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Trejnowska E, Skoczyński S, Swinarew AS, Tarczyńska-Słomian M, Armatowicz P, Cyprys P, Cieśla D, Zembala MO, Knapik P, Hryniewicz K. Value, time and outcomes of elevated lactate levels in adult patients on extracorporeal membrane oxygenation. Perfusion 2024; 39:124-133. [PMID: 36168831 DOI: 10.1177/02676591221130177] [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: 11/16/2022]
Abstract
INTRODUCTION Lactate levels have been recognized as a reliable tool for monitoring critically ill patients requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) or venovenous extracorporeal membrane oxygenation (VV ECMO) but the reasons behind the overproduction of lactate are different and the influance for survival remains controversial. We analyzed the lactate values and lactate clearance in adult patients in these two forms of extracorporeal support. METHODS Patient demographics, ECMO duration, 30-day mortality, lactate values and lactate clearance at 24, 48 and 72 h from ECMO initiation of patients supported with VV and VA ECMO at Silesian Centre for Heart Deasese, between January 2011 and April 2020 were retrospectively analyzed. The changes in lactate levels were analyzed using the non-parametric U Mann-Whitney tests and Chi-square test. The ROC curves were draw and the area under the curve was calculated. RESULTS The study comprised 91 adult patients, Mortality in the first 30 days from initiation of VV and VA ECMO was 39% and 66%, respectively. Lactate levels were significantly higher in non-survivors that received VV and VA ECMO (p < .001), while lactate clearance was similar (p = .256 and p = 1.000, respectively). Survival curves for patients with elevated (>2.0 mmol/L) vs normal (≤2.0 mmol/L) lactate levels at 72 h were significantly different for VV ECMO (p = .007) and VA ECMO (p = .037) but in both groups of ECMO, lactate levels above 2.0 mmol/L at 72 h from ECMO initiation predicted 30 day-mortality. CONCLUSION This results emphasized the importance of lactate levels below 2.0 mmol/L at 72 h from both VV and VA ECMO initiation.
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Affiliation(s)
- Ewa Trejnowska
- Clinical Department of Cardioanesthesia and Intensive Care Unit, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Szymon Skoczyński
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Andrzej S Swinarew
- Faculty of Science and Technology, University of Silesia, Katowice, Poland
- Department of Individual Sports, Institute of Sport Science, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - Magda Tarczyńska-Słomian
- III Clinical Department of Cardiology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Paul Armatowicz
- Department of General and Endocrine Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Cyprys
- Doctoral School, Clinical Department of Cardioanesthesiology and Intensive Care Unit, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Daniel Cieśla
- Department of Science and New Technologies,Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Michał O Zembala
- Department of Cardiac Surgery, Heart and Lung Transplantation and Mechanical Circulatory Support, Silesian Center For Heart Diseases, Zabrze, Poland
- Pomeranian Medical University, Szczecin, Poland
| | - Piotr Knapik
- Clinical Department of Cardioanesthesia and Intensive Care Unit, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Katarzyna Hryniewicz
- Minneapolis Heart Institute Section of Advanced Heart Failure/MCS/ Heart Transplantation, Abbott Northwestern Hospital Minneapolis, MN, USA
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Lee H, Song MJ, Cho YJ, Kim DJ, Hong SB, Jung SY, Lim SY. Supervised machine learning model to predict mortality in patients undergoing venovenous extracorporeal membrane oxygenation from a nationwide multicentre registry. BMJ Open Respir Res 2023; 10:e002025. [PMID: 38154913 PMCID: PMC10759084 DOI: 10.1136/bmjresp-2023-002025] [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] [Received: 08/19/2023] [Accepted: 12/01/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Existing models have performed poorly when predicting mortality for patients undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to develop and validate a machine learning (ML)-based prediction model to predict 90-day mortality in patients undergoing VV-ECMO. METHODS This study included 368 patients with acute respiratory failure undergoing VV-ECMO from 16 tertiary hospitals across South Korea between 2012 and 2015. The primary outcome was the 90-day mortality after ECMO initiation. The inputs included all available features (n=51) and those from the electronic health record (EHR) systems without preprocessing (n=40). The discriminatory strengths of ML models were evaluated in both internal and external validation sets. The models were compared with conventional models, such as respiratory ECMO survival prediction (RESP) and predicting death for severe acute respiratory distress syndrome on VV-ECMO (PRESERVE). RESULTS Extreme gradient boosting (XGB) (areas under the receiver operating characteristic curve, AUROC 0.82, 95% CI (0.73 to 0.89)) and light gradient boosting (AUROC 0.81 (95% CI 0.71 to 0.88)) models achieved the highest performance using EHR's and all other available features. The developed models had higher AUROCs (95% CI 0.76 to 0.82) than those of RESP (AUROC 0.66 (95% CI 0.56 to 0.76)) and PRESERVE (AUROC 0.71 (95% CI 0.61 to 0.81)). Additionally, we achieved an AUROC (0.75) for 90-day mortality in external validation in the case of the XGB model, which was higher than that of RESP (0.70) and PRESERVE (0.67) in the same validation dataset. CONCLUSIONS ML prediction models outperformed previous mortality risk models. This model may be used to identify patients who are unlikely to benefit from VV-ECMO therapy during patient selection.
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Affiliation(s)
- Haeun Lee
- Department of Digital Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Myung Jin Song
- Devision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young-Jae Cho
- Devision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Dong Jung Kim
- Department of Cardiovascular and Thoracic Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Se Young Jung
- Department of Digital Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung Yoon Lim
- Devision of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Rajsic S, Breitkopf R, Kojic D, Bukumiric Z, Treml B. Extracorporeal Life Support for Patients With Newly Diagnosed HIV and Acute Respiratory Distress Syndrome: A Systematic Review and Analysis of Individual Patient Data. ASAIO J 2023; 69:e513-e519. [PMID: 37738393 DOI: 10.1097/mat.0000000000002047] [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: 09/24/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) may improve survival in patients with severe acute respiratory distress syndrome (ARDS). However, presence of immunosuppression is a relative contraindication for ECMO, which is withheld in HIV patients. We performed a systematic review to investigate the outcome of newly diagnosed HIV patients with ARDS receiving ECMO support. Our search yielded 288 publications, with 22 studies finally included. Initial presentation included fever, respiratory distress, and cough. Severe immunodeficiency was confirmed in most patients. Deceased patients had a higher viral load, a lower Horovitz index, and antiretroviral therapy utilized before ECMO. Moreover, ECMO duration was longer ( p = 0.0134), and all deceased suffered from sepsis ( p = 0.0191). Finally, despite the development of therapeutic options for HIV patients, ECMO remains a relative contraindication. We found that ECMO may successfully bridge the time for pulmonary recovery in 93% of patients, with a very good outcome. Using ECMO, the time for antimicrobial therapy, lung-protective ventilation, and immune system restitution may be gained. Further studies clarifying the role of ECMO in HIV are crucial and until these data are available, ECMO might be appropriate in immunocompromised patients. This holds especially true in newly diagnosed HIV patients, who are usually young, without comorbidities, with a good rehabilitation potential.
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Affiliation(s)
- Sasa Rajsic
- From the Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Robert Breitkopf
- From the Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Dejan Kojic
- Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Benedikt Treml
- From the Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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Tonetti T, Zanella A, Pérez-Torres D, Grasselli G, Ranieri VM. Current knowledge gaps in extracorporeal respiratory support. Intensive Care Med Exp 2023; 11:77. [PMID: 37962702 PMCID: PMC10645840 DOI: 10.1186/s40635-023-00563-x] [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] [Received: 01/18/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction ("ultra-protective ventilation") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
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Affiliation(s)
- Tommaso Tonetti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - David Pérez-Torres
- Servicio de Medicina Intensiva, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León (SACYL), Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - V Marco Ranieri
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy
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Burša F, Frelich M, Sklienka P, Jor O, Máca J. Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure. J Clin Med 2023; 12:5196. [PMID: 37629239 PMCID: PMC10455442 DOI: 10.3390/jcm12165196] [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: 06/27/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.
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Affiliation(s)
- Filip Burša
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Michal Frelich
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Peter Sklienka
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Ondřej Jor
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
| | - Jan Máca
- Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, 17. Listopadu 1790, 708 00 Ostrava, Czech Republic; (F.B.); (M.F.); (P.S.); (O.J.)
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic
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Kahrizi MS, Mousavi E, Khosravi A, Rahnama S, Salehi A, Nasrabadi N, Ebrahimzadeh F, Jamali S. Recent advances in pre-conditioned mesenchymal stem/stromal cell (MSCs) therapy in organ failure; a comprehensive review of preclinical studies. Stem Cell Res Ther 2023; 14:155. [PMID: 37287066 DOI: 10.1186/s13287-023-03374-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 05/10/2023] [Indexed: 06/09/2023] Open
Abstract
Mesenchymal stem/stromal cells (MSCs)-based therapy brings the reassuring capability to regenerative medicine through their self-renewal and multilineage potency. Also, they secret a diversity of mediators, which are complicated in moderation of deregulated immune responses, and yielding angiogenesis in vivo. Nonetheless, MSCs may lose biological performance after procurement and prolonged expansion in vitro. Also, following transplantation and migration to target tissue, they encounter a harsh milieu accompanied by death signals because of the lack of proper tensegrity structure between the cells and matrix. Accordingly, pre-conditioning of MSCs is strongly suggested to upgrade their performances in vivo, leading to more favored transplantation efficacy in regenerative medicine. Indeed, MSCs ex vivo pre-conditioning by hypoxia, inflammatory stimulus, or other factors/conditions may stimulate their survival, proliferation, migration, exosome secretion, and pro-angiogenic and anti-inflammatory characteristics in vivo. In this review, we deliver an overview of the pre-conditioning methods that are considered a strategy for improving the therapeutic efficacy of MSCs in organ failures, in particular, renal, heart, lung, and liver.
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Affiliation(s)
| | - Elnaz Mousavi
- Department of Endodontics, School of Dentistry, Guilan University of Medical Sciences, Rasht, Iran
| | - Armin Khosravi
- Department of Periodontics, Dental School, Islamic Azad University, Isfahan (Khorasgan) Branch, Isfahan, Iran
| | - Sara Rahnama
- Department of Pediatric Dentistry, School of Dentistry, Semnan University of Medical Sciences, Semnan, Iran
| | - Ali Salehi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Islamic Azad University, Isfahan (Khorasgan) Branch, Isfahan, Iran
| | - Navid Nasrabadi
- Department of Endodontics, School of Dentistry, Birjand University of Medical Sciences, Birjand, Iran
| | - Farnoosh Ebrahimzadeh
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Samira Jamali
- Department of Endodontics, Stomatological Hospital, College of Stomatology, Xi'an Jiaotong University, Shaanxi, People's Republic of China.
