 10 adult patients were included. Full texts of 331 articles were obtained, and 54 were included in the final analysis. All studies were observational (2 were designed prospectively, and two were multicentre). A total of 3808 patients were reported (range 10–517). Mean exposure to ECMO was 8.2 days (95% confidence interval (CI) 7.0–9.4). A median of 5.6% was not transfused (interquartile range (IQR) 0–11.3%, 19 studies). The mean red cell transfusion per ECMO run was 17.7 units (CI 14.2–21.2, from 52 studies) or 2.60 units per day (CI 1.93–3.27, from 49 studies). The median survival to discharge was 50.8% (IQR 40.0–64.9%). Conclusion: Current evidence on transfusion practice in ECMO is mainly drawn from single-centre observational trials and varies widely. The need for transfusions is highly variable. Confounding factors influencing transfusion practice need to be identified in prospective multicentre studies to mitigate potential harmful effects and generate hypotheses for interventional trials.
Collapse
|
16
|
Point-of-care testing of plasma free hemoglobin and hematocrit for mechanical circulatory support. Sci Rep 2021; 11:3788. [PMID: 33589647 PMCID: PMC7884396 DOI: 10.1038/s41598-021-83327-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/01/2021] [Indexed: 11/17/2022] Open
Abstract
Hematological analysis is essential for patients who are supported by a mechanical circulatory support (MCS). The laboratory methods used to analyze blood components are conventional and accurate, but they require a mandatory turn-around-time for laboratory results, and because of toxic substances, can also be hazardous to analysis workers. Here, a simple and rapid point-of-care device is developed for the measurement of plasma free hemoglobin (PFHb) and hematocrit (Hct), based on colorimetry. The device consists of camera module, minimized centrifuge system, and the custom software that includes the motor control algorithm for the centrifuge system, and the image processing algorithm for measuring the color components of blood from the images. We show that our device measured PFHb with a detection limit of 0.75 mg/dL in the range of (0–100) mg/dL, and Hct with a detection limit of 2.14% in the range of (20–50)%. Our device had a high correlation with the measurement method generally used in clinical laboratories (PFHb R = 0.999, Hct R = 0.739), and the quantitative analysis resulted in precision of 1.44 mg/dL for PFHb value of 14.5 mg/dL, 1.36 mg/dL for PFHb value of 53 mg/dL, and 1.24% for Hct 30%. Also, the device can be measured without any pre-processing when compared to the clinical laboratory method, so results can be obtained within 5 min (about an 1 h for the clinical laboratory method). Therefore, we conclude that the device can be used for point-of-care measurement of PFHb and Hct for MCS.
Collapse
|
17
|
Calvaresi EC, La'ulu SL, Snow TM, Allison TR, Genzen JR. Plasma hemoglobin: A method comparison of six assays for hemoglobin and hemolysis index measurement. Int J Lab Hematol 2021; 43:1145-1153. [PMID: 33449436 DOI: 10.1111/ijlh.13457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/04/2020] [Accepted: 12/27/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Plasma hemoglobin (Hb) is measured for assessment of in vivo and in vitro hemolysis. The objective of the present investigation was to conduct a method comparison of five quantitative and one semi-quantitative Hb and H-index (hemolysis index) assays to evaluate their performance measuring plasma Hb in clinical specimens. METHODS One hundred and fourteen clinical specimens previously tested for plasma Hb using a laboratory-developed spectrophotometric assay were also tested for Hb using a HemoCue Plasma/Low Hb assay (azide methemoglobin), a laboratory-modified Pointe Scientific Hb assay (cyanmethemoglobin), tested for H-index measurements using a Roche cobas c501, an Abbott Architect c8000, and a semi-quantitative (binned) H-index measurement on a Beckman AU5800. The reference result was defined as the median Hb score (median of all Hb or H-index results). RESULTS The laboratory-developed spectrophotometric Hb assay and Roche H-index methods mostly closely matched the median Hb score across all data, as well as for lower range median Hb score results ≤2.0 g/L. Two-way frequency table analysis using an Hb (or H-index) cutoff of 0.5 g/L (or 0.5 H-index units) was then performed to compare methods to the median Hb score cutoff. The Beckman method had the highest accuracy at this cutoff, the Roche and Abbott methods had the highest positive predictive value (PPV), and the Beckman, HemoCue, and Pointe methods had the highest negative predictive value (NPV). CONCLUSIONS Plasma Hb and H-index results vary by method. Laboratories should evaluate the performance characteristics of their respective assays when considering adoption of spectrophotometric or chemical methods for plasma Hb assessment.
