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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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Wang T, Zhang M, Dong W, Wang J, Zhang H, Wang Y, Ji B. Venoarterial Extracorporeal Membrane Oxygenation Implementation in Septic Shock Rat Model. ASAIO J 2024:00002480-990000000-00422. [PMID: 38421440 DOI: 10.1097/mat.0000000000002168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Septic shock, a global health concern, boasts high mortality rates. Research exploring the efficacy of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in septic shock remains limited. Our study aimed to establish a rodent model employing VA-ECMO in septic shock rats, assessing the therapeutic impact of VA-ECMO on septic shock. Nineteen Sprague-Dawley rats were randomly assigned to sham, septic shock, and (septic shock + VA-ECMO; SSE) groups. Septic shock was induced by intravenous lipopolysaccharides, confirmed by a mean arterial pressure drop to 25-30% of baseline. Rats in the SSE group received 2 hours of VA-ECMO support and 60 minutes of post-weaning ventilation. Sham and septic shock groups underwent mechanical ventilation for equivalent durations. Invasive mean arterial pressure monitoring, echocardiographic examinations, and blood gas analysis revealed the efficacy of VA-ECMO in restoring circulation and ensuring adequate tissue oxygenation in septic shock rats. Post-experiment pathology exhibited the potential of VA-ECMO in mitigating major organ injury. In summary, our study successfully established a stable septic shock rat model with the implementation of VA-ECMO, offering a valuable platform to explore molecular mechanisms underlying VA-ECMO's impact on septic shock.
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Affiliation(s)
- Tianlong Wang
- From the Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mingru Zhang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wenhao Dong
- Surgical IntensiveCare Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jing Wang
- From the Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Han Zhang
- From the Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuefu Wang
- Surgical IntensiveCare Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Bingyang Ji
- From the Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, State Key Laboratory of Cardiovascular Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Cho SM, Gusdon AM. Assessing Acute Brain Injury after Rapid Reduction of PaCO 2 using Plasma Biomarkers in Patients Undergoing ECMO. Neurocrit Care 2024:10.1007/s12028-024-01944-0. [PMID: 38356080 DOI: 10.1007/s12028-024-01944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Aaron M Gusdon
- Division of Neurocritical Care, Department of Neurosurgery, McGovern School of Medicine, University of Texas Health Science Center, Houston, TX, USA
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Kalra A, Bachina P, Shou BL, Hwang J, Barshay M, Kulkarni S, Sears I, Eickhoff C, Bermudez CA, Brodie D, Ventetuolo CE, Kim BS, Whitman GJR, Abbasi A, Cho SM. Predicting Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation Patients with Tree-Based Machine Learning: Analysis of the Extracorporeal Life Support Organization Registry. Res Sq 2024:rs.3.rs-3848514. [PMID: 38260374 PMCID: PMC10802703 DOI: 10.21203/rs.3.rs-3848514/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Objective To determine if machine learning (ML) can predict acute brain injury (ABI) and identify modifiable risk factors for ABI in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. Design Retrospective cohort study of the Extracorporeal Life Support Organization (ELSO) Registry (2009-2021). Setting International, multicenter registry study of 676 ECMO centers. Patients Adults (≥18 years) supported with VA-ECMO or extracorporeal cardiopulmonary resuscitation (ECPR). Interventions None. Measurements and Main Results Our primary outcome was ABI: central nervous system (CNS) ischemia, intracranial hemorrhage (ICH), brain death, and seizures. We utilized Random Forest, CatBoost, LightGBM and XGBoost ML algorithms (10-fold leave-one-out cross-validation) to predict and identify features most important for ABI. We extracted 65 total features: demographics, pre-ECMO/on-ECMO laboratory values, and pre-ECMO/on-ECMO settings.Of 35,855 VA-ECMO (non-ECPR) patients (median age=57.8 years, 66% male), 7.7% (n=2,769) experienced ABI. In VA-ECMO (non-ECPR), the area under the receiver-operator characteristics curves (AUC-ROC) to predict ABI, CNS ischemia, and ICH was 0.67, 0.67, and 0.62, respectively. The true positive, true negative, false positive, false negative, positive, and negative predictive values were 33%, 88%, 12%, 67%, 18%, and 94%, respectively for ABI. Longer ECMO duration, higher 24h ECMO pump flow, and higher on-ECMO PaO2 were associated with ABI.Of 10,775 ECPR patients (median age=57.1 years, 68% male), 16.5% (n=1,787) experienced ABI. The AUC-ROC for ABI, CNS ischemia, and ICH was 0.72, 0.73, and 0.69, respectively. The true positive, true negative, false positive, false negative, positive, and negative predictive values were 61%, 70%, 30%, 39%, 29% and 90%, respectively, for ABI. Longer ECMO duration, younger age, and higher 24h ECMO pump flow were associated with ABI. Conclusions This is the largest study predicting neurological complications on sufficiently powered international ECMO cohorts. Longer ECMO duration and higher 24h pump flow were associated with ABI in both non-ECPR and ECPR VA-ECMO.