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Predictive models in extracorporeal membrane oxygenation (ECMO): a systematic review. Syst Rev 2023; 12:44. [PMID: 36918967 PMCID: PMC10015918 DOI: 10.1186/s13643-023-02211-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the last years to provide hemodynamic and respiratory support in critically ill patients. In this scenario, prognostic scores remain essential to choose which patients should initiate ECMO. This systematic review aims to assess the current landscape and inform subsequent efforts in the development of risk prediction tools for ECMO. METHODS PubMed, CINAHL, Embase, MEDLINE and Scopus were consulted. Articles between Jan 2011 and Feb 2022, including adults undergoing ECMO reporting a newly developed and validated predictive model for mortality, were included. Studies based on animal models, systematic reviews, case reports and conference abstracts were excluded. Data extraction aimed to capture study characteristics, risk model characteristics and model performance. The risk of bias was evaluated through the prediction model risk-of-bias assessment tool (PROBAST). The protocol has been registered in Open Science Framework ( https://osf.io/fevw5 ). RESULTS Twenty-six prognostic scores for in-hospital mortality were identified, with a study size ranging from 60 to 4557 patients. The most common candidate variables were age, lactate concentration, creatinine concentration, bilirubin concentration and days in mechanical ventilation prior to ECMO. Five out of 16 venous-arterial (VA)-ECMO scores and 3 out of 9 veno-venous (VV)-ECMO scores had been validated externally. Additionally, one score was developed for both VA and VV populations. No score was judged at low risk of bias. CONCLUSION Most models have not been validated externally and apply after ECMO initiation; thus, some uncertainty whether ECMO should be initiated still remains. It has yet to be determined whether and to what extent a new methodological perspective may enhance the performance of predictive models for ECMO, with the ultimate goal to implement a model that positively influences patient outcomes.
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Pladet LCA, Barten JMM, Vernooij LM, Kraemer CVE, Bunge JJH, Scholten E, Montenij LJ, Kuijpers M, Donker DW, Cremer OL, Meuwese CL. Prognostic models for mortality risk in patients requiring ECMO. Intensive Care Med 2023; 49:131-141. [PMID: 36600027 PMCID: PMC9944134 DOI: 10.1007/s00134-022-06947-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To provide an overview and evaluate the performance of mortality prediction models for patients requiring extracorporeal membrane oxygenation (ECMO) support for refractory cardiocirculatory or respiratory failure. METHODS A systematic literature search was undertaken to identify studies developing and/or validating multivariable prediction models for all-cause mortality in adults requiring or receiving veno-arterial (V-A) or veno-venous (V-V) ECMO. Estimates of model performance (observed versus expected (O:E) ratio and c-statistic) were summarized using random effects models and sources of heterogeneity were explored by means of meta-regression. Risk of bias was assessed using the Prediction model Risk Of BiAS Tool (PROBAST). RESULTS Among 4905 articles screened, 96 studies described a total of 58 models and 225 external validations. Out of all 58 models which were specifically developed for ECMO patients, 14 (24%) were ever externally validated. Discriminatory ability of frequently validated models developed for ECMO patients (i.e., SAVE and RESP score) was moderate on average (pooled c-statistics between 0.66 and 0.70), and comparable to general intensive care population-based models (pooled c-statistics varying between 0.66 and 0.69 for the Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score). Nearly all models tended to underestimate mortality with a pooled O:E > 1. There was a wide variability in reported performance measures of external validations, reflecting a large between-study heterogeneity. Only 1 of the 58 models met the generally accepted Prediction model Risk Of BiAS Tool criteria of good quality. Importantly, all predicted outcomes were conditional on the fact that ECMO support had already been initiated, thereby reducing their applicability for patient selection in clinical practice. CONCLUSIONS A large number of mortality prediction models have been developed for ECMO patients, yet only a minority has been externally validated. Furthermore, we observed only moderate predictive performance, large heterogeneity between-study populations and model performance, and poor methodological quality overall. Most importantly, current models are unsuitable to provide decision support for selecting individuals in whom initiation of ECMO would be most beneficial, as all models were developed in ECMO patients only and the decision to start ECMO had, therefore, already been made.
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Affiliation(s)
- Lara C A Pladet
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jaimie M M Barten
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J H Bunge
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erik Scholten
- Department of Intensive Care Medicine, Sint Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Leon J Montenij
- Department of Intensive Care Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Marijn Kuijpers
- Department of Intensive Care Medicine, Isala Hospital Zwolle, Zwolle, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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9
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Yoon YI, Lim JH, Lee SG, Kang PJ, Hwang GS, Ha SM, Do HY, Hong SK, Huh JW. Role of extracorporeal membrane oxygenation as a salvage therapy for liver transplantation recipients in a high-volume transplant center. Liver Transpl 2023; 29:67-79. [PMID: 36030502 DOI: 10.1002/lt.26567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/08/2022] [Accepted: 07/20/2022] [Indexed: 01/14/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been used sporadically in adult orthotopic liver transplantation (OLT) recipients for the treatment of acute cardiopulmonary failure. This retrospective study aimed to identify OLT patients who would benefit from ECMO support. We reviewed 109 OLT patients who received ECMO support for more than 24 h from January 2007 to December 2020. Among the enrolled patients, 15 (13.8%) experienced 18 ECMO-related complications and 12 (11.0%) experienced ECMO reapplication after weaning during the same hospitalization period. The successful weaning rates were 50.98% in patients who received ECMO support during the peritransplantation period (0-30 days from transplantation) and 51.72% in patients who received ECMO support in the post-OLT period (more than 30 days after OLT); 24 (47.1%) and 23 (39.7%) patients survived until hospital discharge, respectively. The 109 enrolled OLT recipients who received ECMO support during the perioperative period had a 1-year survival rate of 42.6%. Multivariate analyses identified the following as significant and independent risk factors for in-hospital mortality: ECMO treatment prior to 2011 ( p = 0.04), septic shock as the indication for ECMO treatment ( p = 0.001), and a total bilirubin level of ≥5.0 mg/dl ( p = 0.02). The outcomes of adult OLT recipients with ECMO treatment were acceptable in terms of weaning success and survival until hospital discharge. This study confirmed that ECMO treatment for OLT recipients with septic shock and elevated bilirubin levels might be associated with a higher in-hospital mortality and demonstrated the importance of a multidisciplinary ECMO team approach.
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Affiliation(s)
- Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Jung-Hyeon Lim
- Department of Thoracic and Cardiovascular Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Pil-Je Kang
- Department of Thoracic and Cardiovascular Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Su-Min Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Ha-Yeon Do
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
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10
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Outcome of post-traumatic acute respiratory distress syndrome in young patients requiring extracorporeal membrane oxygenation (ECMO). Sci Rep 2022; 12:10609. [PMID: 35739167 PMCID: PMC9226058 DOI: 10.1038/s41598-022-14741-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
We aimed to evaluate the outcomes of post-traumatic acute respiratory distress syndrome (ARDS) in young patients with and without Extracorporeal membrane oxygenation (ECMO) support. A retrospective analysis was conducted for trauma patients who developed ARDS at a level I trauma facility between 2014 and 2020. Data were analyzed and compared between ECMO and non-ECMO group. We identified 85 patients with ARDS (22 patients had ECMO support and 63 matched patients managed by the conventional mechanical ventilation; 1:3 matching ratio). The two groups were comparable for age, sex, injury severity score, abbreviated injury score, shock index, SOFA score, and head injury. Kaplan Meier survival analysis showed that the survival in the ECMO group was initially close to that of the non-ECMO, however, during follow-up, the survival rate was better in the ECMO group, but did not reach statistical significance (Log-rank, p = 0.43 and Tarone-Ware, p = 0.37). Multivariable logistic regression analysis showed that acute kidney injury (AKI) (Odds ratio 13.03; 95% CI 3.17–53.54) and brain edema (Odds ratio 4.80; 95% CI 1.10–21.03) were independent predictors of mortality. Sub-analysis showed that in patients with severe Murray Lung Injury (MLI) scores, non-ECMO group had higher mortality than the ECMO group (100% vs 36.8%, p = 0.004). Although ARDS is uncommon in young trauma patients, it has a high mortality. ECMO therapy was used in a quarter of ARDS cases. AKI and brain edema were the predictors of mortality among ARDS patients. ECMO use did not worsen the outcome in trauma patients; however, the survival was better in those who had severe MLI and ECMO support. Further prospective study is needed to define the appropriate selection criteria for the use of ECMO to optimize the outcomes in trauma patients.
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11
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A Nomogram for Predicting the Mortality of Patients with Acute Respiratory Distress Syndrome. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:5940900. [PMID: 35432833 PMCID: PMC9010168 DOI: 10.1155/2022/5940900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is an acute lung injury associated with high morbidity and mortality. This study aimed to establish an accurate prediction model for mortality risk in ARDS. 70% of patients from the Medical Information Mart for Intensive Care Database (MIMIC-III) were selected as the training group, and the remaining 30% as the testing group. Patients from a Chinese hospital were used for external validation. Univariate and multivariate regressions were used to screen the independent predictors. The receiver operating characteristic curve (ROC) analysis, the Hosmer–Lemeshow test, and the calibration curve were used for evaluating the performance of the model. Age, hemoglobin, heart failure, renal failure, Simplified Acute Physiology Score II (SAPS II), immune function impairment, total bilirubin (TBIL), and PaO2/FiO2 were identified as independent predictors. The algorithm of the prediction model was: ln (Pr/(1 + Pr)) = −3.147 + 0.037 ∗ age − 0.068 ∗ hemoglobin + 0.522 ∗ heart failure (yes) + 0.487 ∗ renal failure (yes) + 0.029 ∗ SAPS II + 0.697 ∗ immune function impairment (yes) + 0.280 ∗ TBIL (abnormal) − 0.006 ∗ PaO2/FiO2 (Pr represents the probability of death occurring). The AUC of the model was 0.791 (0.766–0.816), and the internal and the external validations both confirmed the good performance of the model. A nomogram for predicting the risk of death in ARDS patients was developed and validated. It may help clinicians early identify ARDS patients with high risk of death and thereby help reduce the mortality and improve the survival of ARDS.
