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Panda K, Glance LG, Mazzeffi M, Gu Y, Wood KL, Moitra VK, Wu IY. Perioperative Extracorporeal Cardiopulmonary Resuscitation in Adult Patients: A Review for the Perioperative Physician. Anesthesiology 2024; 140:1026-1042. [PMID: 38466188 DOI: 10.1097/aln.0000000000004916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest has grown rapidly over the previous decade. Considerations for the implementation and management of extracorporeal cardiopulmonary resuscitation are presented for the perioperative physician.
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Affiliation(s)
- Kunal Panda
- Division of Cardiac Anesthesiology, Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Laurent G Glance
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York; and RAND Health, Boston, Massachusetts
| | - Michael Mazzeffi
- Division of Cardiothoracic Anesthesiology, Division of Critical Care Medicine, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Yang Gu
- Division of Cardiac Anesthesiology, Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Katherine L Wood
- Division of Cardiac Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Vivek K Moitra
- Division of Critical Care Medicine, Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Isaac Y Wu
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Winiszewski H, Vieille T, Guinot PG, Nesseler N, Le Berre M, Crognier L, Roche AC, Fellahi JL, D'Ostrevy N, Ltaief Z, Didier J, Arab OA, Meslin S, Scherrer V, Besch G, Monnier A, Piton G, Kimmoun A, Capellier G. Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study. Ann Intensive Care 2024; 14:56. [PMID: 38597975 PMCID: PMC11006645 DOI: 10.1186/s13613-024-01286-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGOUND Hyperoxemia is common and associated with poor outcome during veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. However, little is known about practical daily management of oxygenation. Then, we aim to describe sweep gas oxygen fraction (FSO2), postoxygenator oxygen partial pressure (PPOSTO2), inspired oxygen fraction (FIO2), and right radial arterial oxygen partial pressure (PaO2) between day 1 and day 7 of peripheral VA ECMO support. We also aim to evaluate the association between oxygenation parameters and outcome. In this retrospective multicentric study, each participating center had to report data on the last 10 eligible patients for whom the ICU stay was terminated. Patients with extracorporeal cardiopulmonary resuscitation were excluded. Primary endpoint was individual mean FSO2 during the seven first days of ECMO support (FSO2 mean (day 1-7)). RESULTS Between August 2019 and March 2022, 139 patients were enrolled in 14 ECMO centers in France, and one in Switzerland. Among them, the median value for FSO2 mean (day 1-7) was 70 [57; 79] % but varied according to center case volume. Compared to high volume centers, centers with less than 30 VA-ECMO runs per year were more likely to maintain FSO2 ≥ 70% (OR 5.04, CI 95% [1.39; 20.4], p = 0.017). Median value for right radial PaO2 mean (day 1-7) was 114 [92; 145] mmHg, and decreased from 125 [86; 207] mmHg at day 1, to 97 [81; 133] mmHg at day 3 (p < 0.01). Severe hyperoxemia (i.e. right radial PaO2 ≥ 300 mmHg) occurred in 16 patients (12%). PPOSTO2, a surrogate of the lower body oxygenation, was measured in only 39 patients (28%) among four centers. The median value of PPOSTO2 mean (day 1-7) value was 198 [169; 231] mmHg. By multivariate analysis, age (OR 1.07, CI95% [1.03-1.11], p < 0.001), FSO2 mean (day 1-3)(OR 1.03 [1.00-1.06], p = 0.039), and right radial PaO2 mean (day 1-3) (OR 1.03, CI95% [1.00-1.02], p = 0.023) were associated with in-ICU mortality. CONCLUSION In a multicentric cohort of cardiogenic shock supported by VA ECMO, the median value for FSO2 mean (day 1-7) was 70 [57; 79] %. PPOSTO2 monitoring was infrequent and revealed significant hyperoxemia. Higher FSO2 mean (day 1-3) and right radial PaO2 mean (day 1-3) were independently associated with in-ICU mortality.
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Affiliation(s)
- Hadrien Winiszewski
- Service de réanimation médicale, CHU Besançon, Besançon, France.
- Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France.
| | | | | | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, University Hospital of Rennes, Pontchaillou, Rennes, France
| | - Mael Le Berre
- Service de réanimation médicale, CHU Besançon, Besançon, France
| | - Laure Crognier
- Intensive Care Unit, Anesthesia and Critical Care Department, Rangueil University Hospital, Toulouse, France
| | - Anne-Claude Roche
- Anesthesia, Intensive Care and Perioperative Medicine, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Nicolas D'Ostrevy
- Cardiac Surgery Department, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Zied Ltaief
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and Lausanne University, Lausanne, 1011, Switzerland
| | - Juliette Didier
- Service de médecine intensive réanimation, CHU Pitié Salpêtrière, Paris, France
| | - Osama Abou Arab
- Department of Anaesthesia and Critical Care Medicine, Amiens University Medical Center, Amiens, France
| | - Simon Meslin
- Anesthesiology and Critical Care Medicine Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Vincent Scherrer
- Department of Anaesthesiology and Critical Care, CHU Rouen, Rouen, F-76000, France
| | - Guillaume Besch
- Département d'Anesthésie Réanimation Chirurgicale, Université de Franche-Comté, CHU Besançon, CIC Inserm 1431, Besançon, EA3920, F-25000, France
| | - Alexandra Monnier
- Service de Médecine Intensive-Réanimation Médicale, CHU Strasbourg, Nouvel Hôpital Civil, Université de Strasbourg, Strasbourg, 67000, France
| | - Gael Piton
- Service de réanimation médicale, CHU Besançon, Besançon, France
| | - Antoine Kimmoun
- Service de médecine intensive réanimation, CHU Nancy, Créteil, France
| | - Gilles Capellier
- Service de réanimation médicale, CHU Besançon, Besançon, France
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia
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Premraj L, Brown A, Fraser JF, Pellegrino V, Pilcher D, Burrell A. Oxygenation During Venoarterial Extracorporeal Membrane Oxygenation: Physiology, Current Evidence, and a Pragmatic Approach to Oxygen Titration. Crit Care Med 2024; 52:637-648. [PMID: 38059745 DOI: 10.1097/ccm.0000000000006134] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES This review aims to: 1) identify the key circuit and patient factors affecting systemic oxygenation, 2) summarize the literature reporting the association between hyperoxia and patient outcomes, and 3) provide a pragmatic approach to oxygen titration, in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (ECMO). DATA SOURCES Searches were performed using PubMed, SCOPUS, Medline, and Google Scholar. STUDY SELECTION All observational and interventional studies investigating the association between hyperoxia, and clinical outcomes were included, as well as guidelines from the Extracorporeal Life Support Organization. DATA EXTRACTION Data from relevant literature was extracted, summarized, and integrated into a concise narrative review. For ease of reference a summary of relevant studies was also produced. DATA SYNTHESIS The extracorporeal circuit and the native cardiorespiratory circuit both contribute to systemic oxygenation during venoarterial ECMO. The ECMO circuit's contribution to systemic oxygenation is, in practice, largely determined by the ECMO blood flow, whereas the native component of systemic oxygenation derives from native cardiac output and residual respiratory function. Interactions between ECMO outflow and native cardiac output (as in differential hypoxia), the presence of respiratory support, and physiologic parameters affecting blood oxygen carriage also modulate overall oxygen exposure during venoarterial ECMO. Physiologically those requiring venoarterial ECMO are prone to hyperoxia. Hyperoxia has a variety of definitions, most commonly Pa o2 greater than 150 mm Hg. Severe hypoxia (Pa o2 > 300 mm Hg) is common, seen in 20%. Early severe hyperoxia, as well as cumulative hyperoxia exposure was associated with in-hospital mortality, even after adjustment for disease severity in both venoarterial ECMO and extracorporeal cardiopulmonary resuscitation. A pragmatic approach to oxygenation during peripheral venoarterial ECMO involves targeting a right radial oxygen saturation target of 94-98%, and in selected patients, titration of the fraction of oxygen in the mixture via the air-oxygen blender to target postoxygenator Pa o2 of 150-300 mm Hg. CONCLUSIONS Hyperoxia results from a range of ECMO circuit and patient-related factors. It is common during peripheral venoarterial ECMO, and its presence is associated with poor outcome. A pragmatic approach that avoids hyperoxia, while also preventing hypoxia has been described for patients receiving peripheral venoarterial ECMO.
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Affiliation(s)
- Lavienraj Premraj
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Alastair Brown
- Griffith University School of Medicine and Dentistry, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Hopkins Education, Research, and Advancement in Life Support Devices (HERALD) Group, Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- St Andrew's War Memorial Hospital, UnitingCare, Brisbane, QLD, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Vincent Pellegrino
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Melbourne, VIC, Australia
| | - Aidan Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health, Monash University, Melbourne, VIC, Australia
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Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients. DATA SOURCES A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted. STUDY SELECTION Selection includes original research, review articles, and guidelines. DATA EXTRACTION Information from relevant publications was reviewed, consolidated, and formulated into a narrative review. DATA SYNTHESIS We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/C o2 , and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes. CONCLUSIONS Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field.
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Affiliation(s)
- Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Zachary Darby
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Thomas P. Bleck
- Davee Department of Neurology, Northwestern University
Feinberg School of Medicine, Chicago IL 60611
| | - Glenn J. R. Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
| | - Bo Soo Kim
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns
Hopkins Hospital, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD
- Division of Neurosciences Critical Care, Departments of
Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins
Hospital, Baltimore, MD
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Battaglini D, Bogossian EG, Anania P, Premraj L, Cho SM, Taccone FS, Sekhon M, Robba C. Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence. Neurocrit Care 2024; 40:349-363. [PMID: 37081276 DOI: 10.1007/s12028-023-01721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes. METHODS The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI. RESULTS Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage. CONCLUSIONS Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.
