Alternative venous access sites for dual-lumen extracorporeal membrane oxygenation cannulation

OBJECTIVES

Dual-lumen cannulas for veno-venous (VV) extracorporeal membrane oxygenation (ECMO) support are typically inserted in the right internal jugular vein (RIJV); however, some scenarios can make this venous route inaccessible. This multicentre case series aims to evaluate if single-site cannulation using an alternative venous access is safe and feasible in patients with an inaccessible RIJV.

METHODS

We performed a multi-institutional retrospective analysis including high-volume ECMO centres with substantial experience in dual-lumen cannulation (DLC) (defined as >10 DLC per year). Three centres [Freiburg (Germany), Toronto (Canada) and Vienna (Austria)] agreed to share their data, including baseline characteristics, technical ECMO and cannulation data as well as complications related to ECMO cannulation and outcome.

RESULTS

A total of 20 patients received alternative DLC for respiratory failure. Cannula insertion sites included the left internal jugular vein (n = 5), the right (n = 7) or left (n = 3) subclavian vein and the right (n = 4) or left (n = 1) femoral vein. The median cannula size was 26 (19-28) French. The median initial target ECMO flow was 2.9 (1.8-3.1) l/min and corresponded with used cannula size and estimated cardiac output. No procedural complications were reported during cannulation and median ECMO runtime was 15 (9-22) days. Ten patients were successfully bridged to lung transplantation (n = 5) or lung recovery (n = 5). Ten patients died during or after ECMO support.

CONCLUSIONS

Alternative venous access sites for single-site dual-lumen catheters are a safe and feasible option to provide veno-venous ECMO support to patients with inaccessible RIJV.

Extracorporeal membrane oxygenation in adults receiving haematopoietic cell transplantation: an international expert statement

Combined advances in haematopoietic cell transplantation (HCT) and intensive care management have improved the survival of patients with haematological malignancies admitted to the intensive care unit. In cases of refractory respiratory failure or refractory cardiac failure, these advances have led to a renewed interest in advanced life support therapies, such as extracorporeal membrane oxygenation (ECMO), previously considered inappropriate for these patients due to their poor prognosis. Given the scarcity of evidence-based guidelines on the use of ECMO in patients receiving HCT and the need to provide equitable and sustainable access to ECMO, the European Society of Intensive Care Medicine, the Extracorporeal Life Support Organization, and the International ECMO Network aimed to develop an expert consensus statement on the use of ECMO in adult patients receiving HCT. A steering committee with expertise in ECMO and HCT searched the literature for relevant articles on ECMO, HCT, and immune effector cell therapy, and developed opinion statements through discussions following a Quaker-based consensus approach. An international panel of experts was convened to vote on these expert opinion statements following the Research and Development/University of California, Los Angeles Appropriateness Method. The Appraisal of Guidelines for Research and Evaluation statement was followed to prepare this Position Paper. 36 statements were drafted by the steering committee, 33 of which reached strong agreement after the first voting round. The remaining three statements were discussed by all members of the steering committee and expert panel, and rephrased before an additional round of voting. At the conclusion of the process, 33 statements received strong agreement and three weak agreement. This Position Paper could help to guide intensivists and haematologists during the difficult decision-making process regarding ECMO candidacy in adult patients receiving HCT. The statements could also serve as a basis for future research focused on ECMO selection criteria and bedside management.

Effect of Cytokine Adsorption on Survival and Circulatory Stabilization in Patients Receiving Extracorporeal Cardiopulmonary Resuscitation