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12
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An External Validation of Scoring Systems in Mortality Prediction in Veno-Venous Extracorporeal Membrane Oxygenation. ASAIO J 2022; 68:255-261. [DOI: 10.1097/mat.0000000000001461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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13
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Rilinger J, Zotzmann V, Bemtgen X, Rieg S, Biever PM, Duerschmied D, Pottgiesser T, Kaier K, Bode C, Staudacher DL, Wengenmayer T. Influence of immunosuppression in patients with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation therapy. Artif Organs 2021; 45:1050-1060. [PMID: 33725377 PMCID: PMC8250998 DOI: 10.1111/aor.13954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/15/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022]
Abstract
Prognosis of patients suffering from acute respiratory distress syndrome (ARDS) is poor. This is especially true for immunosuppressed patients. It is controverisal whether these patients should receive veno-venous extracorporeal membrane oxygenation (VV ECMO) while evidence on this topic is sparse. We report retrospective data of a single-center registry of patients with severe ARDS requiring ECMO support between October 2010 and June 2019. Patients were analyzed by their status of immunosuppression. ECMO weaning success and hospital survival were analyzed before and after propensity score matching (PSM). Moreover, ventilator free days (VFD) were compared. A total of 288 patients were analyzed (age 55 years, 67% male), 88 (31%) presented with immunosuppression. Survival rates were lower in immunosuppressed patients (27% vs. 53%, P < .001 and 27% vs. 48% after PSM, P = .006). VFD (60 days) were lower for patients with immunosuppression (11.9 vs. 22.4, P < .001), and immunosuppression was an independent predictor for mortality in multivariate analysis. Hospital survival was 20%, 14%, 35%, and 46% for patients with oncological malignancies, solid organ transplantation, autoimmune diseases, and HIV, respectively. In this analysis immunosuppression was an independent predictor for mortality. However, there were major differences in the weaning and survival rates between the etiologies of immunosuppression which should be considered in decision making.
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Affiliation(s)
- Jonathan Rilinger
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Viviane Zotzmann
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Xavier Bemtgen
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Paul M. Biever
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Daniel Duerschmied
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Torben Pottgiesser
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, University Medical Center Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Dawid L. Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of MedicineUniversity of FreiburgFreiburgGermany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of MedicineUniversity of FreiburgFreiburgGermany
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14
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(Early and late complications of extracorporeal membrane oxygenation). COR ET VASA 2021. [DOI: 10.33678/cor.2021.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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16
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Diaz RA, Graf J, Zambrano JM, Ruiz C, Espinoza JA, Bravo SI, Salazar PA, Bahamondes JC, Castillo LB, Gajardo AIJ, Kursbaum A, Ferreira LL, Valenzuela J, Castillo RE, Pérez-Araos RA, Bravo M, Aquevedo AF, González MG, Pereira R, Ortega L, Santis C, Fernández PA, Cortés V, Cornejo RA. Extracorporeal Membrane Oxygenation for COVID-19-associated Severe Acute Respiratory Distress Syndrome in Chile: A Nationwide Incidence and Cohort Study. Am J Respir Crit Care Med 2021; 204:34-43. [PMID: 33823118 PMCID: PMC8437120 DOI: 10.1164/rccm.202011-4166oc] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Rationale: The role of and needs for extracorporeal membrane oxygenation (ECMO) at a population level during the coronavirus disease (COVID-19) pandemic have not been completely established. Objectives: To identify the cumulative incidence of ECMO use in the first pandemic wave and to describe the Nationwide Chilean cohort of ECMO-supported patients with COVID-19. Methods: We conducted a population-based study from March 3 to August 31, 2020, using linked data from national agencies. The cumulative incidence of ECMO use and mortality risk of ECMO-supported patients were calculated and age standardized. In addition, a retrospective cohort analysis was performed. Outcomes were 90-day mortality after ECMO initiation, ECMO-associated complications, and hospital length of stay. Cox regression models were used to explore risk factors for mortality in a time-to-event analysis. Measurements and Main Results: Ninety-four patients with COVID-19 were supported with ECMO (0.42 per population of 100,000, 14.89 per 100,000 positive cases, and 1.2% of intubated patients with COVID-19); 85 were included in the cohort analysis, and the median age was 48 (interquartile range [IQR], 41-55) years, 83.5% were men, and 42.4% had obesity. The median number of pre-ECMO intubation days was 4 (IQR, 2-7), the median PaO2/FiO2 ratio was 86.8 (IQR, 64-99) mm Hg, 91.8% of patients were prone positioned, and 14 patients had refractory respiratory acidosis. Main complications were infections (70.6%), bleeding (38.8%), and thromboembolism (22.4%); 52 patients were discharged home, and 33 died. The hospital length of stay was a median of 50 (IQR, 24-69) days. Lower respiratory system compliance and higher driving pressure before ECMO initiation were associated with increased mortality. A duration of pre-ECMO intubation ≥10 days was not associated with mortality. Conclusions: Documenting nationwide ECMO needs may help in planning ECMO provision for future COVID-19 pandemic waves. The 90-day mortality of the Chilean cohort of ECMO-supported patients with COVID-19 (38.8%) is comparable to that of previous reports.
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Affiliation(s)
- Rodrigo A Diaz
- Unidad de Oxigenación por Membrana Extracorpórea, Clínica Las Condes, Santiago, Chile
| | - Jerónimo Graf
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile.,Facultad de Medicina, Clínica Alemana-Universidad de Desarrollo, Santiago, Chile
| | | | - Carolina Ruiz
- Unidad de Paciente Crítico, Complejo Asistencial Dr. Sótero del Río, Santiago, Chile.,Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Sebastian I Bravo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo A Salazar
- Equipo de Oxigenación por Membrana Extracorpórea, Hospital de Las Higueras de Talcahuano, Talcahuano, Chile
| | - Juan C Bahamondes
- Servicio de Cirugía Cardiovascular and.,Departamento de Cirugía, Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
| | - Luis B Castillo
- Unidad de Pacientes Críticos, Hospital Barros Luco Trudeau, Santiago, Chile
| | | | - Andrés Kursbaum
- Departamento de Cirugía Cardiaca, Clínica Dávila, Santiago, Chile
| | - Leonila L Ferreira
- Unidad de Pacientes Críticos, Hospital Regional de Concepción, Concepción, Chile
| | | | - Roberto E Castillo
- Unidad de Oxigenación por Membrana Extracorpórea, Clínica Las Condes, Santiago, Chile
| | - Rodrigo A Pérez-Araos
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile.,Facultad de Medicina, Clínica Alemana-Universidad de Desarrollo, Santiago, Chile
| | | | - Andrés F Aquevedo
- Unidad de Paciente Crítico, Complejo Asistencial Dr. Sótero del Río, Santiago, Chile.,Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Mauricio G González
- Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Rodrigo Pereira
- Equipo de Oxigenación por Membrana Extracorpórea, Hospital de Las Higueras de Talcahuano, Talcahuano, Chile
| | - Leandro Ortega
- Unidad de Pacientes Críticos, Hospital Regional de Temuco, Temuco, Chile
| | - César Santis
- Unidad de Pacientes Críticos, Hospital Barros Luco Trudeau, Santiago, Chile
| | - Paula A Fernández
- Unidad de Pacientes Críticos, Hospital Regional de Concepción, Concepción, Chile
| | - Vilma Cortés
- División de Gestión de Redes Asistenciales, Ministerio de Salud de Chile, Santiago, Chile; and
| | - Rodrigo A Cornejo
- Unidad de Pacientes Críticos, Departamento de Medicina, and.,Center of Acute Respiratory Critical Illness, Santiago, Chile
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17
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Na SJ, Park SH, Hong SB, Cho WH, Lee SM, Cho YJ, Park S, Koo SM, Park SY, Chang Y, Kang BJ, Kim JH, Oh JY, Jung JS, Yoo JW, Sim YS, Jeon K. Clinical outcomes of immunocompromised patients on extracorporeal membrane oxygenation support for severe acute respiratory failure. Eur J Cardiothorac Surg 2021; 57:788-795. [PMID: 31625551 DOI: 10.1093/ejcts/ezz276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/03/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES There are limited data regarding extracorporeal membrane oxygenation (ECMO) support in immunocompromised patients, despite an increase in ECMO use in patients with respiratory failure. The aim of this study was to investigate the clinical characteristics and outcomes of immunocompromised patients requiring ECMO support for severe acute respiratory failure. METHODS Between January 2012 and December 2015, all consecutive adult patients with severe acute respiratory failure who underwent ECMO for respiratory support at 16 tertiary or university-affiliated hospitals in South Korea were enrolled retrospectively. The patients were divided into 2 groups based on the immunocompromised status at the time of ECMO initiation. In-hospital and 6-month mortalities were compared between the 2 groups. In addition, association of immunocompromised status with 6-month mortality was evaluated with logistic regression analysis. RESULTS Among 461 patients, 118 (25.6%) were immunocompromised. Immunocompromised patients were younger and had lower haemoglobin and platelet counts than immunocompetent patients. Ventilatory parameters and the use of adjunctive/rescue therapies were similar between the 2 groups, but prone positioning was more commonly used in immunocompetent patients. Successful weaning rates from ECMO (46.6% vs 58.9%; P = 0.021) was lower and hospital mortality (66.1% vs 59.8%; P = 0.22) was higher in immunocompromised patients. In addition, immunocompromised status was associated with higher 6-month mortality (74.6% vs 64.7%, adjusted odds ratio 2.10, 95% confidence interval 1.02-4.35; P = 0.045). CONCLUSIONS Immunocompromised patients treated with ECMO support for severe acute respiratory failure had poorer short- and long-term prognoses than did immunocompetent patients.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So Hee Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woo Hyun Cho
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Gyeongsangnam-do, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Sunghoon Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Gyeonggi-do, Republic of Korea
| | - So-My Koo
- Division of Pulmonary and Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Seung Yong Park
- Department of Internal Medicine, Chonbuk National University Hospital, Jeollabuk-do, Republic of Korea
| | - Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Byung Ju Kang
- Division of Pulmonology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Jung-Hyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, CHA Bundang Medical Center, Gyeonggi-do, Republic of Korea
| | - Jin Young Oh
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Jae-Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jung-Wan Yoo
- Department of Internal Medicine, College of Medicine, Gyeongsang National University Hospital, Gyeongsangnam-do, Republic of Korea
| | - Yun Su Sim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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18
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Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 48:838-846. [PMID: 32282350 DOI: 10.1097/ccm.0000000000004330] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation. DESIGN Retrospective review of the literature and expert consensus. SETTING Series of in-person meetings, conference calls, and emails from January 2018 to March 2019. SUBJECTS A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field. INTERVENTIONS A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9. MEASUREMENTS AND MAIN RESULTS The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead. CONCLUSIONS The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.