Collapse
Affiliation(s)
| | - Sonia L La'ulu
- ARUP Institute of Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - Taylor M Snow
- ARUP Institute of Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - Tiffany R Allison
- ARUP Institute of Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - Jonathan R Genzen
- Department of Pathology, University of Utah, Salt Lake City, UT, USA.,ARUP Institute of Clinical and Experimental Pathology, Salt Lake City, UT, USA.,ARUP Laboratories, Salt Lake City, UT, USA
| |
Collapse
|
18
|
Materne LA, Hunsicker O, Menk M, Graw JA. Hemolysis in patients with Extracorporeal Membrane Oxygenation therapy for severe Acute Respiratory Distress Syndrome - a systematic review of the literature. Int J Med Sci 2021; 18:1730-1738. [PMID: 33746589 PMCID: PMC7976579 DOI: 10.7150/ijms.50217] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/19/2020] [Indexed: 12/18/2022] Open
Abstract
The Acute Respiratory Distress Syndrome (ARDS) is common in patients on the Intensive Care Unit and associated with significant mortality rates. In situations of severe respiratory insufficiency and failure of all possible conservative therapeutic approaches, veno-venous extracorporeal membrane oxygenation (VV ECMO) is used as a final option for temporary replacement of pulmonary function. ARDS as well as sepsis and VV ECMO treatment are all associated with intravascular hemolysis. The extent and relevance of intravascular hemolysis in the context of ARDS therapy is unclear. This systematic review aims to summarize the current evidence on the incidence and associated complications of intravascular hemolysis in adult patients with ARDS and treatment with VV ECMO. The databases MEDLINE, EMBASE and Web of Science were systematically searched and 19 publications fulfilled inclusion criteria. The incidence of hemolysis in patients with ARDS and treatment with VV ECMO ranged from 0 to 41% with survivors showing lower incidences and less severe hemolysis. A pump head thrombosis and high blood flows (≥3 l/min) as well as use of dual-lumen cannulas but not different pump models were associated with increased hemolysis. In conclusion, intravascular hemolysis in patients with ARDS and treatment with VV ECMO is a common and relevant complication that appears associated with increased mortality. Apart from ECMO hardware-settings, no additional possible causes for increased red cell breakdown such as disease severity, duration of ECMO therapy, or number and quality of red blood cell transfusions were investigated. Further research is needed to determine the origin and relevance of intravascular hemolysis in patients with ARDS and treatment with VV ECMO.
Collapse
Affiliation(s)
- Lorenz A Materne
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Oliver Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Jan A Graw
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| |
Collapse
|
19
|
Hemolysis and Plasma Free Hemoglobin During Extracorporeal Membrane Oxygenation Support: From Clinical Implications to Laboratory Details. ASAIO J 2020; 66:239-246. [PMID: 30985331 DOI: 10.1097/mat.0000000000000974] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) are lifesaving supports that are more and more frequently used in critically ill patients. Despite of major technological improvements observed during the last 20 years, ECMO-associated hemolysis is still a complication that may arise during such therapy. Hemolysis severity, directly appreciated by plasma free hemoglobin concentration, may be present with various intensity, from a nonalarming and tolerable hemolysis to a highly toxic one. Here, we propose a review dedicated to extracorporeal membrane oxygenation (ECMO)-associated hemolysis, with a particular emphasis on pathophysiology, prevalence, and clinical consequences of such complication. We also focus on laboratory assessment of hemolysis and on the limits that have to be known by clinicians to prevent and manage hemolytic events.