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Affiliation(s)
- Denise Battaglini
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pasquale Anania
- Department of Neurosurgery, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Departments of Neurology, Surgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Tigano S, Caruso A, Liotta C, LaVia L, Vargas M, Romagnoli S, Landoni G, Sanfilippo F. Exposure to severe hyperoxemia worsens survival and neurological outcome in patients supported by veno-arterial extracorporeal membrane oxygenation: A meta-analysis. Resuscitation 2024; 194:110071. [PMID: 38061577 DOI: 10.1016/j.resuscitation.2023.110071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a rescue treatment in refractory cardiogenic shock (CS) or refractory cardiac arrest (CA). Exposure to hyperoxemia is common during VA-ECMO, and its impact on patient's outcome remains unclear. METHODS We conducted a systematic review (PubMed and Scopus) and meta-analysis investigating the effects of exposure to severe hyperoxemia on mortality and poor neurological outcome in patients supported by VA-ECMO. When both adjusted and unadjusted Odds Ratio (OR) were provided, we used the adjusted one. Results are reported as OR and 95% confidence interval (CI). Subgroup analyses were conducted according to VA-ECMO indication and hyperoxemia thresholds. RESULTS Data from 10 observational studies were included. Nine studies reported data on mortality (n = 5 refractory CA, n = 4 CS), and 4 on neurological outcome. As compared to normal oxygenation levels, exposure to severe hyperoxemia was associated with higher mortality (nine studies; OR: 1.80 [1.16-2.78]; p = 0.009; I2 = 83%; low certainty of evidence) and worse neurological outcome (four studies; OR: 1.97 [1.30-2.96]; p = 0.001; I2 = 0%; low certainty of evidence). Magnitude and effect of these findings remained valid in subgroup analyses conducted according to different hyperoxemia thresholds (>200 or >300 mmHg) and VA-ECMO indication, although the association with mortality remained uncertain in the refractory CA population (p = 0.13). Analysis restricted to studies providing adjusted OR data confirmed an increased likelihood of poorer neurological outcome (three studies; OR: 2.11 [1.32-3.38]; p = 0.002) in patients exposed to severe hyperoxemia but did not suggest higher mortality (five studies; OR: 1.68 [0.89-3.18]; p = 0.11). CONCLUSIONS Severe hyperoxemia exposure after initiation of VA-ECMO may be associated with an almost doubled increased probability of poor neurological outcome and mortality. Clinical efforts should be made to avoid severe hyperoxemia during VA-ECMO support.
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Affiliation(s)
- Stefano Tigano
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy
| | - Alessandro Caruso
- School of Anaesthesia and Intensive Care, University Hospital "G. Rodolico", University of Catania, Catania, Italy
| | - Calogero Liotta
- School of Anaesthesia and Intensive Care, University "Magna Graecia", Catanzaro, Italy
| | - Luigi LaVia
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Catania, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Florence, Italy; Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, Section of Anesthesia and Intensive Care, University of Catania, Catania, Italy.
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Moynihan KM, Dorste A, Alizadeh F, Phelps K, Barreto JA, Kolwaite AR, Merlocco A, Barbaro RP, Chan T, Thiagarajan RR. Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature. Crit Care Med 2023; 51:843-860. [PMID: 36975216 DOI: 10.1097/ccm.0000000000005866] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population). STUDY SELECTION Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support. DATA EXTRACTION Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool. DATA SYNTHESIS Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors. CONCLUSIONS Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.
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Affiliation(s)
- Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Dorste
- Medical Library, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kayla Phelps
- Department of Pediatrics, Children's Hospital New Orleans, Louisiana State University, New Orleans, LA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Amy R Kolwaite
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Anthony Merlocco
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
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8
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Shou BL, Wilcox C, Florissi I, Kalra A, Caturegli G, Zhang LQ, Bush E, Kim B, Keller SP, Whitman GJR, Cho SM. Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury. Neurocrit Care 2023; 38:612-621. [PMID: 36167950 PMCID: PMC10040467 DOI: 10.1007/s12028-022-01607-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pulse pressure is a dynamic marker of cardiovascular function and is often impaired in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Pulsatile blood flow also serves as a regulator of vascular endothelium, and continuous-flow mechanical circulatory support can lead to endothelial dysfunction. We explored the impact of early low pulse pressure on occurrence of acute brain injury (ABI) in VA-ECMO. METHODS We conducted a retrospective analysis of adults with VA-ECMO at a tertiary care center between July 2016 and January 2021. Patients underwent standardized multimodal neuromonitoring throughout ECMO support. ABI included intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, cerebral edema, seizure, and brain death. Blood pressures were recorded every 15 min. Low pulse pressure was defined as a median pulse pressure < 20 mm Hg in the first 12 h of ECMO. Multivariable logistic regression was performed to investigate the association between pulse pressure and ABI. RESULTS We analyzed 5138 blood pressure measurements from 123 (median age 63; 63% male) VA-ECMO patients (54% peripheral; 46% central cannulation), of whom 41 (33%) experienced ABI. Individual ABIs were as follows: ischemic stroke (n = 18, 15%), hypoxic ischemic brain injury (n = 14, 11%), seizure (n = 8, 7%), intracranial hemorrhage (n = 7, 6%), cerebral edema (n = 7, 6%), and brain death (n = 2, 2%). Fifty-eight (47%) patients had low pulse pressure. In a multivariable model adjusting for preselected covariates, including cannulation strategy (central vs. peripheral), lactate on ECMO day 1, and left ventricle venting strategy, low pulse pressure was independently associated with ABI (adjusted odds ratio 2.57, 95% confidence interval 1.05-6.24). In a model with the same covariates, every 10-mm Hg decrease in pulse pressure was associated with 31% increased odds of ABI (95% confidence interval 1.01-1.68). In a sensitivity analysis model adjusting for systolic pressure, pulse pressure remained significantly associated with ABI. CONCLUSIONS Early low pulse pressure (< 20 mm Hg) was associated with ABI in VA-ECMO patients. Low pulse pressure may serve as a marker of ABI risk, which necessitates close neuromonitoring for early detection.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