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19
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Murugappan KR, Walsh DP, Mittel A, Sontag D, Shaefi S. Veno-venous extracorporeal membrane oxygenation allocation in the COVID-19 pandemic. J Crit Care 2020; 61:221-226. [PMID: 33220575 PMCID: PMC7664357 DOI: 10.1016/j.jcrc.2020.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/17/2020] [Accepted: 11/07/2020] [Indexed: 01/08/2023]
Abstract
Rapid global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resultant clinical illness, coronavirus disease 2019 (COVID-19), drove the World Health Organization to declare COVID-19 a pandemic. Veno-venous Extra-Corporeal Membrane Oxygenation (VV-ECMO) is an established therapy for management of patients demonstrating the most severe forms of hypoxemic respiratory failure from COVID-19. However, features of COVID-19 pathophysiology and necessary length of treatment present distinct challenges for utilization of VV-ECMO within the current healthcare emergency. In addition, growing allocation concerns due to capacity and cost present significant challenges. Ethical and legal aspects pertinent to triage of this resource-intensive, but potentially life-saving, therapy in the setting of the COVID-19 pandemic are reviewed here. Given considerations relevant to VV-ECMO use, additional emphasis has been placed on emerging hospital resource scarcity and disproportionate representation of healthcare workers among the ill. Considerations are also discussed surrounding withdrawal of VV-ECMO and the role for early communication as well as consultation from palliative care teams and local ethics committees. In discussing how to best manage these issues in the COVID-19 pandemic at present, we identify gaps in the literature and policy important to clinicians as this crisis continues. VV-ECMO may successfully treat respiratory failure due to COVID-19. The coronavirus pandemic necessitates judicious use of this resource-intensive therapy. Unique features of COVID-19, including isolation from surrogates, present challenges. Providers face difficult triage decisions that must be communicated appropriately. We review available resources and support tools for clinicians considering VV-ECMO.
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Affiliation(s)
- Kadhiresan R Murugappan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States of America.
| | - Daniel P Walsh
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States of America
| | - Aaron Mittel
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States of America
| | - David Sontag
- Managing General Counsel, Beth Israel Lahey Health, 109 Brookline Ave, Suite 300, Boston, MA 02215, United States of America; Ethics Advisory Committee, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, United States of America
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States of America
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20
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How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation. Chest 2020; 158:1036-1045. [DOI: 10.1016/j.chest.2020.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/30/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023] Open
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21
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Abstract
This review focuses on the use of veno-venous extracorporeal membrane oxygenation for respiratory failure across all blood flow ranges. Starting with a short overview of historical development, aspects of the physiology of gas exchange (i.e., oxygenation and decarboxylation) during extracorporeal circulation are discussed. The mechanisms of phenomena such as recirculation and shunt playing an important role in daily clinical practice are explained.Treatment of refractory and symptomatic hypoxemic respiratory failure (e.g., acute respiratory distress syndrome [ARDS]) currently represents the main indication for high-flow veno-venous-extracorporeal membrane oxygenation. On the other hand, lower-flow extracorporeal carbon dioxide removal might potentially help to avoid or attenuate ventilator-induced lung injury by allowing reduction of the energy load (i.e., driving pressure, mechanical power) transmitted to the lungs during mechanical ventilation or spontaneous ventilation. In the latter context, extracorporeal carbon dioxide removal plays an emerging role in the treatment of chronic obstructive pulmonary disease patients during acute exacerbations. Both applications of extracorporeal lung support raise important ethical considerations, such as likelihood of ultimate futility and end-of-life decision-making. The review concludes with a brief overview of potential technical developments and persistent challenges.
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Lee HK, Kim HS, Ha SO, Park S, Lee HS, Lee SK, Lee SH. Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study. Scand J Trauma Resusc Emerg Med 2020; 28:41. [PMID: 32448260 PMCID: PMC7245644 DOI: 10.1186/s13049-020-00733-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Therapeutic extracorporeal membrane oxygenation (ECMO) is a challenging procedure in patients who have experienced severe trauma. Particularly, patients with traumatic lung injury and posttraumatic acute respiratory distress syndrome (ARDS) have a high risk of bleeding during this procedure. This study aimed to determine the safety and feasibility of ECMO in patients with traumatic ARDS. Methods We retrospectively reviewed medical records and investigated the clinical outcomes of ECMO in 42 patients with traumatic ARDS, among whom near-drowning (42.9%) was the most frequent cause of injury. Results Thirty-four of 42 patients (81%) survived and were discharged after a median hospital stay of 23 days. A multivariate analysis identified a lactate level (odds ratio: 1.493, 95% confidence interval: 1.060–2.103, P = 0.022) and veno-venous (VV) ECMO (odds ratio: 0.075, 95% confidence interval: 0.006–0.901, P = 0.041) as favorable independent predictors of survival in patients with traumatic ARDS who underwent ECMO. The optimal cut off value for pre-ECMO lactate level was 10.5 mmol/L (area under the curve = 0.929, P = 0.001). In Kaplan-Meier analysis, the survival rate at hospital discharge was significant higher among the patients with a pre-ECMO lactate level of 10.5 mmol/L or less compared with patients with pre-ECMO lactate level greater than 10.5 mmol/L (93.8% versus 40.0%, respectively; P = 0.01). Conclusions ECMO yielded excellent survival outcomes, particularly in patients with low pre-treatment lactate levels who received VV ECMO. Therefore, ECMO appears safe and highly feasible in a carefully selected population of trauma patients.
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Affiliation(s)
- Hong Kyu Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea.
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwaseong-si, Gyeonggi-do, South Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea
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Huber W, Findeisen M, Lahmer T, Herner A, Rasch S, Mayr U, Hoppmann P, Jaitner J, Okrojek R, Brettner F, Schmid R, Schmidle P. Prediction of outcome in patients with ARDS: A prospective cohort study comparing ARDS-definitions and other ARDS-associated parameters, ratios and scores at intubation and over time. PLoS One 2020; 15:e0232720. [PMID: 32374755 PMCID: PMC7202606 DOI: 10.1371/journal.pone.0232720] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/20/2020] [Indexed: 12/15/2022] Open
Abstract
Background Early recognition of high-risk-patients with acute respiratory distress syndrome (ARDS) might improve their outcome by less protracted allocation to intensified therapy including extracorporeal membrane oxygenation (ECMO). Among numerous predictors and classifications, the American European Consensus Conferenece (AECC)- and Berlin-definitions as well as the oxygenation index (OI) and the Murray-/Lung Injury Score are the most common. Most studies compared the prediction of mortality by these parameters on the day of intubation and/or diagnosis of ARDS. However, only few studies investigated prediction over time, in particular for more than three days. Objective Therefore, our study aimed at characterization of the best predictor and the best day(s) to predict 28-days-mortality within four days after intubation of patients with ARDS. Methods In 100 consecutive patients with ARDS severity according to OI (mean airway pressure*FiO2/paO2), modified Murray-score without radiological points (Murray_mod), AECC- and Berlin-definition, were daily documented for four days after intubation. In the subgroup of 49 patients with transpulmonary thermodilution (TPTD) monitoring (PiCCO), extravascular lung water index (EVLWI) was measured daily. Primary endpoint Prediction of 28-days-mortality (Area under the receiver-operating-characteristic curve (ROC-AUC)); IBM SPSS 26. Results In the totality of patients the best prediction of 28-days-mortality was found on day-1 and day-2 (mean ROC-AUCs for all predictors/scores: 0.632 and 0.620). OI was the best predictor among the ARDS-scores (AUC=0.689 on day-1; 4-day-mean AUC = 0.625). AECC and Murray_mod had 4-day-means AUCs below 0.6. Among the 49 patients with TPTD, EVLWI (4-day-mean AUC=0.696) and OI (4-day-mean AUC=0.695) were the best predictors. AUCs were 0.789 for OI on day-1, and 0.786 for EVLWI on day-2. In binary regression analysis of patients with TPTD, EVLWI (B=-0.105; Wald=7.294; p=0.007) and OI (B=0.124; Wald=7.435; p=0.006) were independently associated with 28-days-mortality. Combining of EVLWI and OI provided ROC-AUCs of 0.801 (day-1) and 0.824 (day-2). Among the totality of patients, the use of TPTD-monitoring „per se“ and a lower SOFA-score were independently associated with a lower 28-days-mortality. Conclusions Prognosis of ARDS-patients can be estblished within two days after intubation. The best predictors were EVLWI and OI and their combination. TPTD-monitoring „per se“ was independently associated with reduced mortality.
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Affiliation(s)
- Wolfgang Huber
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
- * E-mail:
| | - Michael Findeisen
- Klinik für Pneumologie, Gastroenterologie, Internistische Intensiv- und Beatmungsmedizin, München Klinik Harlaching, München, Germany
| | - Tobias Lahmer
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Alexander Herner
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Sebastian Rasch
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Ulrich Mayr
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Petra Hoppmann
- Medizinische Klinik und Poliklinik I, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Juliane Jaitner
- Medizinische Klinik und Poliklinik I, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Rainer Okrojek
- Medizinische Klinik und Poliklinik I, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Franz Brettner
- Abteilung Intensivmedizin, Krankenhaus Barmherzige Brüder, München, Germany
| | - Roland Schmid
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Paul Schmidle
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
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Petran J, Muelly T, Dembinski R, Steuer N, Arens J, Marx G, Kopp R. Validation of RESP and PRESERVE score for ARDS patients with pumpless extracorporeal lung assist (pECLA). BMC Anesthesiol 2020; 20:102. [PMID: 32359363 PMCID: PMC7195797 DOI: 10.1186/s12871-020-01010-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 04/15/2020] [Indexed: 11/29/2022] Open
Abstract
Background RESP score and PRESERVE score have been validated for veno-venous Extracorporeal Membrane Oxygenation in severe ARDS to assume individual mortality risk. ARDS patients with low-flow Extracorporeal Carbon Dioxide Removal, especially pumpless Extracorporeal Lung Assist, have also a high mortality rate, but there are no validated specific or general outcome scores. This retrospective study tested whether these established specific risk scores can be validated for pumpless Extracorporeal Lung Assist in ARDS patients in comparison to a general organ dysfunction score, the SOFA score. Methods In a retrospective single center cohort study we calculated and evaluated RESP, PRESERVE, and SOFA score for 73 ARDS patients with pumpless Extracorporeal Lung Assist treated between 2002 and 2016 using the XENIOS iLA Membrane Ventilator. Six patients had a mild, 40 a moderate and 27 a severe ARDS according to the Berlin criteria. Demographic data and hospital mortality as well as ventilator settings, hemodynamic parameters, and blood gas measurement before and during extracorporeal therapy were recorded. Results Pumpless Extracorporeal Lung Assist of mechanical ventilated ARDS patients resulted in an optimized lung protective ventilation, significant reduction of PaCO2, and compensation of acidosis. Scoring showed a mean score of alive versus deceased patients of 3 ± 1 versus − 1 ± 1 for RESP (p < 0.01), 3 ± 0 versus 6 ± 0 for PRESERVE (p < 0.05) and 8 ± 1 versus 10 ± 1 for SOFA (p < 0.05). Using receiver operating characteristic curves, area under the curve (AUC) was 0.78 (95% confidence interval (CI) 0.67–0.89, p < 0.01) for RESP score, 0.80 (95% CI 0.70–0.90, p < 0.0001) for PRESERVE score and 0.66 (95% CI 0.53–0.79, p < 0.05) for SOFA score. Conclusions RESP and PRESERVE scores were superior to SOFA, as non-specific critical care score. Although scores were developed for veno-venous ECMO, we could validate RESP and PRESERVE score for pumpless Extracorporeal Lung Assist. In conclusion, RESP and PRESERVE score are suitable to estimate mortality risk of ARDS patients with an arterio-venous pumpless Extracorporeal Carbon Dioxide Removal.