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Affiliation(s)
| | | | | | | | | | | | - Isaac Sears
- Warren Alpert Medical School of Brown University
| | | | | | | | | | - Bo Soo Kim
- Johns Hopkins University School of Medicine
| | | | - Adeel Abbasi
- Warren Alpert Medical School of Brown University
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Bae DJ, Willey JZ, Ibeh C, Yuzefpolskaya M, Colombo PC. Stroke and Mechanical Circulatory Support in Adults. Curr Cardiol Rep 2023; 25:1665-1675. [PMID: 37921947 DOI: 10.1007/s11886-023-01985-5] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 11/05/2023]
Abstract
PURPOSE OF THE REVIEW Short-term and durable mechanical circulatory support (MCS) devices represent life-saving interventions for patients with cardiogenic shock and end-stage heart failure. This review will cover the epidemiology, risk factors, and treatment of stroke in this patient population. RECENT FINDINGS Short-term devices such as intra-aortic balloon pump, Impella, TandemHeart, and Venoatrial Extracorporal Membrane Oxygenation, as well as durable continuous-flow left ventricular assist devices (LVADs), improve cardiac output and blood flow to the vital organs. However, MCS use is associated with high rates of complications, including ischemic and hemorrhagic strokes which carry a high risk for death and disability. Improvements in MCS technology have reduced but not eliminated the risk of stroke. Mitigation strategies focus on careful management of anti-thrombotic therapies. While data on therapeutic options for stroke are limited, several case series reported favorable outcomes with thrombectomy for ischemic stroke patients with large vessel occlusions, as well as with reversal of anticoagulation for those with hemorrhagic stroke. Stroke in patients treated with MCS is associated with high morbidity and mortality. Preventive strategies are targeted based on the specific form of MCS. Improvements in the design of the newest generation device have reduced the risk of ischemic stroke, though hemorrhagic stroke remains a serious complication.
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Affiliation(s)
- David J Bae
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
| | - Joshua Z Willey
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Irving Medical Center, New York, NY, 10032, USA.
| | - Chinwe Ibeh
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Melana Yuzefpolskaya
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
| | - Paolo C Colombo
- Division of Medicine, Center for Advanced Cardiac Care, Columbia University, New York, NY, USA
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6
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Kalra A, Kang JK, Wilcox C, Brown P, Rycus P, Anders MM, Zaaqoq AM, Brodie D, Whitman GJR, Cho SM. Impact of Pulse Pressure on Acute Brain Injury in Venoarterial ECMO Patients with Cardiogenic Shock During the First 24 Hours of ECMO Cannulation: Analysis of the Extracorporeal Life Support Organization Registry. Res Sq 2023:rs.3.rs-3646443. [PMID: 38045281 PMCID: PMC10690326 DOI: 10.21203/rs.3.rs-3646443/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background : Low pulse pressure (PP) in venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a marker of cardiac dysfunction and has been associated with acute brain injury (ABI) as continuous-flow centrifugal pump may lead to endothelial dysregulation. Methods : We retrospectively analyzed adults (≥18 years) on "peripheral" VA-ECMO support for cardiogenic shock in the Extracorporeal Life Support Organization Registry (1/2018-7/2023). Cubic splines were used to establish a threshold (PP≤10 mmHg at 24 hours of ECMO support) for "early low" PP. ABI included central nervous system (CNS) ischemia, intracranial hemorrhage, brain death, and seizures. Multivariable logistic regressions were performed to examine whether PP≤10 mmHg was associated with ABI. Covariates included age, sex, body mass index, pre-ECMO variables (temporary mechanical support, vasopressors, cardiac arrest), on-ECMO variables (pH, PaO 2 , PaCO 2 ), and on-ECMO complications (hemolysis, arrhythmia, renal replacement therapy). Results : Of 9,807 peripheral VA-ECMO patients (median age=57.4 years, 67% male), 8,294 (85%) had PP>10 mmHg vs. 1,513 (15%) had PP≤10 mmHg. Patients with PP≤10 mmHg experienced ABI more frequently vs. PP>10 mmHg (15% vs. 11%, p<0.001). After adjustment, PP≤10 mmHg was independently associated with ABI (adjusted odds ratio [aOR]=1.25, 95% confidence interval [CI]=1.06-1.48, p=0.01). CNS ischemia and brain death were more common in patients with PP≤10 mmHg vs. PP>10 mmHg (8% vs. 6%, p=0.008; 3% vs. 1%, p<0.001). PP≤10 mmHg was associated with CNS ischemia (aOR=1.26, 95%CI=1.02-1.56, p=0.03) but not intracranial hemorrhage (aOR=1.14, 95%CI=0.85-1.54, p=0.38). Conclusions : Early low PP (≤10 mmHg) at 24 hours of ECMO support was associated with ABI, particularly CNS ischemia, in peripheral VA-ECMO patients.