| | - Christopher Wilcox
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Isabella Florissi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lucy Q Zhang
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Errol Bush
- Division of General Thoracic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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Shou BL, Ong CS, Premraj L, Brown P, Tonna JE, Dalton HJ, Kim BS, Keller SP, Whitman GJR, Cho SM. Arterial oxygen and carbon dioxide tension and acute brain injury in extracorporeal cardiopulmonary resuscitation patients: Analysis of the extracorporeal life support organization registry. J Heart Lung Transplant 2023; 42:503-511. [PMID: 36435686 PMCID: PMC10050131 DOI: 10.1016/j.healun.2022.10.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/31/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Acute brain injury (ABI) remains common after extracorporeal cardiopulmonary resuscitation (ECPR). Using a large international multicenter cohort, we investigated the impact of peri-cannulation arterial oxygen (PaO2) and carbon dioxide (PaCO2) on ABI occurrence. METHODS We retrospectively analyzed adult (≥18 years old) ECPR patients in the Extracorporeal Life Support Organization registry from 1/2009 through 12/2020. Composite ABI included ischemic stroke, intracranial hemorrhage (ICH), seizures, and brain death. The registry collects 2 blood gas data pre- (6 hours) and post- (24 hours) cannulation. Blood gas parameters were classified as: hypoxia (<60mm Hg), normoxia (60-119mm Hg), and mild (120-199mm Hg), moderate (200-299mm Hg), and severe hyperoxia (≥300mm Hg); hypocarbia (<35mm Hg), normocarbia (35-44mm Hg), mild (45-54mm Hg) and severe hypercarbia (≥55mm Hg). Missing values were handled using multiple imputation. Multivariable logistic regression analysis was used to assess the relationship of PaO2 and PaCO2 with ABI. RESULTS Of 3,125 patients with ECPR intervention (median age=58, 69% male), 488 (16%) experienced ABI (7% ischemic stroke; 3% ICH). In multivariable analysis, on-ECMO moderate (aOR=1.42, 95%CI: 1.02-1.97) and severe hyperoxia (aOR=1.59, 95%CI: 1.20-2.10) were associated with composite ABI. Additionally, severe hyperoxia was associated with ischemic stroke (aOR=1.63, 95%CI: 1.11-2.40), ICH (aOR=1.92, 95%CI: 1.08-3.40), and in-hospital mortality (aOR=1.58, 95%CI: 1.21-2.06). Mild hypercarbia pre-ECMO was protective of composite ABI (aOR=0.61, 95%CI: 0.44-0.84) and ischemic stroke (aOR=0.56, 95%CI: 0.35-0.89). CONCLUSIONS Early severe hyperoxia (≥300mm Hg) on ECMO was a significant risk factor for ABI and mortality. Careful consideration should be given in early oxygen delivery in ECPR patients who are at risk of reperfusion injury.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chin Siang Ong
- Division of Surgical Outcomes, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Patricia Brown
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery; Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah
| | - Heidi J Dalton
- Adult and Pediatric Extracorporeal Life Support, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Neuroscience Critical Care, Department of Neurology, Neurosurgery, Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Jentzer JC, Miller PE, Alviar C, Yalamuri S, Bohman JK, Tonna JE. Exposure to Arterial Hyperoxia During Extracorporeal Membrane Oxygenator Support and Mortality in Patients With Cardiogenic Shock. Circ Heart Fail 2023; 16:e010328. [PMID: 36871240 PMCID: PMC10121893 DOI: 10.1161/circheartfailure.122.010328] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/01/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Exposure to hyperoxia, a high arterial partial pressure of oxygen (PaO2), may be associated with worse outcomes in patients receiving extracorporeal membrane oxygenator (ECMO) support. We examined hyperoxia in the Extracorporeal Life Support Organization Registry among patients receiving venoarterial ECMO for cardiogenic shock. METHODS We included Extracorporeal Life Support Organization Registry patients from 2010 to 2020 who received venoarterial ECMO for cardiogenic shock, excluding extracorporeal CPR. Patients were grouped based on PaO2 after 24 hours of ECMO: normoxia (PaO2 60-150 mmHg), mild hyperoxia (PaO2 151-300 mmHg), and severe hyperoxia (PaO2 >300 mmHg). In-hospital mortality was evaluated using multivariable logistic regression. RESULTS Among 9959 patients, 3005 (30.2%) patients had mild hyperoxia and 1972 (19.8%) had severe hyperoxia. In-hospital mortality increased across groups: normoxia, 47.8%; mild hyperoxia, 55.6% (adjusted odds ratio, 1.37 [95% CI, 1.23-1.53]; P<0.001); severe hyperoxia, 65.4% (adjusted odds ratio, 2.20 [95% CI, 1.92-2.52]; P<0.001). A higher PaO2 was incrementally associated with increased in-hospital mortality (adjusted odds ratio, 1.14 per 50 mmHg higher [95% CI, 1.12-1.16]; P<0.001). Patients with a higher PaO2 had increased in-hospital mortality in each subgroup and when stratified by ventilator settings, airway pressures, acid-base status, and other clinical variables. In the random forest model, PaO2 was the second strongest predictor of in-hospital mortality, after older age. CONCLUSIONS Exposure to hyperoxia during venoarterial ECMO support for cardiogenic shock is strongly associated with increased in-hospital mortality, independent from hemodynamic and ventilatory status. Until clinical trial data are available, we suggest targeting a normal PaO2 and avoiding hyperoxia in CS patients receiving venoarterial ECMO.