Collapse
|
20
|
Kuroda T, Mutsuga M, Yamada M, Yamakawa M, Yuhara S, Hasegawa H, Yokote J, Yokoyama Y, Yamada T, Koyama T, Usui A. Efficacy of Plasma free Hemoglobin for detecting centrifugal pump thrombosis. Perfusion 2020; 36:620-625. [PMID: 32909509 DOI: 10.1177/0267659120957183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Lactate dehydrogenase (LDH) is widely used as an indicator of pump thrombosis in a centrifugal pump. However, due to the low specificity of LDH, pump thrombosis is difficult to detect in the clinical environment. We measured plasma free hemoglobin (pfHb) with the portable device in ICU. The goal of this investigation is to evaluate its diagnostic ability for pump thrombosis. METHODS We enrolled 31 consecutive patients who needed Extracorporeal Membrane Oxygenation (ECMO) therapy and pfHb was determined with HemoCue® plasma/Low Hb photometer. Pump thrombosis was analyzed macroscopically at the timing of pump explantation or exchange. Also, we divided the pump thrombosis into a grading scale by the place of thrombosis. RESULTS The median of peak pfHb was significantly lower in the none thrombus group (0.03 g/dL) than that of in the thrombus group (0.05g/dL) (p = 0.01). In our grading criteria, pfHb was significantly higher when the thrombus is existing near the shaft (p = 0.015). Contrary, no significant difference was found for LDH.The ROC analysis of pfHb revealed an AUC of 0.77 for detecting pump thrombosis with the best statistical cutoff value at 0.05 g/dL (specificity, 78%; sensitivity, 77%). Also, ROC analysis of LDH was performed (AUC, 0.44; cutoff value, 1200 IU/L; specificity, 59%; sensitivity, 54%) and compared with pfHb. AUC was significantly higher in pfHb (p = 0.04). CONCLUSION Our results showed the efficacy of pfHb for detecting centrifugal pump thrombosis.
Collapse
Affiliation(s)
- Taiyo Kuroda
- Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masao Yamada
- Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Masato Yamakawa
- Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Satoshi Yuhara
- Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Hiroki Hasegawa
- Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Jun Yokote
- Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Yukifusa Yokoyama
- Department of Thoracic and Cardiovascular Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Tetsuya Yamada
- Department of Clinical Engineering, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Tomio Koyama
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| |
Collapse
|
21
|
Chen X, Bai M, Zhao L, Li Y, Yu Y, Zhang W, Ma F, Sun S, Chen X. Characteristics and outcomes of Stanford type A aortic dissection patients with severe post-operation hyperbilirubinemia: a retrospective cohort study. J Cardiothorac Surg 2020; 15:195. [PMID: 32723390 PMCID: PMC7388495 DOI: 10.1186/s13019-020-01243-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hyperbilirubinemia is one of the common complications after cardiac surgery and is associated with increased mortality. However, to the best of our knowledge, the reports on clinical significance of postoperative severe hyperbilirubinemia in Stanford type A aortic dissection (AAD) patients were limited. METHODS Patients who underwent surgical treatment for AAD in our center between January 2015 and December 2018 were retrospectively screened. In-hospital mortality, long-term mortality, acute kidney injury (AKI), and the requirement of continuous renal replacement therapy (CRRT) were assessed as endpoints. Univariate and multivariate regression models were employed to identify the risk factors of these endpoints. RESULTS After screening, 271 patients were included in our present study. Of the included patients, 222 (81.9%) experienced postoperative AKI, and 50 (18.5%) received CRRT. The in-hospital mortality was 30.3%. The 1-year, 2-year, and 3-year cumulative mortality were 32.9, 33.9, and 35.3%, respectively. Multivariate Logistic regression analysis indicated that age (P < 0.033), AKI stage 3 (P < 0.001), the amount of blood transfusion after surgery (P = 0.019), mean arterial pressure (MAP) in the first postoperative day (P = 0.012), the use of extracorporeal membrane oxygenation (ECMO) (P = 0.02), and the peak total bilirubin (TB) concentration (P = 0.023) were independent risk factors of in-hospital mortality. The optimal cut-off value of peak TB on predicting in-hospital mortality was 121.2 μmol/L. Patients with post-operation TB ≥ 121 μmol/L was associated with worse long-term survival as well. CONCLUSIONS Severe post-operation hyperbilirubinemia is a common clinical situation in patients had AAD repair. In AAD patients with severe post-operation hyperbilirubinemia, older age, lower MAP, increased blood transfusion, stage 3 AKI, the use of ECMO, and the increased peak TB lead to increase in-hospital mortality.