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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Khanduja S, Kim J, Kang JK, Feng CY, Vogelsong MA, Geocadin RG, Whitman G, Cho SM. Hypoxic-Ischemic Brain Injury in ECMO: Pathophysiology, Neuromonitoring, and Therapeutic Opportunities. Cells 2023; 12:1546. [PMID: 37296666 PMCID: PMC10252448 DOI: 10.3390/cells12111546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/04/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO), in conjunction with its life-saving benefits, carries a significant risk of acute brain injury (ABI). Hypoxic-ischemic brain injury (HIBI) is one of the most common types of ABI in ECMO patients. Various risk factors, such as history of hypertension, high day 1 lactate level, low pH, cannulation technique, large peri-cannulation PaCO2 drop (∆PaCO2), and early low pulse pressure, have been associated with the development of HIBI in ECMO patients. The pathogenic mechanisms of HIBI in ECMO are complex and multifactorial, attributing to the underlying pathology requiring initiation of ECMO and the risk of HIBI associated with ECMO itself. HIBI is likely to occur in the peri-cannulation or peri-decannulation time secondary to underlying refractory cardiopulmonary failure before or after ECMO. Current therapeutics target pathological mechanisms, cerebral hypoxia and ischemia, by employing targeted temperature management in the case of extracorporeal cardiopulmonary resuscitation (eCPR), and optimizing cerebral O2 saturations and cerebral perfusion. This review describes the pathophysiology, neuromonitoring, and therapeutic techniques to improve neurological outcomes in ECMO patients in order to prevent and minimize the morbidity of HIBI. Further studies aimed at standardizing the most relevant neuromonitoring techniques, optimizing cerebral perfusion, and minimizing the severity of HIBI once it occurs will improve long-term neurological outcomes in ECMO patients.
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Affiliation(s)
- Shivalika Khanduja
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Jiah Kim
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Jin Kook Kang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Cheng-Yuan Feng
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (J.K.); (C.-Y.F.)
| | - Melissa Ann Vogelsong
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Romergryko G. Geocadin
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (S.K.); (J.K.K.); (G.W.)
- Divisions of Neurosciences Critical Care, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
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Akbar AF, Shou BL, Feng CY, Zhao DX, Kim BS, Whitman G, Bush EL, Cho SM. Lower Oxygen Tension and Intracranial Hemorrhage in Veno-venous Extracorporeal Membrane Oxygenation. Lung 2023; 201:315-320. [PMID: 37086285 PMCID: PMC10578342 DOI: 10.1007/s00408-023-00618-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/11/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION AND METHODS We examined the relationship between 24-h pre- and post-cannulation arterial oxygen tension (PaO2) and arterial carbon dioxide tension (PaCO2) and subsequent acute brain injury (ABI) in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) with granular arterial blood gas (ABG) data and institutional standardized neuromonitoring. RESULTS Eighty-nine patients underwent VV-ECMO (median age = 50, 63% male). Twenty (22%) patients experienced ABI; intracranial hemorrhage (ICH) was the most common diagnosis (n = 14, 16%). Lower post-cannulation PaO2 levels were significantly associated with ICH (66 vs. 81 mmHg, p = 0.007) and a post-cannulation PaO2 level < 70 mmHg was more frequent in these patients (71% vs. 33%, p = 0.007). PaCO2 parameters were not associated with ABI. By multivariable logistic regression, hypoxemia post-cannulation increased the odds of ICH (OR = 5.06, 95% CI:1.41-18.17; p = 0.01). CONCLUSION In summary, lower oxygen tension in the 24-h post-cannulation was associated with ICH development. The precise roles of peri-cannulation ABG changes deserve further investigation, as they may influence the management of VV-ECMO patients.
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Affiliation(s)
- Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Cheng-Yuan Feng
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps, Baltimore, MD, 455, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - David X Zhao
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps, Baltimore, MD, 455, USA
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Errol L Bush
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps, Baltimore, MD, 455, USA.
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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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