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Affiliation(s)
- Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Carlos Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | - Suraj Yalamuri
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - J. Kyle Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Joseph E. Tonna
- Divisions of Cardiothoracic Surgery and Emergency Medicine, University of Utah Health and School of Medicine, Salt Lake City, UT
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Rambaud J, Barbaro RP, Macrae DJ, Dalton HJ; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Extracorporeal Membrane Oxygenation in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S124-34. [PMID: 36661441 DOI: 10.1097/PCC.0000000000003164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To systematically review and assimilate literature on children receiving extracorporeal membrane oxygenation (ECMO) support in pediatric acute respiratory distress syndrome (PARDS) with the goal of developing an update to the Pediatric Acute Lung Injury Consensus Conference recommendations and statements about clinical practice and research. DATA SOURCES Electronic searches of MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION The search used a medical subject heading terms and text words to capture studies of ECMO in PARDS or acute respiratory failure. Studies using animal models and case reports were excluded from our review. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. There were 18 studies identified for full-text extraction. When pediatric data was lacking, adult and neonatal data from randomized clinical trials and observational studies were considered. Six clinical recommendations were generated related to ECMO indications, initiation, and management in PARDS. There were three good practice statements generated related to ECMO indications, initiation, and follow-up in PARDS. Two policy statements were generated involving the impact of ECMO team organization and training in PARDS. Last, there was one research statement. CONCLUSIONS Based on a systematic literature review, we propose clinical management, good practice and policy statements within the domains of ECMO indications, initiation, team organization, team training, management, and follow-up as they relate to PARDS.
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12
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Máca J, Sklienka P. Year 2022 in review - Respiratory failure and lung support therapy. Anest intenziv Med 2022. [DOI: 10.36290/aim.2022.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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13
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Premraj L, Brown A, Burrell A, Fraser JF, Pilcher D. Hyperoxia during venoarterial ECMO: Culprit or co-variate? A comment from the BLENDER investigators. Crit Care 2022; 26:345. [DOI: 10.1186/s13054-022-04213-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
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14
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Andrei S, Nguyen M, Berthoud V, Durand B, Duclos V, Morgant MC, Bouchot O, Bouhemad B, Guinot PG. Determinants of Arterial Pressure of Oxygen and Carbon Dioxide in Patients Supported by Veno-Arterial ECMO. J Clin Med 2022; 11:jcm11175228. [PMID: 36079158 PMCID: PMC9457238 DOI: 10.3390/jcm11175228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The present study aimed to assess the determinants of arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2) in the early phase of veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Even though the guidelines considered both the risks of hypoxemia and hyperoxemia during ECMO support, there are a lack of data concerning the patients supported by VA ECMO. Methods: This is a retrospective, monocentric, observational cohort study in a university-affiliated cardiac intensive care unit. Hemodynamic parameters, ECMO parameters, ventilator settings, and blood gas analyses were collected at several time points during the first 48 h of VA ECMO support. For each timepoint, the blood samples were drawn simultaneously from the right radial artery catheter, VA ECMO venous line (before the oxygenator), and from VA ECMO arterial line (after the oxygenator). Univariate followed by multivariate mixed-model analyses were performed for longitudinal data analyses. Results: Forty-five patients with femoro-femoral peripheral VA ECMO were included. In multivariate analysis, the patients' PaO2 was independently associated with QEC, FDO2, and time of measurement. The patients' PaCO2 was associated with the sweep rate flow and the PpreCO2. Conclusions: During acute VA ECMO support, the main determinants of patient oxygenation are determined by VA ECMO parameters.
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Affiliation(s)
- Stefan Andrei
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- Department of Anaesthesiology and Critical Care Medicine, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucharest, Romania
- Correspondence: ; Tel.: +33-38-029-3031
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Bastian Durand
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | - Valerian Duclos
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
| | | | - Olivier Bouchot
- Cardiac Surgery Department, Dijon University Hospital, F-21000 Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, F-21000 Dijon, France
- LNC UMR1231, University of Burgundy and Franche-Comté, F-21000 Dijon, France
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Moussa MD, Beyls C, Lamer A, Roksic S, Juthier F, Leroy G, Petitgand V, Rousse N, Decoene C, Dupré C, Caus T, Huette P, Guilbart M, Guinot PG, Besserve P, Mahjoub Y, Dupont H, Robin E, Meynier J, Vincentelli A, Abou-Arab O. Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis. Crit Care 2022; 26:257. [PMID: 36028883 PMCID: PMC9414410 DOI: 10.1186/s13054-022-04133-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background The mortality rate for a patient with a refractory cardiogenic shock on venoarterial (VA) extracorporeal membrane oxygenation (ECMO) remains high, and hyperoxia might worsen this prognosis. The objective of the present study was to evaluate the association between hyperoxia and 28-day mortality in this setting.