Even after the introduction of extracorporeal cardiopulmonary resuscitation (ECPR), survival after cardiac arrest remains poor. Excess release of vasoactive cytokines may be a reason for cardiovascular instability and death after ECPR. Recently, an extracorporeal cytokine adsorption device (CytoSorb) to reduce elevated levels of circulating cytokines has been introduced. So far, it remains unclear if this device may improve survival and cardiovascular stabilization after ECPR. We report data from our investigator-initiated, single-center ECPR registry. We compared 23 ECPR patients treated with cytokine adsorption with a propensity-matched cohort of ECPR patients without cytokine adsorption. We analyzed survival, lactate clearance, vasopressor need, and fluid demand in both groups and performed between-group comparisons. Survival to discharge from intensive care unit (ICU) was 17.4% (4/23) in the cytokine adsorption group and 21.7% in the control group (5/23, P > 0.99). In both groups, we observed a decrease of serum-lactate, need for vasopressors, and fluid demand during the first 72 hours after ECPR. However, in direct comparison, we did not find significant between-group differences. In this retrospective registry study employing propensity score matching, cytokine adsorption in severely ill patients after ECPR was not associated with improved ICU survival nor a decrease of lactate, fluid, or vasopressor levels. Due to small case numbers and the retrospective design of the study, our results neither disprove nor confirm a clinically relevant treatment effect of cytokine adsorption. Results from larger trials, preferably randomized-controlled trials are required to better understand the clinical benefit of cytokine adsorption after ECPR.

Two siblings with early repolarization syndrome: clinical and genetic characterization by whole-exome sequencing

Aims 

The early repolarization syndrome (ERS) can cause ventricular fibrillation (VF) and sudden death in young, otherwise healthy individuals. There are limited data suggesting that ERS might be heritable. The aim of this study was to characterize the clinical phenotype and to identify a causal variant in an affected family using an exome-sequencing approach.

Methods and results 

Early repolarization syndrome was diagnosed according to the recently proposed Shanghai ERS Score. After sequencing of known ERS candidate genes, whole-exome sequencing (WES) was performed. The index patient (23 years, female) showed a dynamic inferolateral early repolarization (ER) pattern and electrical storm with intractable VF. Isoproterenol enabled successful termination of electrical storm with no recurrence on hydroquinidine therapy during 33 months of follow-up. The index patient’s brother (25 years) had a persistent inferior ER pattern with malignant features and a history of syncope. Both parents were asymptomatic and showed no ER pattern. While there was no pathogenic variant in candidate genes, WES detected a novel missense variant affecting a highly conserved residue (p. H2245R) in the ANK3 gene encoding Ankyrin-G in the two siblings and the father.

Conclusion 

We identified two siblings with a malignant ERS phenotype sharing a novel ANK3 variant. A potentially pathogenic role of the novel ANK3 variant is suggested by the direct interaction of Ankyrin-G with the cardiac sodium channel, however, more patients with ANK3 variants and ERS would be required to establish ANK3 as novel ERS susceptibility gene. Our study provides additional evidence that ERS might be a heritable condition.

The Use and Outcomes of Cerebral Protection Devices for Patients Undergoing Transfemoral Transcatheter Aortic Valve Replacement in Clinical Practice

OBJECTIVES

This study hypothesized that cerebral protection prevents strokes in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR) in clinical practice.

BACKGROUND

Preventing strokes is an important aim in TAVR procedures. Embolic protection devices may protect against cardiac embolism during TAVR, but their use and outcomes in clinical practice remain controversial.

METHODS

Isolated transfemoral TAVR procedures performed in Germany with or without cerebral protection devices were extracted from a comprehensive nationwide billing dataset.

RESULTS

A total of 41,654 TAVR procedures performed between 2015 and 2017 were analyzed. The overall share of procedures incorporating cerebral protection devices was 3.8%. Patients receiving cerebral protection devices were at increased operative risk (European System for Cardiac Operative Risk Evaluation score 13.8 vs. 14.7; p < 0.001) but of lower age (81.1 vs. 80.6 years; p = 0.001). To compare outcomes that may be related to the use of cerebral protection devices, a propensity score comparison was performed. The use of a cerebral protection device did not reduce the risk for stroke (adjusted risk difference [aRD]: +0.88%; 95% confidence interval [CI]: -0.07% to 1.83%; p = 0.069) or the risk for developing delirium (aRD: +1.31%; 95% CI: -0.28% to 2.89%; p = 0.106) as a sign of acute brain failure. Although brain damage could not be prevented, in-hospital mortality was lower in the group receiving a cerebral protection device (aRD: -0.76%; 95% CI: -1.46% to -0.06%; p = 0.034).