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Affiliation(s)
- Jan Petran
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr 30, 52074, Aachen, Germany
| | - Thorsten Muelly
- Department of Anaesthesiology and Intensive Care Medicine, St. Antonius Hospital, Dechant-Deckers-Straße 8, 52249, Eschweiler, Germany
| | - Rolf Dembinski
- Clinic for Intensive Care and Emergency Medicine, Bremen-Mitte Hospital, Sankt-Jürgen-Straße 1, 28205, Bremen, Germany
| | - Niklas Steuer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelsstr 20, 52074, Aachen, Germany
| | - Jutta Arens
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Pauwelsstr 20, 52074, Aachen, Germany.,Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Horst Complex, 7500 AE, Enschede, Netherlands
| | - Gernot Marx
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr 30, 52074, Aachen, Germany
| | - Ruedger Kopp
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstr 30, 52074, Aachen, Germany.
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25
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Lim JKB, Qadri SK, Toh TSW, Lin CB, Mok YH, Lee JH. Extracorporeal Membrane Oxygenation for Severe Respiratory Failure During Respiratory Epidemics and Pandemics: A Narrative Review. ANNALS ACADEMY OF MEDICINE SINGAPORE 2020. [DOI: 10.47102/annals-acadmed.sg.202046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Epidemics and pandemics from zoonotic respiratory viruses, such as the 2019 novel coronavirus, can lead to significant global intensive care burden as patients progress to acute respiratory distress syndrome (ARDS). A subset of these patients develops refractory hypoxaemia despite maximal conventional mechanical ventilation and require extracorporeal membrane oxygenation (ECMO). This review focuses on considerations for ventilatory strategies, infection control and patient selection related to ECMO for ARDS in a pandemic. We also summarise the experiences with ECMO in previous respiratory pandemics. Materials and Methods: A review of pertinent studies was conducted via a search using MEDLINE, EMBASE and Google Scholar. References of articles were also examined to identify other relevant publications. Results: Since the H1N1 Influenza pandemic in 2009, the use of ECMO for ARDS continues to grow despite limitations in evidence for survival benefit. There is emerging evidence to suggest that lung protective ventilation for ARDS can be further optimised while receiving ECMO so as to minimise ventilator-induced lung injury and subsequent contributions to multi-organ failure. Efforts to improve outcomes should also encompass appropriate infection control measures to reduce co-infections and prevent nosocomial transmission of novel respiratory viruses. Patient selection for ECMO in a pandemic can be challenging. We discuss important ethical considerations and predictive scoring systems that may assist clinical decision-making to optimise resource allocation. Conclusion: The role of ECMO in managing ARDS during respiratory pandemics continues to grow. This is supported by efforts to redefine optimal ventilatory strategies, reinforce infection control measures and enhance patient selection. Ann Acad Med Singapore 2020;49:199–214 Key words: Acute Respiratory Distress Syndrome, Coronavirus disease 2019, ECMO, Infection control, Mechanical ventilation
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Affiliation(s)
- Joel KB Lim
- KK Women’s and Children’s Hospital, Singapore
| | | | | | | | - Yee Hui Mok
- KK Women’s and Children’s Hospital, Singapore
| | - Jan Hau Lee
- KK Women’s and Children’s Hospital, Singapore
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26
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Na SJ, Jeon K. Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome. Expert Rev Respir Med 2020; 14:511-519. [PMID: 32089016 DOI: 10.1080/17476348.2020.1734457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: The global number of patients receiving extracorporeal membrane oxygenation (ECMO) support has been growing after several studies highlighted the favorable results attained in cases of severe respiratory failure. However, evidence-based guidelines for optimal use of ECMO are lacking.Areas covered: This review covers optimal candidates, timing of initiation, strategies for patient management including mechanical ventilation, and decision-making regarding discontinuation of ECMO based on its potential role in treatment of patients with acute respiratory distress syndrome.Expert opinion: Early initiation of ECMO should be considered if hypoxemia and uncompensated hypercapnia do not respond to optimal conventional treatment. Use of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical during ECMO support to ensure the best outcome. The possibility of weaning from ECMO should be fully assessed by a multidisciplinary team during ECMO support. Futility should not be determined solely by duration of ECMO, and use of prolonged ECMO for lung recovery may be worthwhile.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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27
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Recent advances in venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Curr Opin Crit Care 2020; 25:71-76. [PMID: 30516588 DOI: 10.1097/mcc.0000000000000567] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize results of the most recent trials on venovenous extracorporeal membrane oxygenation (VV-ECMO) in severe acute respiratory distress syndrome (ARDS) and to elaborate on the unmet needs regarding VV-ECMO management in this setting. RECENT FINDINGS Although it was terminated early for futility (i.e., failure to demonstrate a difference in 60-day mortality of 20%), the ECMO to Rescue Lung Injury in Severe ARDS trial of VV-ECMO for severe ARDS reported a nonsignificant, but clinically important, reduction in mortality (35 vs. 46%; relative risk 0.76; 95% confidence interval 0.55-1.04, P = 0.09). Refractory hypoxemia led to rescue ECMO in 28% of controls, who had more severe ARDS at inclusion, were extremely sick at the time of ECMO cannulation and for whom mortality was 57%. Beyond the rescue of patients dying of refractory hypoxemia, ECMO may now be used early in severe ARDS patients to reduce the intensity of mechanical ventilation and to minimize ventilator-induced lung injury. Future research in the field should focus on identification of patients who are more likely to benefit from this technique and the right timing for its initiation, optimization of daily management of patients under ECMO to further reduce complications, and selection of optimal ventilator management on ECMO. SUMMARY VV-ECMO is a reasonable therapeutic option for patients with severe ARDS and major hypoxemia or excessive pressures. Future trials should be designed to optimize patients' management while on VV-ECMO support.
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28
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Knudson KA, Gustafson CM, Sadler LS, Whittemore R, Redeker NS, Andrews LK, Mangi A, Funk M. Long-term health-related quality of life of adult patients treated with extracorporeal membrane oxygenation (ECMO): An integrative review. Heart Lung 2019; 48:538-552. [DOI: 10.1016/j.hrtlng.2019.08.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022]
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29
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Abrams D, Curtis JR, Prager KM, Garan AR, Hastie J, Brodie D. Ethical Considerations for Mechanical Support. Anesthesiol Clin 2019; 37:661-673. [PMID: 31677684 DOI: 10.1016/j.anclin.2019.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Extracorporeal life support can support patients with severe forms of cardiac and respiratory failure. Uncertainty remains about its optimal use owing in large part to its resource-intensive nature and the high acuity illness in supported patients. Specific issues include the identification of patients most likely to benefit, the appropriate duration of support when prognosis is uncertain, and what to do when patients become dependent on extracorporeal life support but no longer have hope for recovery or transplantation. Careful deliberation of ethical principles and potential dilemmas should be made when considering the use of extracorporeal life support in advanced cardiopulmonary failure.
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Affiliation(s)
- Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 8E, 101, New York, NY 10032, USA.
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA 98104, USA
| | - Kenneth M Prager
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 161 Ft. Washington Avenue, Room 307, New York, NY 10032, USA
| | - A Reshad Garan
- Division of Cardiology, Columbia University College of Physicians and Surgeons, 177 Ft. Washington Avenue, 5th Floor, Room 5-435, New York, NY 10032, USA
| | - Jonathan Hastie
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 5-505, New York, NY 10032, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 8E, 101, New York, NY 10032, USA
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30
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Predicting Survival of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) Extracorporeal Membrane Oxygenation. ASAIO J 2019; 66:825-833. [DOI: 10.1097/mat.0000000000001067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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31
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Balke L, Panholzer B, Haneya A, Bewig B. [ECMO treatment in acute lung failure : Who profits?]. Med Klin Intensivmed Notfmed 2019; 115:682-689. [PMID: 31363799 DOI: 10.1007/s00063-019-0597-0] [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: 03/11/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
Abstract
In intensive care medicine, rapid technical developments that are often beneficial to patients are taking place. On the other hand, there are also voices that generally criticize an increasing "interventionalism". This area of tension includes other important questions regarding usefulness, quality, ethical compliance, scientific evidence, structural capacities and economy. The treatment of acute respiratory distress syndrome (ARDS) using extracorporeal membrane oxygenation (ECMO) is an example of these considerations. Although ECMO has rarely been prospectively evaluated according to scientific criteria, it is still used with an increasing tendency, not least since the documented register survival rates in ECMO patients with severe ARDS are 60%. However, the implementation of this therapy means an immense effort. The necessary centralization and certification for ECMO treatment is currently under intensive discussion. Closely related to this are considerations about which criteria represent good quality in patient care. In order to be able to guarantee high quality, a precise indication is the first step. And here indications and contraindications still need to be defined. It has not yet been sufficiently clarified which prognosis factors need to be taken into account. This article summarizes what is known about ECMO prognosis and indication criteria. In conclusion, parameters are identified that should be developed scientifically in the future.