Methods We conducted a retrospective bicenter study in two French academic centers. The study population comprised adult patients admitted for refractory cardiogenic shock. The following arterial partial pressure of oxygen (PaO2) variables were recorded for 48 h following admission: the absolute peak PaO2 (the single highest value measured during the 48 h), the mean daily peak PaO2 (the mean of each day’s peak values), the overall mean PaO2 (the mean of all values over 48 h), and the severity of hyperoxia (mild: PaO2 < 200 mmHg, moderate: PaO2 = 200–299 mmHg, severe: PaO2 ≥ 300 mmHg). The main outcome was the 28-day all-cause mortality. Inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalances in baseline characteristics. Results From January 2013 to January 2020, 430 patients were included and assessed. The 28-day mortality rate was 43%. The mean daily peak, absolute peak, and overall mean PaO2 values were significantly higher in non-survivors than in survivors. In a multivariate logistic regression analysis, the mean daily peak PaO2, absolute peak PaO2, and overall mean PaO2 were independent predictors of 28-day mortality (adjusted odds ratio [95% confidence interval per 10 mmHg increment: 2.65 [1.79–6.07], 2.36 [1.67–4.82], and 2.85 [1.12–7.37], respectively). After IPW, high level of oxygen remained significantly associated with 28-day mortality (OR = 1.41 [1.01–2.08]; P = 0.041). Conclusions High oxygen levels were associated with 28-day mortality in patients on VA-ECMO support for refractory cardiogenic shock. Our results confirm the need for large randomized controlled trials on this topic. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04133-7.
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Affiliation(s)
| | - Christophe Beyls
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Antoine Lamer
- CHU Lille, ULR 2694-METRICS : Évaluation des Technologies de Santé Et des Pratiques Médicales, 59000, Lille, France
| | - Stefan Roksic
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Francis Juthier
- Cardiac Surgery, Lille Hospital University, 59000, Lille, France
| | - Guillaume Leroy
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Vincent Petitgand
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Natacha Rousse
- Cardiac Surgery, Lille Hospital University, 59000, Lille, France
| | - Christophe Decoene
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Céline Dupré
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Thierry Caus
- Cardiac Surgery, Amiens University Medical Center, 80054, Amiens, France
| | - Pierre Huette
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Mathieu Guilbart
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, 21000, Dijon, France
| | - Patricia Besserve
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Yazine Mahjoub
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Hervé Dupont
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France
| | - Emmanuel Robin
- Pôle d'Anesthésie-Réanimation, Lille Hospital University, 59000, Lille, France
| | - Jonathan Meynier
- Department of Biostatistics, Amiens Picardy University Hospital, 80054, Amiens, France
| | | | - Osama Abou-Arab
- Anesthesia and Critical Care Medicine Department, Amiens University Medical Center, 1 rue du Professeur Christian Cabrol, 80054, Amiens, France.
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Thomas A, van Diepen S, Beekman R, Sinha SS, Brusca SB, Alviar CL, Jentzer J, Bohula EA, Katz JN, Shahu A, Barnett C, Morrow DA, Gilmore EJ, Solomon MA, Miller PE. Oxygen Supplementation and Hyperoxia in Critically Ill Cardiac Patients: From Pathophysiology to Clinical Practice. JACC Adv 2022; 1:100065. [PMID: 36238193 PMCID: PMC9555075 DOI: 10.1016/j.jacadv.2022.100065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Oxygen supplementation has been a mainstay in the management of patients with acute cardiac disease. While hypoxia is known to be detrimental, the adverse effects of artificially high oxygen levels (hyperoxia) have only recently been recognized. Hyperoxia may induce harmful hemodynamic effects, including peripheral and coronary vasoconstriction, and direct cellular toxicity through the production of reactive oxygen species. In addition, emerging evidence has shown that hyperoxia is associated with adverse clinical outcomes. Thus, it is essential for the cardiac intensive care unit (CICU) clinician to understand the available evidence and titrate oxygen therapies to specific goals. This review summarizes the pathophysiology of oxygen within the cardiovascular system and the association between supplemental oxygen and hyperoxia in patients with common CICU diagnoses, including acute myocardial infarction, heart failure, shock, cardiac arrest, pulmonary hypertension, and respiratory failure. Finally, we highlight lessons learned from available trials, gaps in knowledge, and future directions.
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Affiliation(s)
- Alexander Thomas
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Rachel Beekman
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA
| | - Samuel B. Brusca
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Carlos L. Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Erin A. Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jason N. Katz
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Christopher Barnett
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Emily J. Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Michael A. Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute, of the National Institutes of Health, Bethesda, MD
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
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Winiszewski H, Guinot PG, Schmidt M, Besch G, Piton G, Perrotti A, Lorusso R, Kimmoun A, Capellier G. Optimizing PO 2 during peripheral veno-arterial ECMO: a narrative review. Crit Care 2022; 26:226. [PMID: 35883117 PMCID: PMC9316319 DOI: 10.1186/s13054-022-04102-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/13/2022] [Indexed: 01/01/2023] Open
Abstract
During refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (PPOSTO2) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this PPOSTO2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (FSO2). Because of the oxygenator's performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO2) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting FSO2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of PPOSTO2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.
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Affiliation(s)
- Hadrien Winiszewski
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France. .,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France.