CONCLUSIONS

In this large national database, cerebral embolic protection devices were infrequently used during TAVR procedures. Device use was associated with lower mortality but not a reduction in stroke or delirium. Future studies are needed to confirm these findings.

Mobile ECMO retrieval of patients during the COVID-19 pandemic

ECMO support is particularly resource‐intensive and should be provided in highly specialized centers. Occasionally, ECMO needs to be initiated in non‐ECMO centers by mobile ECMO retrieval teams. Subsequently, patients must be transferred on ECMO to the ECMO center. We report single‐center data from out‐of‐center initiations of ECMO during the COVID‐19 pandemic. From March 2020 through February 2021, nine patients were connected to ECMO before transfer to our center. Median travel distance (IQR) from the referring hospital to our center was 66 km (20‐92), median land travel time (IQR) was 51 minutes (26‐92). Personal protective equipment was available for all team members and used throughout the missions. No infections of team members with SARS‐CoV‐2 occurred. Three patients survived until hospital discharge. Median duration of ECMO (IQR) was 18 days (2‐78) in survivors and 19 days (9‐42) in non‐survivors, respectively. Out‐of‐center initiation of ECMO during the COVID‐19 pandemic was feasible and safe for patients and staff.

Conservative management of COVID-19 associated hypoxaemia

With great interest we read the article by Voshaaret al. [1] reporting data from a retrospective analysis of 78 coronavirus disease 2019 (COVID-19) patients treated with or without invasive mechanical ventilation. The authors conclude that avoiding invasive mechanical ventilation by allowing permissive hypoxaemia was superior to current treatment standards and guidelines. Overall mortality in this cohort was 7.7% (six out of 78), but 50% (four out of eight) of the patients supported with invasive mechanical ventilation eventually died [1].

This correspondence argues that data presented previously cannot justify a novel approach for treating hypoxic patients with severe #COVID19https://bit.ly/3dLaPlk

Cytokine adsorption in patients with severe COVID-19 pneumonia requiring extracorporeal membrane oxygenation (CYCOV): a single centre, open-label, randomised, controlled trial

Background

We sought to clarify the benefit of cytokine adsorption in patients with COVID-19 supported with venovenous extracorporeal membrane oxygenation (ECMO).

Methods

We did a single-centre, open-label, randomised, controlled trial to investigate cytokine adsorption in adult patients with severe COVID-19 pneumonia requiring ECMO. Patients with COVID-19 selected for ECMO at the Freiburg University Medical Center (Freiburg, Germany) were randomly assigned (1:1) to receive cytokine adsorption using the CytoSorb device or not. Randomisation was computer-generated, allocation was concealed by opaque, sequentially numbered sealed envelopes. The CytoSorb device was incorporated into the ECMO circuit before connection to the patient circuit, replaced every 24 h, and removed after 72 h. The primary endpoint was serum interleukin-6 (IL-6) concentration 72 h after initiation of ECMO analysed by intention to treat. Secondary endpoints included 30-day survival. The trial is registered with ClinicalTrials.gov (NCT04324528) and the German Clinical Trials Register (DRKS00021300) and is closed.

Findings

From March 29, 2020, to Dec 29, 2020, of 34 patients assessed for eligibility, 17 (50%) were treated with cytokine adsorption and 17 (50%) without. Median IL-6 decreased from 357·0 pg/mL to 98·6 pg/mL in patients randomly assigned to cytokine adsorption and from 289·0 pg/mL to 112·0 pg/mL in the control group after 72 h. One patient in each group died before 72 h. Adjusted mean log IL-6 concentrations after 72 h were 0·30 higher in the cytokine adsorption group (95% CI −0·70 to 1·30, p=0·54). Survival after 30 days was three (18%) of 17 with cytokine adsorption and 13 (76%) of 17 without cytokine adsorption (p=0·0016).

Interpretation

Early initiation of cytokine adsorption in patients with severe COVID-19 and venovenous ECMO did not reduce serum IL-6 and had a negative effect on survival. Cytokine adsorption should not be used during the first days of ECMO support in COVID-19.

Funding

None.