Collapse
Affiliation(s)
- Xiaolan Chen
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Ming Bai
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China.
| | - Lijuan Zhao
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Yangping Li
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Yan Yu
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Wei Zhang
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Feng Ma
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Shiren Sun
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China.
| | - Xiangmei Chen
- The Nephrology Department of Xijing Hospital, the Fourth Military Medical University, No. 127 Changle West Road, Xi'an, 710032, Shaanxi, China. .,State Key Laboratory of Kidney Disease, Department of Nephrology, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, 28th Fuxing Road, Beijing, 100853, China.
| |
Collapse
|
22
|
Sniderman J, Monagle P, Annich GM, MacLaren G. Hematologic concerns in extracorporeal membrane oxygenation. Res Pract Thromb Haemost 2020; 4:455-468. [PMID: 32548547 PMCID: PMC7292669 DOI: 10.1002/rth2.12346] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.
Collapse
Affiliation(s)
| | - Paul Monagle
- Department of PaediatricsDepartment of HaematologyUniversity of MelbourneThe Royal Children's HospitalHaematology Research Murdoch Children’s Research InstituteMelbourneVic.Australia
| | - Gail M. Annich
- Department of Critical Care MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Graeme MacLaren
- Paediatric ICURoyal Children’s HospitalMelbourneVic.Australia
- Department of PaediatricsUniversity of MelbourneParkvilleVic.Australia
- Cardiothoracic ICUNational University Health SystemSingapore CitySingapore
| |
Collapse
|
23
|
Appelt H, Philipp A, Mueller T, Foltan M, Lubnow M, Lunz D, Zeman F, Lehle K. Factors associated with hemolysis during extracorporeal membrane oxygenation (ECMO)-Comparison of VA- versus VV ECMO. PLoS One 2020; 15:e0227793. [PMID: 31986168 PMCID: PMC6984694 DOI: 10.1371/journal.pone.0227793] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022] Open
Abstract
Venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) are effective support modalities to treat critically ill patients. ECMO-associated hemolysis remains a serious complication. The aim was to disclose similarities and differences in VA- and VV ECMO-associated hemolysis. This is a retrospective single-center analysis (January 2012 to September 2018) including 1,063 adult consecutive patients (VA, n = 606; VV, n = 457). Severe hemolysis (free plasma hemoglobin, fHb > 500 mg/l) during therapy occurred in 4% (VA) and 2% (VV) (p≤0.001). VV ECMO showed significantly more hemolysis by pump head thrombosis (PHT) compared to VA ECMO (9% vs. 2%; p≤0.001). Pretreatments (ECPR, cardiac surgery) of patients who required VA ECMO caused high fHb pre levels which aggravates the proof of ECMO-induced hemolysis (median (interquartile range), VA: fHb pre: 225.0 (89.3–458.0); VV: fHb pre: 72.0 (42.0–138.0); p≤0.001). The survival rate to discharge from hospital differed depending on ECMO type (40% (VA) vs. 63% (VV); p≤0.001). Hemolysis was dominant in VA ECMO patients, mainly caused by different indications and not by the ECMO support itself. PHT was the most severe form of ECMO-induced hemolysis that occurs in both therapies with low frequency, but more commonly in VV ECMO due to prolonged support time.