| | - Pierre-Grégoire Guinot
- Service d'Anesthésie-Réanimation Chirurgicale, centre hospitalier universitaire de Dijon, Dijon, France
| | - Matthieu Schmidt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Guillaume Besch
- Service d'Anesthésie-Réanimation Chirurgicale, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Gael Piton
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Andrea Perrotti
- Service de Chirurgie Cardiaque, centre hospitalier universitaire de Besançon, Besançon, France.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Antoine Kimmoun
- Service de Médecine Intensive Réanimation, centre hospitalier universitaire de Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - Gilles Capellier
- Service de Réanimation Médicale, centre hospitalier universitaire de Besançon, Besançon, France.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia.,Research Unit EA 3920 and SFR FED 4234, University of Franche Comté, Besancon, France
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Kashiura M, Yasuda H, Kishihara Y, Tominaga K, Nishihara M, Hiasa KI, Tsutsui H, Moriya T. Association between short-term neurological outcomes and extreme hyperoxia in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective observational study from a multicenter registry. BMC Cardiovasc Disord 2022; 22:163. [PMID: 35410132 PMCID: PMC9003952 DOI: 10.1186/s12872-022-02598-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/28/2022] [Indexed: 01/14/2023] Open
Abstract
Background To investigate the impact of hyperoxia that developed immediately after extracorporeal membrane oxygenation (ECMO)-assisted cardiopulmonary resuscitation (ECPR) on patients’ short-term neurological outcomes after out-of-hospital cardiac arrest (OHCA). Methods This study retrospectively analyzed data from the Japanese OHCA registry from June 2014 to December 2017. We analyzed adult patients (≥ 18 years) who had undergone ECPR. Eligible patients were divided into the following three groups based on their initial partial pressure of oxygen in arterial blood (PaO2) levels after ECMO pump-on: normoxia group, PaO2 ≤ 200 mm Hg; moderate hyperoxia group, 200 mm Hg < PaO2 ≤ 400 mm Hg; and extreme hyperoxia group, PaO2 > 400 mm Hg. The primary and secondary outcomes were 30-day favorable neurological outcomes. Logistic regression statistical analysis model of 30-day favorable neurological outcomes was performed after adjusting for multiple propensity scores calculated using pre-ECPR covariates and for confounding factors post-ECPR. Results Of the 34,754 patients with OHCA enrolled in the registry, 847 were included. The median PaO2 level was 300 mm Hg (interquartile range: 148–427 mm Hg). Among the eligible patients, 277, 313, and 257 were categorized as normoxic, moderately hyperoxic, and extremely hyperoxic, respectively. Moderate hyperoxia was not significantly associated with 30-day neurologically favorable outcomes compared with normoxia as a reference (adjusted odds ratio, 0.86; 95% confidence interval: 0.55–1.35; p = 0.51). However, extreme hyperoxia was associated with less 30-day neurologically favorable outcomes when compared with normoxia (adjusted odds ratio, 0.48; 95% confidence interval: 0.29–0.82; p = 0.007). Conclusions For patients with OHCA who received ECPR, extreme hyperoxia (PaO2 > 400 mm Hg) was associated with 30-day poor neurological outcomes. Avoidance of extreme hyperoxia may improve neurological outcomes in patients with OHCA treated with ECPR. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02598-6.
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Affiliation(s)
- Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan.
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Keiichiro Tominaga
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
| | - Masaaki Nishihara
- Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.,Kyushu University Hospital, Fukuoka, Japan
| | - Ken-Ichi Hiasa
- Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, 330-8503, Japan
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Al-Kawaz M, Shou B, Prokupets R, Whitman G, Geocadin R, Cho SM. Mild hypothermia and neurologic outcomes in patients undergoing venoarterial extracorporeal membrane oxygenation. J Card Surg 2022; 37:825-830. [PMID: 35152478 PMCID: PMC8891050 DOI: 10.1111/jocs.16308] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/07/2021] [Accepted: 12/24/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 h post-ECMO on neurological outcomes in VA-ECMO patients. METHODS This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 h post-ECMO. The primary outcome was a good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. RESULTS Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 h of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 h while 18 of those 88 patients (14.2%) had a mean temperature <36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.04-1.31, p = .01) after adjusting for age, the severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-h PaO2 . Neither duration of mild hypothermia (OR = 0.93, CI = 0.84-1.03, p = .17) nor mean temperature (OR = 0.78, CI = 0.29-2.08, p = .62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p = .47) and mean 24-h temperature (p = .76) were not significantly associated with the frequency of systemic hemorrhages. CONCLUSIONS In this single-center study, a longer duration of mild hypothermia during the first 24 h of ECMO support was significantly associated with improved neurological outcomes. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.
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Affiliation(s)
- Mais Al-Kawaz
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin Shou
- Division of Cardiac Surgery, Heart and Vascular Institute, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rochelle Prokupets
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Heart and Vascular Institute, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko Geocadin
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Stoll SE, Paul E, Pilcher D, Udy A, Burrell A. Hyperoxia and mortality in conventional versus extracorporeal cardiopulmonary resuscitation. J Crit Care 2022; 69:154001. [PMID: 35217372 DOI: 10.1016/j.jcrc.2022.154001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/14/2022] [Accepted: 01/24/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Hyperoxia has been associated with adverse outcomes in post cardiac arrest (CA) patients. Study-objective was to examine the association between hyperoxia and 30-day mortality in a mixed cohort of two different modes of Cardiopulmonary Resuscitation (CPR): Extracorporeal (ECPR) vs. Conventional (CCPR). MATERIAL AND METHODS In this retrospective cohort study of CA patients admitted to a tertiary level CA centre in Australia (over a 6.5-year time period) mean arterial oxygen levels (PaO2) and episodes of extreme hyperoxia (maximum of mean PaO2 ≥ 300 mmHg) were analysed over the first 8 days post CA. RESULTS One hundred and sixty-nine post CA patients were assessed (ECPR n = 79 / CCPR n = 90). Mean PaO2-levels were higher in the ECPR vs CCPR group (211 mmHg ± 58.4 vs 119 mmHg ± 18.1; p < 0.0001) as was the proportion with at least one episode of extreme hyperoxia (74.7% vs 16.7%; p < 0.001). After adjusting for confounders and the mode of CPR any episode of extreme hyperoxia was independently associated with a 2.52-fold increased risk of 30-day mortality (OR: 2.52, 95% CI: 1.06-5.98; p = 0.036). CONCLUSIONS We found extreme hyperoxia was more common in ECPR patients in the first 8 days post CA and independently associated with higher 30-day mortality, irrespective of the CPR-mode.