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Affiliation(s)
- L Balke
- Klinik für Innere Medizin 1, Universitätsklinikum Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Straße 12, 24105, Kiel, Deutschland. .,Interdisziplinäres ARDS-ECMO-Zentrum, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland.
| | - B Panholzer
- Interdisziplinäres ARDS-ECMO-Zentrum, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland.,Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - A Haneya
- Interdisziplinäres ARDS-ECMO-Zentrum, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland.,Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - B Bewig
- Klinik für Innere Medizin 1, Universitätsklinikum Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Straße 12, 24105, Kiel, Deutschland.,Interdisziplinäres ARDS-ECMO-Zentrum, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
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32
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Austin DE, Burns B, Lowe D, Cartwright B, Clarke A, Dennis M, D'Souza M, Nathan R, Bannon PG, Gattas D, Connellan M, Forrest P. Retrieval of critically ill adults using extracorporeal membrane oxygenation: the nine-year experience in New South Wales. Anaesth Intensive Care 2019; 46:579-588. [PMID: 30447667 DOI: 10.1177/0310057x1804600608] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In New South Wales, a coordinated extracorporeal membrane oxygenation (ECMO) retrieval program has been in operation since 2007. This study describes the characteristics and outcomes of patients transported by this service. We performed a retrospective observational study and included patients who were transported on ECMO to either of two adult tertiary referral hospitals in Sydney, New South Wales, between February 28, 2007 and February 29, 2016. One hundred and sixty-four ECMO-facilitated transports occurred, involving 160 patients. Of these, 118 patients (74%) were treated with veno-venous (VV) ECMO and 42 patients (26%) were treated with veno-arterial ECMO. The mean (standard deviation, SD) age was 40.4 (15.0) years. Seventy-seven transports (47%) occurred within metropolitan Sydney, 52 (32%) were from rural or regional areas within NSW, 17 (10%) were interstate transfers and 18 (11%) were international transfers. Transfers were by road (58%), fixed wing aircraft (27%) or helicopter (15%). No deaths occurred during transport. The median (interquartile range) duration of ECMO treatment was 8.9 (5.2-15.3) days. One hundred and nineteen patients (74%) were successfully weaned from ECMO and 109 (68%) survived to hospital discharge or transfer. In patients treated with VV ECMO, age, sequential organ failure assessment score, pre-existing immunosuppressive disease, pre-existing diabetes, renal failure requiring dialysis and failed prone positioning prior to ECMO were independently associated with increased mortality. ECMO-facilitated patient transport is feasible, safe, and results in acceptable short-term outcomes. The NSW ECMO Retrieval Service provides specialised support to patients with severe respiratory and cardiovascular illness, who may otherwise be too unstable to undergo inter-hospital transfer to access advanced cardiovascular and critical care services.
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33
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Banjas N, Hopf HB, Hanisch E, Friedrichson B, Fichte J, Buia A. ECMO-treatment in patients with acute lung failure, cardiogenic, and septic shock: mortality and ECMO-learning curve over a 6-year period. J Intensive Care 2018; 6:84. [PMID: 30598825 PMCID: PMC6299557 DOI: 10.1186/s40560-018-0352-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/03/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Based on promising results over the past 10 years, the method of extracorporeal membrane oxygenation (ECMO) has developed from being used as a 'rescue therapy' to become an accepted treatment option for patients with acute lung failure (ARDS). Subsequently, the indication was extended also to patients suffering from cardiogenic and septic shock. Our aim was to evaluate hospital mortality and associated prognostic variables in patients with lung failure, cardiogenic, and septic shock undergoing ECMO. Furthermore, a cumulative sum (CUSUM) analysis was used to assess the learning curve of ECMO-treatment in our department. METHODS We retrospectively analysed the data of 131 patients undergoing ECMO treatment in the intensive care unit of the Asklepios Hospital of Langen over the time period from April 2011 to July 2016. We categorised the patients into three groups: lung failure (n = 54); cardiogenic shock (n = 58); and septic shock (n = 19). The primary outcome variable was hospital mortality along with identification of prognostic variables on mortality before initiating ECMO using logistic regression. Second outcome variable was the learning curve of our department in patients with ECMO. RESULTS 6-year hospital mortality was 54% in patients with lung failure, 59% in patients with cardiogenic shock, and 58% in patients with septic shock.The CUSUM analysis revealed a typical learning curve with a point of inflection in the year 2014. Patients treated before 2014 had a worse outcome (p = 0.04 whole cohort; p = 0.03 for lung failure). Furthermore, less than 20 treatments per year respectively treatment before 2014 were associated negatively with hospital mortality of lung failure patients showing an odds ratio of 4.04, as well as in the entire cohort with an odds ratio of 3.19. CONCLUSION For the first time, a steep ECMO-learning curve using the CUSUM tool has been described. Obviously, the experience with ECMO has to be taken into account when defining the role of ECMO in ARDS, cardiogenic, and septic shock.
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Affiliation(s)
- Norbert Banjas
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Hans-Bernd Hopf
- Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Ernst Hanisch
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Benjamin Friedrichson
- Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Julia Fichte
- Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Alexander Buia
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
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Lazzeri C, Bonizzoli M, Cianchi G, Batacchi S, Guetti C, Cozzolino M, Bernardo P, Peris A. Right ventricular dysfunction and Pre Implantation Vasopressors in Refractory ARDS Supported by VV-ECMO. Heart Lung Circ 2018; 27:1483-1488. [DOI: 10.1016/j.hlc.2017.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 09/26/2017] [Accepted: 10/14/2017] [Indexed: 01/28/2023]
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Periche Pedra E, Koborzan MR, Sbraga F, Blasco Lucas A, Toral Sepúlveda D. Outcomes of extracorporeal membrane oxygenation in adult patients with hypoxemic respiratory failure refractory to mechanical ventilation. Respir Med Case Rep 2018; 25:220-224. [PMID: 30237974 PMCID: PMC6143695 DOI: 10.1016/j.rmcr.2018.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that has been used to support cardiopulmonary disease refractory to conventional therapy. The experience with the use of ECMO in acute hypoxemic respiratory failure is still limited. The aim of this study was to report clinical outcomes in adult patients with acute hypoxemic respiratory failure refractory to mechanical ventilation treated with ECMO. Methods Between July 2011 and October 2017, 18 adult patients with hypoxemic respiratory failure refractory to mechanical ventilation were admitted to the Intensive Care Unit of an acute care tertiary hospital in Barcelona, Spain. These patients were treated with ECMO as salvage respiratory therapy. Outcomes included clinical data, ventilatory and blood gas characteristics, survival, and complications. Results Fifteen patients (83.3%) were previously treated in prone position. The indication of VV-ECMO was established at an early stage after a mean (SD) of 3.8 (2.5) days on mechanical ventilation. The mean duration of ECMO was 10.4 days, and 16 patients (88.9%) required venous cannulation, mostly femoral-internal jugular. The mean length of ICU stay was 27 days and the mean hospital stay was 42.1 days. The ICU survival rate was 55.5% (n = 10) and the hospital survival rate was 50% (n = 9). Conclusions This clinical study in a small series of ICU patients treated with ECMO confirms the usefulness of this technique as a ventilatory support in patients with refractory hypoxemic respiratory failure. However, the indication of this procedure is also committed to an ethical reflection considering the possible futility of the measure on a case-by-case basis and associated complications.
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Affiliation(s)
- Elisabet Periche Pedra
- Intensive Care Unit, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- Corresponding author. Intensive Care Unit, Hospital Universitario de Bellvitge, C/ Feixa Llarga s/n, E-08907 L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Melinda Rita Koborzan
- Intensive Care Unit, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Fabrizio Sbraga
- Service of Cardiac Surgery, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Arnau Blasco Lucas
- Service of Cardiac Surgery, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - David Toral Sepúlveda
- Service of Cardiac Surgery, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Burrell A, Müller T. Inflammation in venovenous extracorporeal membrane oxygenation: villain or innocent bystander? J Thorac Dis 2018; 10:E652-E653. [PMID: 30233906 DOI: 10.21037/jtd.2018.07.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Aidan Burrell
- Department of Intensive Care, Alfred Hospital, Melbourne, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Ried M, Sommerauer L, Lubnow M, Müller T, Philipp A, Lunz D, Hofmann HS. Thoracic Bleeding Complications in Patients With Venovenous Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2018; 106:1668-1674. [PMID: 30193999 DOI: 10.1016/j.athoracsur.2018.07.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 06/11/2018] [Accepted: 07/09/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with respiratory failure are treated more frequently with venovenous extracorporeal membrane oxygenation (vv-ECMO). These patients are at risk for bleeding due to complex multifactorial coagulation disorders resulting from the extracorporeal circulation. METHODS A retrospective analysis was conducted of prospectively collected data on all patients requiring vv-ECMO between December 2010 and December 2016. End points were the incidence, consequence, and in-hospital mortality of patients with thoracic bleeding complications. RESULTS The study included 418 patients (aged 50 ± 16.5 years) requiring vv-ECMO. In 23.2% (n = 97) of patients, relevant hemorrhage was documented. Thoracic bleeding developed in 40 patients (41.2%), followed by diffuse (21.6%), cerebral (14.4%), gastrointestinal (6.2%), cannulation site (6.2%), and other bleeding locations. Thoracic bleeding complications occurred spontaneously (40%), postoperatively (37.5%), after interventions (20%), and after trauma (2.5%). A thoracic operation was performed in 60% (n = 24) of these patients, and a repeated operation due to bleeding was necessary in 45.8%. Mean ECMO duration (18.6 ± 16.8 days; p = 0.035) and hospital length of stay (58 ± 50 days; p = 0.002) were significantly longer than that in patients without bleeding. In-hospital mortality was significantly higher in patients with thoracic bleeding complications (52.5%) than in patients without bleeding complications (32.7%; p = 0.013). CONCLUSIONS Thoracic bleeding complications were observed in 9.6% of patients and represented the most frequent bleeding complication during vv-ECMO treatment. Almost 60% of patients required surgical revision, and nearly half of these patients underwent a repeated operation. Because mortality is high in these patients, vv-ECMO should be performed in only centers experienced with thoracic surgery.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
| | - Laura Sommerauer
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Hans-Stefan Hofmann
- Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
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Montero S, Slutsky AS, Schmidt M. The PRESET-Score: the extrapulmonary predictive survival model for extracorporeal membrane oxygenation in severe acute respiratory distress syndrome. J Thorac Dis 2018; 10:S2040-S2044. [PMID: 30023113 DOI: 10.21037/jtd.2018.05.184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Santiago Montero
- Acute and Intensive Cardiovascular Care Unit, Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris, France
| | - Arthur S Slutsky
- Keenan Research Center for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Matthieu Schmidt
- Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris, France
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Ahuja A, Shekar K. Patient selection for VV ECMO: have we found the crystal ball? J Thorac Dis 2018; 10:S1979-S1981. [PMID: 30023096 DOI: 10.21037/jtd.2018.05.83] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Abhilasha Ahuja
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, Brisbane, Australia.,Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Brisbane, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, Brisbane, Australia.,Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Brisbane, Australia.,University of Queensland, Brisbane, Queensland, Australia.,Bond University, Gold Coast, Queensland, Australia
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Life span of different extracorporeal membrane systems for severe respiratory failure in the clinical practice. PLoS One 2018; 13:e0198392. [PMID: 29856834 PMCID: PMC5983427 DOI: 10.1371/journal.pone.0198392] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/25/2018] [Indexed: 11/19/2022] Open
Abstract
Over the past decade, veno-venous extracorporeal membrane oxygenation (vvECMO) has been increasingly utilized in respiratory failure in patients. This study presents our institution´s experience focusing on the life span of ECMO systems reflecting the performance of a particular system. A retrospective review of our ECMO database identified 461 adult patients undergoing vvECMO (2010-2017). Patients that required more than one system and survived the first exchange >24 hours (n = 139) were included. Life span until the first exchange and exchange criteria were analyzed for all systems (PLS, Cardiohelp HLS-set, both Maquet Cardiopulmonary, Rastatt, Germany; Deltastream/Hilite7000LT, iLA-activve, Xenios/NovaLung, Heilbronn, Germany; ECC.O5, LivaNova, Mirandola, Italy). At our ECMO center, the frequency of a system exchange was 30%. The median (IQR) life span was 9 (6-12) days. There was no difference regarding the different systems (p = 0.145 and p = 0.108, respectively). However, the Deltastream systems were exchanged more frequently due to elective technical complications (e. g. worsened gas transfer, development of coagulation disorder, increased bleedings complications) compared to the other exchanged systems (p = 0.013). In summary, the used ECMO systems are safe and effective for acute respiratory failure. There is no evidence for the usage of a specific system. Only the increased predictability of an imminent exchange preferred the usage of a Deltastream system. However, the decision to use a particular system should not depend solely on the possible criteria for an exchange.