Collapse
Affiliation(s)
- Hannah Appelt
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
- * E-mail:
| |
Collapse
|
24
|
Saeed O, Jakobleff WA, Forest SJ, Chinnadurai T, Mellas N, Rangasamy S, Xia Y, Madan S, Acharya P, Algodi M, Patel SR, Shin J, Vukelic S, Sims DB, Reyes Gil M, Billett HH, Kizer JR, Goldstein DJ, Jorde UP. Hemolysis and Nonhemorrhagic Stroke During Venoarterial Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2019; 108:756-763. [PMID: 30980824 PMCID: PMC6708732 DOI: 10.1016/j.athoracsur.2019.03.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/24/2019] [Accepted: 03/07/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hemolysis, even at low levels, activates platelets to create a prothrombotic state and is common during mechanical circulatory support. We examined the association of low-level hemolysis (LLH) and nonhemorrhagic stroke during venoarterial extracorporeal membrane oxygenation (VA ECMO) support. METHODS A single-center retrospective review of all adult patients placed on VA ECMO from January 2012 to September 2017 was conducted. To determine the association between LLH and nonhemorrhagic stroke, patients were categorized as those with and without LLH. LLH was defined by 48-hour plasma free hemoglobin (PFHb) of 11 to 50 mg/dL after VA ECMO implantation. RESULTS Of 201 patients who underwent VA ECMO placement, 150 (75%) met inclusion criteria and comprised the study population. They were 55 ± 14 years of age and 50 (33%) were women. Sixty-two (41%) patients had LLH. Patients with LLH had a higher likelihood of incident nonhemorrhagic stroke during VA ECMO support (20 [32%] versus 4 [5%]; adjusted hazard ratio [HR], 7.6; 95% confidence interval [CI], 2.2 to 25.9; p = 0.001). The severity of LLH was associated with an incrementally higher likelihood of a nonhemorrhagic stroke (PFHb 26 to 50 mg/dL: HR, 11.3; 95% CI, 3.6 to 35.1; p = 0.001; PFHb 11 to 25 mg/dL: HR, 4.4; 95% CI, 1.36 to 14.85; p = 0.014) in comparison with no LLH. Those with LLH had a 2-fold greater increase in mean platelet volume after VA ECMO placement (0.98 ± 1.1 fL versus 0.49 ± 0.96 fL; p = 0.03). Patients with a nonhemorrhagic stroke had a higher operative mortality (20 [83%] versus 57 [45%]; adjusted HR, 3.1; 95% CI, 1.8 to 5.3; p < 0.001). CONCLUSIONS Hemolysis at low levels during VA ECMO support is associated with subsequent nonhemorrhagic stroke.
Collapse
Affiliation(s)
- Omar Saeed
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - William A Jakobleff
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Stephen J Forest
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Thiru Chinnadurai
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Nicolas Mellas
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sabarivinoth Rangasamy
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Yu Xia
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Shivank Madan
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Prakash Acharya
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Mohammad Algodi
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Snehal R Patel
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Julia Shin
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sasa Vukelic
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel B Sims
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Morayma Reyes Gil
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Henny H Billett
- Division of Hematology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jorge R Kizer
- Section of Cardiology, San Francisco Veterans Affairs Health Care System, San Francisco, California; Department of Medicine, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Daniel J Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
25
|
Bosma M, Waanders F, Van Schaik HP, Van Loon D, Rigter S, Scholten E, Hackeng CM. Automated and cost-efficient early detection of hemolysis in patients with extracorporeal life support: Use of the hemolysis-index of routine clinical chemistry platforms. J Crit Care 2019; 51:29-33. [PMID: 30735903 DOI: 10.1016/j.jcrc.2019.01.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/10/2019] [Accepted: 01/29/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE Patients with extracorporeal life support (ECLS) are at risk for hemolysis-related complications. Therefore, monitoring of free hemoglobin (fHb) levels is indicated. Conventional methods for fHb are laborious and not always available. Here we evaluated the suitability of the hemolysis-index (H-index), an internal quality control parameter of clinical chemistry platforms, as a clinical parameter for ECLS patients. MATERIALS AND METHODS The performance of the H-index assay was evaluated using standard procedures. Furthermore, H-index data from ECLS patients (n = 56) was analyzed retrospectively. RESULTS The H-index significantly correlated with fHb and showed good analytical performance. During ECLS 19.6% of the patients had an H-index above 20 in at least 2 consecutive blood draws, indicating significant hemolysis. In the patients with clot formation in the pumphead the H-index peaked above 100. Visible clots at other locations did not always coincide with hemolysis. H-index peaks were more prevalent in patients that died during ECLS support. CONCLUSIONS We conclude that the H-index is a suitable and cost-efficient alternative for the conventional fHb analysis with good analytic performance. The H-index aids in the early detection of hemolysis in patients with ECLS. A repeated H-index>20 was a predictor of mortality.