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Katsuta K, Matsunaga H, Kushimoto S. Possible Underestimation of Cerebral Hyperoxia in Patients With Left Ventricular Output Encountering With Extracorporeal Membrane Oxygenation Flow at the Aortic Arch. Crit Care Med 2022; 50:e98-9. [PMID: 34914657 DOI: 10.1097/CCM.0000000000005249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ishii J, Ohshimo S, Shime N. Potential Confounders in Evaluating the Impact of Hyperoxia on Neurological Outcomes in Patients Receiving Extracorporeal Membrane Oxygenation. Crit Care Med 2022; 50:e97-8. [PMID: 34914656 DOI: 10.1097/CCM.0000000000005239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Justus A, Burrell A, Anstey C, Cornmell G, Brodie D, Shekar K. The Association of Oxygenation, Carbon Dioxide Removal, and Mechanical Ventilation Practices on Survival During Venoarterial Extracorporeal Membrane Oxygenation. Front Med (Lausanne) 2021; 8:756280. [PMID: 34869455 PMCID: PMC8636903 DOI: 10.3389/fmed.2021.756280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/25/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction: Oxygenation and carbon dioxide removal during venoarterial extracorporeal membrane oxygenation (VA ECMO) depend on a complex interplay of ECMO blood and gas flows, native lung and cardiac function as well as the mechanical ventilation strategy applied. Objective: To determine the association of oxygenation, carbon dioxide removal, and mechanical ventilation practices with in-hospital mortality in patients who received VA ECMO. Methods: Single center, retrospective cohort study. All consecutive patients who received VA ECMO in a tertiary ECMO referral center over a 5-year period were included. Data on demographics, ECMO and ventilator support details, and blood gas parameters for the duration of ECMO were collected. A multivariable logistic time-series regression model with in-hospital mortality as the primary outcome variable was used to analyse the data with significant factors at the univariate level entered into the multivariable regression model. Results: Overall, 52 patients underwent VA ECMO: 26/52 (50%) survived to hospital discharge. The median PaO2 for the duration of ECMO support was 146 mmHg [IQR 131-188] and PaCO2 was 37.2 mmHg [IQR 35.3, 39.9]. Patients who survived to hospital discharge had a significantly lower median PaO2 (117 [98, 140] vs. 154 [105, 212] mmHg, P = 0.04) and higher median PaCO2 (38.3 [36.1, 41.1] vs. 36.3 [34.5, 37.8] mmHg, p = 0.03). Survivors also had significantly lower median VA ECMO blood flow rate (EBFR, 3.6 [3.3, 4.2] vs. 4.3 [3.8, 5.2] L/min, p = < 0.001) and greater measured minute ventilation (7.04 [5.63, 8.35] vs. 5.32 [4.43, 6.83] L/min, p = 0.01). EBFR, PaO2, PaCO2, and minute ventilation, however, were not independently associated with death in a multivariable analysis. Conclusion: This exploratory analysis in a small group of VA ECMO supported patients demonstrated that hyperoxemia was common during VA ECMO but was not independently associated with increased mortality. Survivors also received lower EBFR and had greater minute ventilation, but this was also not independently associated with survival. These findings highlight that interactions between EBFR, PaO2, and native lung ventilation may be more relevant than their individual association with survival. Further research is indicated to determine the optimal ECMO and ventilator settings on outcomes in VA ECMO.
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Affiliation(s)
- Angelo Justus
- Adult Intensive Care, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care-Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Chris Anstey
- School of Medicine, Griffith University, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - George Cornmell
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, United States
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Zhang H, Xu J, Yang X, Zou X, Shu H, Liu Z, Shang Y. Narrative Review of Neurologic Complications in Adults on ECMO: Prevalence, Risks, Outcomes, and Prevention Strategies. Front Med (Lausanne) 2021; 8:713333. [PMID: 34660625 PMCID: PMC8513760 DOI: 10.3389/fmed.2021.713333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/02/2021] [Indexed: 01/18/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.
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Affiliation(s)
- Hongling Zhang
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Liu'an Hospital, Anhui Medical University, Liu'an, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Shah N, Said AS. Extracorporeal Support Prognostication-Time to Move the Goal Posts? Membranes (Basel) 2021; 11:537. [PMID: 34357187 PMCID: PMC8304743 DOI: 10.3390/membranes11070537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 12/21/2022]
Abstract
Advances in extracorporeal membrane oxygenation (ECMO) technology are associated with expanded indications, increased utilization and improved outcome. There is growing interest in developing ECMO prognostication scores to aid in bedside decision making. To date, the majority of available scores have been limited to mostly registry-based data and with mortality as the main outcome of interest. There continues to be a gap in clinically applicable decision support tools to aid in the timing of ECMO cannulation to improve patients' long-term outcomes. We present a brief review of the commonly available adult and pediatric ECMO prognostication tools, their limitations, and future directions.
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Affiliation(s)
- Neel Shah
- Division of Pediatric Critical Care, Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, MO 63130, USA;
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