Cytokine adsorption in patients with severe COVID-19 pneumonia requiring extracorporeal membrane oxygenation: protocol for a randomised, controlled, open-label intervention, multicentre trial

INTRODUCTION

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a last resort treatment option in patients with severe COVID-19 related acute respiratory distress syndrome (ARDS). Mortality in these critically ill patients is high. Elevated interleukin-6 (IL-6) levels in these severe courses are associated with poor outcome. Extracorporeal cytokine adsorption is an approach to lower elevated IL-6 levels. However, there is no randomised controlled data on the efficacy of cytokine adsorption and its effect on patient outcome in severe COVID-19 related ARDS requiring V-V ECMO support.

METHODS AND ANALYSIS

We here report the protocol of a 1:1 randomised, controlled, parallel group, open-label intervention, superiority multicentre trial to evaluate the effect of extracorporeal cytokine adsorption using the CytoSorb device in severe COVID-19 related ARDS treated with V-V ECMO. We hypothesise that extracorporeal cytokine adsorption in these patients is effectively reducing IL-6 levels by 75% or more after 72 hours as compared with the baseline measurement and also reducing time to successful V-V ECMO explantation. We plan to include a total of 80 patients at nine centres in Germany.

ETHICS AND DISSEMINATION

The protocol of this study was approved by the ethical committee of the University of Freiburg as the leading institution (EK 285/20). Additional votes will be obtained at all participating centres.

TRIAL REGISTRATION NUMBERS

NCT04385771 and DRKS 00021248.

Clinical scenarios for use of transvalvular microaxial pumps in acute heart failure and cardiogenic shock - A European experienced users working group opinion

For patients with myocardial infarct-related cardiogenic shock (CS), urgent percutaneous coronary intervention is the recommended treatment strategy to limit cardiac and systemic ischemia. However, a specific therapeutic intervention is often missing in non-ischemic CS cases. Though drug treatment with inotropes and/or vasopressors may be required to stabilize the patient initially, their ongoing use is associated with excess mortality. Coronary intervention in unstable patients often leads to further hemodynamic compromise either during or shortly after revascularization. Support devices like the intra-aortic balloon pump failed to improve clinical outcomes in infarct-related CS. Currently, more powerful and active hemodynamic support devices unloading the left ventricle such as transvalvular microaxial pumps are available and are being increasingly used. However, as for other devices large randomized trials are not yet available, and device use is based on registry data and expert consensus. In this article, a multidisciplinary group of experienced users of transvalvular microaxial pumps outlines the pathophysiological background on hemodynamic changes in CS, the available mechanical support devices, and current guideline recommendations. Furthermore, different hemodynamic situations in several case-based scenarios are used to illustrate candidate settings and to provide the theoretic and scientific rationale for left-ventricular unloading in these scenarios. Finally, organization of shock networks, monitoring, weaning, and typical complications and their prevention are discussed.

[Near-Drowning with Good Outcome after ECMO-Therapy and Therapeutic Hypothermia Despite 20 Minutes of Anoxia and 16 Hours of Hypoxia]

Introduction Drowning with submersion over 10 minutes is associated with a high mortality. Here, we present a case, in which a good neurological outcome was achieved after interdisciplinary, intensive care therapy despite submersion of 20 minutes followed by 16 hours of hypoxia. History A 19 year old man drowned in fresh-water. After 20 minutes submersion he was localized and salvaged from 8 meters depth and primarily resuscitated successfully after 10 minutes. Within the next hour, there condition worsened by respiratory deterioration due to a massive capillary leak syndrome in addition to a disseminated intravascular coagulation. Treatment This made implantation of a veno-venous ECMO (extracorporeal membrane oxygenation) therapy necessary. Despite intensive care medicine including extracorporeal therapy a sufficient oxygenation (arterial pO₂ > 60 mmHg) was reached only 16 hours after the drowning. Clinical Course During this time the patient was treated with a mild therapeutic hypothermia for cerebral protection. Despite the prolonged hypoxia, ECMO could be removed five days after the drowning and the patient was extubated after another five days without significant neurological deficits. Conclusion Despite submersion of 20 minutes followed by prolonged hypoxia, a good neurological outcome could be achieved in our patient. This case suggests, that tolerance of hypoxia is possibly underestimated after drowning.