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Schmidt M, Schellongowski P, Patroniti N, Taccone FS, Reis Miranda D, Reuter J, Prodanovic H, Pierrot M, Dorget A, Park S, Balik M, Demoule A, Crippa IA, Mercat A, Wohlfarth P, Sonneville R, Combes A. Six-Month Outcome of Immunocompromised Patients with Severe Acute Respiratory Distress Syndrome Rescued by Extracorporeal Membrane Oxygenation. An International Multicenter Retrospective Study. Am J Respir Crit Care Med 2018; 197:1297-1307. [PMID: 29298095 DOI: 10.1164/rccm.201708-1761oc] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rationale: Because encouraging rates for hospital and long-term survival of immunocompromised patients in ICUs have been described, these patients are more likely to receive invasive therapies, like extracorporeal membrane oxygenation (ECMO).Objectives: To report outcomes of immunocompromised patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and to identify their pre-ECMO predictors of 6-month mortality and main ECMO-related complications.Methods: Retrospective multicenter study in 10 international ICUs with high volumes of ECMO cases. Immunocompromised patients, defined as having hematological malignancies, active solid tumor, solid-organ transplant, acquired immunodeficiency syndrome, or long-term or high-dose corticosteroid or immunosuppressant use, and severe ECMO-treated ARDS, from 2008 to 2015 were included.Measurements and Main Results: We collected demographics, clinical data, ECMO-related complications, and ICU- and 6 month-outcome data for 203 patients (median Acute Physiology and Chronic Health Evaluation II score, 28 [25th-75th percentile, 20-33]; age, 51 [38-59] yr; PaO2/FiO2, 60 [50-82] mm Hg before ECMO) who fulfilled our inclusion criteria. Six-month survival was only 30%, with a respective median ECMO duration and ICU stay of 8 (5-14) and 25 (16-50) days. Patients with hematological malignancies had significantly poorer outcomes than others (log-rank P = 0.02). ECMO-related major bleeding, cannula infection, and ventilator-associated pneumonia were frequent (36%, 10%, and 50%, respectively). Multivariate analyses retained fewer than 30 days between immunodeficiency diagnosis and ECMO cannulation as being associated with lower 6-month mortality (odds ratio, 0.32 [95% confidence interval, 0.16-0.66]; P = 0.002), and lower platelet count, higher Pco2, age, and driving pressure as independent pre-ECMO predictors of 6-month mortality.Conclusions: Recently diagnosed immunodeficiency is associated with a much better prognosis in ECMO-treated severe ARDS. However, low 6-month survival of our large cohort of immunocompromised patients supports restricting ECMO to patients with realistic oncological/therapeutic prognoses, acceptable functional status, and few pre-ECMO mortality-risk factors.
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Universités, UPMC University Paris 06, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Medical Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Nicolò Patroniti
- School of Medicine and Surgery, University of Milan-Bicocca, Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme-Université Libre de Bruxelles, Brussels, Belgium
| | - Dinis Reis Miranda
- Department of Intensive Care, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Jean Reuter
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Helène Prodanovic
- Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Marc Pierrot
- Service de Réanimation Médicale, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Amandine Dorget
- Medical Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea; and
| | - Martin Balik
- Department of Anaesthesia and Intensive Care, 1st Medical Faculty, Charles University, General University Hospital, Prague, Czech Republic
| | - Alexandre Demoule
- Sorbonne Universités, UPMC University Paris 06, INSERM, UMRS_1158 Neurophysiologie Respiratoire Expérimentale et Clinique, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Ilaria Alice Crippa
- Department of Intensive Care, Hôpital Erasme-Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Mercat
- Service de Réanimation Médicale, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Philipp Wohlfarth
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
| | - Romain Sonneville
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, Sorbonne Paris Cité, INSERM/Paris Diderot University, Paris, France
| | - Alain Combes
- Sorbonne Universités, UPMC University Paris 06, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France.,Medical Intensive Care Unit, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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42
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Enger TB, Müller T. Predictive tools in VVECMO patients: handicap or benefit for clinical practice? J Thorac Dis 2018; 10:1347-1351. [PMID: 29708164 DOI: 10.21037/jtd.2018.03.93] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Tone B Enger
- Clinic of Surgery, St. Olav University Hospital, Trondheim, Norway
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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43
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Jenq CC, Tsai FC, Tsai TY, Hsieh SY, Lai YW, Tian YC, Chang MY, Lin CY, Fang JT, Yang CW, Chen YC. Effect of Anemia on Prognosis in Patients on Extracorporeal Membrane Oxygenation. Artif Organs 2018; 42:705-713. [PMID: 29602175 DOI: 10.1111/aor.13123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/02/2017] [Accepted: 01/02/2018] [Indexed: 12/23/2022]
Abstract
Anemia is a component of the pathological triangle in cardiorenal anemia syndrome and is a risk factor for mortality in acute respiratory distress syndrome. This study assessed the predictive value of anemia for outcomes in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) support. This retrospective study analyzed patients who received ECMO support at the cardiovascular surgery intensive care unit in the study institute between July 2003 and March 2012. Patient data, such as demographic information, etiologies of ECMO implementation, clinical parameters, and in-hospital and 6-month mortality rates, were statistically analyzed. The overall in-hospital mortality rate among the enrolled 295 patients was 55.6%. Multivariate logistical regression analysis indicated that age, albumin levels, sequential organ failure assessment (SOFA) score, and hemoglobin (Hb) level on ECMO day 1 exhibited independent prognostic significance for predicting in-hospital mortality rate. The SOFA score exhibited the highest areas under the receiver operating characteristic curve value (0.812 ± 0.025). The Hb level on ECMO day 1 exhibited satisfactory calibration and discriminatory power. The cumulative 6-month survival rates differed significantly between patients with Hb levels less than and more than 8.85 g/dL (30.6 vs. 54.0%, respectively, P < 0.001). This study indicated that old age, low albumin levels, low Hb levels, and higher SOFA scores on ECMO day 1 increased the risk of mortality. The Hb level is a readily measurable parameter and with good predictive power for critical patients on ECMO.
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Affiliation(s)
- Chang-Chyi Jenq
- Kidney Institute, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan.,School of Medicine, Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Feng-Chun Tsai
- Division of Cardiovascular Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Tsung-Yu Tsai
- Kidney Institute, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Sue-Yun Hsieh
- School of Medicine, Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Yi-Wen Lai
- School of Medicine, Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Ya-Chung Tian
- Kidney Institute, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Yang Chang
- Kidney Institute, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chan-Yu Lin
- Kidney Institute, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ji-Tseng Fang
- Kidney Institute, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Wei Yang
- Kidney Institute, Department of Nephrology, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
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44
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Pappalardo F, Crivellari M. Predicting outcome of venovenous ECMO: look outside the lung! J Thorac Dis 2018; 10:1356-1360. [PMID: 29708154 DOI: 10.21037/jtd.2018.02.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Federico Pappalardo
- San Raffaele Scientific Institute, Vita-Salute University Milan, Milano, Italy
| | - Martina Crivellari
- San Raffaele Scientific Institute, Vita-Salute University Milan, Milano, Italy
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45
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Yeo HJ, Cho WH. A novel survival prediction model of ECMO in acute respiratory distress syndrome: things to consider for optimal use. J Thorac Dis 2018; 10:1149-1151. [PMID: 29708146 DOI: 10.21037/jtd.2018.03.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Hye Ju Yeo
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University, Yangsan Hospital, Yangsan, Republic of Korea
| | - Woo Hyun Cho
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University, Yangsan Hospital, Yangsan, Republic of Korea
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Baek MS, Chung CR, Kim HJ, Cho WH, Cho YJ, Park S, Park SY, Kang BJ, Kim JH, Park SH, Oh JY, Sim YS, Hong SB. Age is major factor for predicting survival in patients with acute respiratory failure on extracorporeal membrane oxygenation: a Korean multicenter study. J Thorac Dis 2018; 10:1406-1417. [PMID: 29707290 DOI: 10.21037/jtd.2018.03.71] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background The proportion of elderly patients in the intensive care unit population is increasing. Although the Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score is widely used for survival prediction of extracorporeal membrane oxygenation (ECMO) patients, it is questionable whether the RESP score is applicable to older patients. The aim of this study was to investigate the applicability of the RESP score in Korean cohort. Methods Data were retrospectively analyzed from 209 acute respiratory failure (ARF) patients treated with ECMO from 2014 to 2015 at 11 hospitals. A comparison of outcome prediction models was conducted and multivariate logistic regression analysis was performed to identify independent risk factors for hospital mortality. Results In all patients, the median age was 58 (IQR, 45-65) years. Overall survival at hospital discharge was 45.9%, and veno-venous ECMO was used in 82.3% of patients. Patients older than 65 years treated with ECMO support were 51 with 31.4% of hospital survival. The PRedicting dEath for SEvere ARDS on VV-ECMO (PRESERVE) and RESP scores significantly predicted mortality in patients, with areas under the curve (AUCs) of 0.63 [95% confidence interval (CI), 0.54-0.72] and 0.66 (95% CI, 0.58-0.73), respectively. In multivariate logistic regression analysis, age is independent risk factor for hospital mortality [odds ratio 1.044 (95% CI, 1.020-1.068), P<0.001] with AUC of 0.67 (95% CI, 0.59-0.74). The RESP score was modified using reclassified age and the modified RESP score obtained AUC of 0.71 (95% CI, 0.63-0.78). Conclusions The RESP score is significant model for predicting outcomes in a Korean ECMO population. Elderly patients had higher mortality, and age alone showed similar discrimination ability for prediction of mortality compared to the RESP score.