Collapse
Affiliation(s)
- Madeleen Bosma
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands.
| | - Frans Waanders
- Department of Perfusion, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - H P Van Schaik
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Douwe Van Loon
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Sander Rigter
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Erik Scholten
- Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Chris M Hackeng
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| |
Collapse
|
26
|
Lyu L, Yao J, Gao G, Long C, Hei F, Ji B, Liu J, Yu K, Hu Q, Hu J. Incidence, Risk Factors, and Outcomes of Hyperbilirubinemia in Adult Cardiac Patients Supported by Veno-Arterial ECMO. Artif Organs 2017; 42:148-154. [PMID: 28877352 DOI: 10.1111/aor.12979] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/26/2017] [Accepted: 04/26/2017] [Indexed: 12/12/2022]
Abstract
The aims of this study were to evaluate the incidence, risk factors, and outcomes of hyperbilirubinemia in cardiac patients with veno-arterial (VA) ECMO. Data on 89 adult patients with cardiac diseases who received VA ECMO implantation in our hospital were retrospectively reviewed. All patients were divided into the following three groups: 24 in normal group (N, total bilirubin [TBIL] ≤3 mg/dL), 30 in high bilirubin group (HB, 6 mg/dL ≥ TBIL > 3 mg/dL), and 35 in severe high bilirubin group (SHB, TBIL > 6 mg/dL). lg(variables + 1) was performed for nonnormally distributed variables. The incidence of hyperbilirubinemia (>3 mg/dL) was 73%. In a multiple linear regression analysis, lg(peak TBIL + 1) was significantly associated with lg(peak AST + 1) (b-coefficient 0.188, P = 0.001), lg(peak pFHb + 1) (b-coefficient 0.201, P = 0.003), and basic TBIL (b-coefficient 0.006, P = 0.009). Repeated measurement analysis of variance revealed that the main effect for three groups in pFHb and lg(AST + 1) was significant at first 3 days during ECMO. The patients in SHB had low platelets during ECMO and low in-hospital survival rate. Hyperbilirubinemia remains common in patients with VA ECMO and is associated with low platelets and high in-hospital mortality. Hemolysis and liver dysfunction during ECMO and basic high bilirubin levels are risk factors of hyperbilirubinemia.
Collapse
Affiliation(s)
- Lin Lyu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jingxin Yao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Guodong Gao
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Cun Long
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Feilong Hei
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kun Yu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qiang Hu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinxiao Hu
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Medicine, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| |
Collapse
|
27
|
Karatolios K, Chatzis G, Markus B, Luesebrink U, Richter A, Schieffer B. Biventricular unloading in patients with refractory cardiogenic shock. Int J Cardiol 2016; 222:247-252. [DOI: 10.1016/j.ijcard.2016.07.227] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
|
28
|
Abstract
OBJECTIVES The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Children with critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
Collapse
|
29
|
Krueger K, Schmutz A, Zieger B, Kalbhenn J. Venovenous Extracorporeal Membrane Oxygenation With Prophylactic Subcutaneous Anticoagulation Only: An Observational Study in More Than 60 Patients. Artif Organs 2016; 41:186-192. [DOI: 10.1111/aor.12737] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 01/16/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Kirsten Krueger
- Department of Anaesthesiology and Critical Care Medicine; Freiburg University Medical Center; Freiburg Germany
| | - Axel Schmutz
- Department of Anaesthesiology and Critical Care Medicine; Freiburg University Medical Center; Freiburg Germany
| | - Barbara Zieger
- Department of Paediatrics and Adolescent Medicine, Laboratory for Haemostaseology; Freiburg University Medical Center; Freiburg Germany
| | - Johannes Kalbhenn
- Department of Anaesthesiology and Critical Care Medicine; Freiburg University Medical Center; Freiburg Germany
| |
Collapse
|
30
|
Venovenous extracorporeal membrane oxygenation for acute respiratory failure : A clinical review from an international group of experts. Intensive Care Med 2016; 42:712-724. [PMID: 27007108 DOI: 10.1007/s00134-016-4314-7] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/08/2016] [Indexed: 01/15/2023]
Abstract
Despite expensive life-sustaining interventions delivered in the ICU, mortality and morbidity in patients with acute respiratory failure (ARF) remain unacceptably high. Extracorporeal membrane oxygenation (ECMO) has emerged as a promising intervention that may provide more efficacious supportive care to these patients. Improvements in technology have made ECMO safer and easier to use, allowing for the potential of more widespread application in patients with ARF. A greater appreciation of the complications associated with the placement of an artificial airway and mechanical ventilation has led clinicians and researchers to seek viable alternatives to providing supportive care in these patients. Thus, this review will summarize the current knowledge regarding the use of venovenous (VV)-ECMO for ARF and describe some of the recent controversies in the field, such as mechanical ventilation, anticoagulation and transfusion therapy, and ethical concerns in patients supported with VV-ECMO.
Collapse
|
31
|
Butt W, MacLaren G. Concepts from paediatric extracorporeal membrane oxygenation for adult intensivists. Ann Intensive Care 2016; 6:20. [PMID: 26940318 PMCID: PMC4777978 DOI: 10.1186/s13613-016-0121-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/17/2016] [Indexed: 01/21/2023] Open
Abstract
Over the last 5 years, there has been a dramatic increase in the use of extracorporeal membrane oxygenation (ECMO) in adult patients with severe respiratory or cardiac failure. This contrasts to the use of the technology in neonatal and paediatric intensive care units, where it has been regarded as a standard of care for a number of conditions for over 25 years. Many innovations in ECMO circuitry or clinical management evolve first in one particular discipline and it may be helpful for individual clinicians to keep abreast of developments in ECMO across the entire age range, from neonatology to older adults. This review addresses nine concepts in ECMO that are better studied or established in paediatric medicine and considers their application in adult patients.
Collapse
Affiliation(s)
- Warwick Butt
- Paediatric Intensive Care Unit, Royal Children's Hospital, Flemington Rd, Parkville, VIC, 3052, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Clinical Sciences, Melbourne, Australia
| | - Graeme MacLaren
- Paediatric Intensive Care Unit, Royal Children's Hospital, Flemington Rd, Parkville, VIC, 3052, Australia. .,Department of Paediatrics, University of Melbourne, Melbourne, Australia. .,Cardiothoracic Intensive Care Unit, National University Health System, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore.
| |
Collapse
|
32
|
Lehle K, Philipp A, Zeman F, Lunz D, Lubnow M, Wendel HP, Göbölös L, Schmid C, Müller T. Technical-Induced Hemolysis in Patients with Respiratory Failure Supported with Veno-Venous ECMO - Prevalence and Risk Factors. PLoS One 2015; 10:e0143527. [PMID: 26606144 PMCID: PMC4659553 DOI: 10.1371/journal.pone.0143527] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 11/05/2015] [Indexed: 11/18/2022] Open
Abstract
The aim of the study was to explore the prevalence and risk factors for technical-induced hemolysis in adults supported with veno-venous extracorporeal membrane oxygenation (vvECMO) and to analyze the effect of hemolytic episodes on outcome. This was a retrospective, single-center study that included 318 adult patients (Regensburg ECMO Registry, 2009–2014) with acute respiratory failure treated with different modern miniaturized ECMO systems. Free plasma hemoglobin (fHb) was used as indicator for hemolysis. Throughout a cumulative support duration of 4,142 days on ECMO only 1.7% of the fHb levels were above a critical value of 500 mg/l. A grave rise in fHb indicated pumphead thrombosis (n = 8), while acute oxygenator thrombosis (n = 15) did not affect fHb. Replacement of the pumphead normalized fHb within two days. Neither pump or cannula type nor duration on the first system was associated with hemolysis. Multiple trauma, need for kidney replacement therapy, increased daily red blood cell transfusion requirements, and high blood flow (3.0–4.5 L/min) through small-sized cannulas significantly resulted in augmented blood cell trauma. Survivors were characterized by lower peak levels of fHb [90 (60, 142) mg/l] in comparison to non-survivors [148 (91, 256) mg/l, p≤0.001]. In conclusion, marked hemolysis is not common in vvECMO with modern devices. Clinically obvious hemolysis often is caused by pumphead thrombosis. High flow velocity through small cannulas may also cause technical-induced hemolysis. In patients who developed lung failure due to trauma, fHb was elevated independantly of ECMO. In our cohort, the occurance of hemolysis was associated with increased mortality.
Collapse
Affiliation(s)
- Karla Lehle
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
- * E-mail:
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Peter Wendel
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Laszlo Göbölös
- Department of Cardiothoracic Surgery, Southampton University Hospital Trust, Southampton, United Kingdom
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| |
Collapse
|