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Affiliation(s)
- Moon Seong Baek
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Republic of Korea
| | - Woo Hyun Cho
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sunghoon Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Anyang-si, Gyeonggi-do, Republic of Korea
| | - Seung Yong Park
- Department of Internal Medicine, Chonbuk National University Hospital, Jeonju-si, Jeollabuk-do, Republic of Korea
| | - Byung Ju Kang
- Division of Pulmonology, Department of Internal Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Jung-Hyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Bundang CHA Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - So Hee Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Jin Young Oh
- Divisions of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Yun Su Sim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Republic of Korea
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Lazzeri C, Cianchi G, Mauri T, Pesenti A, Bonizzoli M, Batacchi S, Chiostri M, Socci F, Peris A. A novel risk score for severe ARDS patients undergoing ECMO after retrieval from peripheral hospitals. Acta Anaesthesiol Scand 2018; 62:38-48. [PMID: 29058310 DOI: 10.1111/aas.13022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/10/2017] [Accepted: 10/04/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Extracorporeal Membrane Oxygenation in severe ARDS unresponsive to conventional protective ventilation is associated with elevated costs, resource and complications, and appropriate risk stratification of candidate patients could be useful to recognize those more likely to benefit from ECMO. We aimed to derive a new outcome prediction score for patients retrieved by our ECMO team from peripheral centers, including systematic echocardiographic evaluation before ECMO start. METHODS Sixty-nine consecutive patients with refractory ARDS requiring ECMO transferred from peripheral centers to our ICU (a tertiary ECMO referral center), from 1 October 2009 to 31 December 2015, were assessed. RESULTS All patients were transported on ECMO (distance, median 77, range 4-456 km) The mortality rate was 41% (28/69). Our new risk score included age ≥ 42 years, BMI < 31 kg/m2 , RV dilatation, and pH < 7.35. The proposed cut off (Youden's index method) of nine had a sensitivity of 96% and a specificity of 30% (AUC-ROC: 0.85, 95% CI: 0.76-0.94, P < 0.001). When assessing the discriminatory ability of our risk score in the population of local patients, survivors had a mean value of 15.4 ± 8.6, whereas non-survivors showed a mean value of 20.1 ± 7.4 (P < 0.001). CONCLUSIONS Our new risk score shows good discriminatory ability both in patients retrieved from peripheral centers and in those implanted at our center. This score includes variables easily available at bedside, and, for the first time, a pathophysiologic element, RV dilatation.
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Affiliation(s)
- C. Lazzeri
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - G. Cianchi
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - T. Mauri
- Department of Anesthesia, Critical Care and Emergency; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - A. Pesenti
- Department of Anesthesia, Critical Care and Emergency; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - M. Bonizzoli
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - S. Batacchi
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - M. Chiostri
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - F. Socci
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - A. Peris
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
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Hilder M, Herbstreit F, Adamzik M, Beiderlinden M, Bürschen M, Peters J, Frey UH. Comparison of mortality prediction models in acute respiratory distress syndrome undergoing extracorporeal membrane oxygenation and development of a novel prediction score: the PREdiction of Survival on ECMO Therapy-Score (PRESET-Score). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:301. [PMID: 29233160 PMCID: PMC5728043 DOI: 10.1186/s13054-017-1888-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy in acute respiratory distress syndrome (ARDS) patients but is associated with complications and costs. Here, we validate various scores supposed to predict mortality and develop an optimized categorical model. Methods In a derivation cohort, 108 ARDS patients (2010–2015) on veno-venous ECMO were retrospectively analysed to assess four established risk scores (ECMOnet-Score, RESP-Score, PRESERVE-Score, Roch-Score) for mortality prediction (receiver operating characteristic analysis) and to identify by multivariable logistic regression analysis independent variables for mortality to yield the new PRESET-Score (PREdiction of Survival on ECMO Therapy-Score). This new score was then validated both in independent internal (n = 82) and external (n = 59) cohorts. Results The median (25%; 75% quartile) Sequential Organ Failure Assessment score was 14 (12; 16), Simplified Acute Physiology Score II was 62.5 (57; 72.8), median intensive care unit stay was 17 days (range 1–124), and mortality was 62%. Only the ECMOnet-Score (area under curve (AUC) 0.69) and the RESP-Score (AUC 0.64) discriminated survivors and non-survivors. Admission pHa, mean arterial pressure, lactate, platelet concentrations, and pre-ECMO hospital stay were independent predictors of death and were used to build the PRESET-Score. The score’s internal (AUC 0.845; 95% CI 0.76–0.93; p < 0.001) and external (AUC 0.70; 95% CI 0.56–0.84; p = 0.008) validation revealed excellent discrimination. Conclusions While our data confirm that both the ECMOnet-Score and the RESP-Score predict mortality in ECMO-treated ARDS patients, we propose a novel model also incorporating extrapulmonary variables, the PRESET-Score. This score predicts mortality much better than previous scores and therefore is a more precise choice for decision support in ARDS patients to be placed on ECMO.
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Affiliation(s)
- Michael Hilder
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, and Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Frank Herbstreit
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, and Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Michael Adamzik
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, and Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Martin Beiderlinden
- Klinik für Anästhesiologie und Intensivmedizin, Marienhospital Osnabrück, Osnabrück, Germany
| | - Markus Bürschen
- Klinik für Anästhesiologie und Intensivmedizin, Marienhospital Osnabrück, Osnabrück, Germany
| | - Jürgen Peters
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, and Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Ulrich H Frey
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, and Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Germany.
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49
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Gillon SA, Rowland K, Shankar-Hari M, Camporota L, Glover GW, Wyncoll DLA, Barrett NA, Ioannou N, Meadows CIS. Acceptance and transfer to a regional severe respiratory failure and veno-venous extracorporeal membrane oxygenation (ECMO) service: predictors and outcomes. Anaesthesia 2017; 73:177-186. [DOI: 10.1111/anae.14083] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 01/19/2023]
Affiliation(s)
- S. A. Gillon
- Department of Critical Care; Queen Elizabeth University Hospital; Glasgow UK
| | - K. Rowland
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - M. Shankar-Hari
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - L. Camporota
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - G. W. Glover
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - D. L. A. Wyncoll
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - N. A. Barrett
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - N. Ioannou
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
| | - C. I. S. Meadows
- Department of Critical Care; Guy's and St Thomas' NHS Foundation Trust; London UK
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50
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Delmas C, Zapetskaia T, Conil JM, Georges B, Vardon-Bounes F, Seguin T, Crognier L, Fourcade O, Brouchet L, Minville V, Silva S. 3-month prognostic impact of severe acute renal failure under veno-venous ECMO support: Importance of time of onset. J Crit Care 2017; 44:63-71. [PMID: 29073534 DOI: 10.1016/j.jcrc.2017.10.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/19/2017] [Accepted: 10/17/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Veno-venous ECMO is increasingly used for the management of refractory ARDS. In this context, acute kidney injury (AKI) is a major and frequent complication, often associated with poor outcome. We aimed to identify characteristics associated with severe renal failure (Kidney Disease Improving Global Outcome (KDIGO) 3) and its impact on 3-month outcome. METHODS Between May 2009 and April 2016, 60 adult patients requiring VV-ECMO in our University Hospital were prospectively included. RESULTS AKI occurrence was frequent (75%; n=45), 51% of patients (n=31) developed KDIGO 3 - predominantly prior to ECMO insertion - and renal replacement therapy was required in 43% (n=26) of cases. KDIGO 3 was associated with a lower mechanical ventilation weaning rate (24% vs 68% for patients with no AKI or other stages of AKI; p<0.001) and a higher 90-day mortality rate (72% vs 32%, p=0.002). Multivariate logistic regression suggested that KDIGO 3 occurrence prior to ECMO insertion, as well as PaCO2>57mmHg and mSOFA>12 were independent risks factors for 90-day mortality. CONCLUSION KDIGO 3 AKI occurrence is correlated with the severity of patients' clinical condition prior to ECMO insertion and is negatively associated with 90-day survival.
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Affiliation(s)
- C Delmas
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France; Intensive Cardiac care, Cardiology department, Rangueil University Hospital, 1 Av Jean-Poulhes, 31059 Toulouse, France; Institut des Maladies Métaboliques et Cardiovasculaires, INSERM 1048, Rangueil, Toulouse, France.
| | - T Zapetskaia
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France
| | - J M Conil
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France
| | - B Georges
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France
| | - F Vardon-Bounes
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France; Institut des Maladies Métaboliques et Cardiovasculaires, INSERM 1048, Rangueil, Toulouse, France
| | - T Seguin
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France
| | - L Crognier
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France
| | - O Fourcade
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France
| | - L Brouchet
- Thoracic Surgery department, Larrey University Hospital, 24 chemin de Pouvourville, TSA 30030, 31059 Toulouse, France
| | - V Minville
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France; Institut des Maladies Métaboliques et Cardiovasculaires, INSERM 1048, Rangueil, Toulouse, France
| | - S Silva
- Intensive Care Unit, Anesthesia and Critical Care department, Rangueil University Hospital, 1 Avenue Jean-Poulhes, 31059 Toulouse, France
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