Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation

OBJECTIVE

As survival with extracorporeal membrane oxygenation (ECMO) therapy improves, it is important to study patients who do not survive secondary to withdrawal of life-sustaining therapy (WLST). The purpose of the present study was to determine the population and clinical characteristics of those who experienced short latency to WLST.

DESIGN

Retrospective cohort study.

SETTING

Single academic hospital center.

PARTICIPANTS

Adult ECMO patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the study period, 150 patients (mean age 54.8 ± 15.9 y, 43.3% female) underwent ECMO (80% venoarterial ECMO and 20% venovenous ECMO). Seventy-three (48.7%) had WLST from ECMO support (median five days), and 33 of those (45.2%) had early WLST (≤five days). Patients who underwent WLST were older (60.3 ± 15.3 y v 49.6 ± 14.7 y; p < 0.001) than those who did not undergo WLST and had greater body mass index (31.7 ± 7.6 kg/m²v 28.3 ± 5.5 kg/m²; p = 0.002), longer ECMO duration (six v four days; p = 0.01), and higher Acute Physiology and Chronic Health Evaluation (25 v 21; p < 0.001) and Sequential Organ Failure Assessment (12 v 11; p = 0.037) scores. Family request frequently (91.7%) was cited as part of the WLST decision. WLST patients experienced more chaplaincy (89% v 65%; p < 0.001), palliative care consults (53.4% v 29.9%; p = 0.003), and code status change (do not resuscitate: 83.6% v 7.8%; p < 0.001).

CONCLUSIONS

Nearly 50% of ECMO patients underwent WLST, with approximately 25% occurring in the first 72 hours. These patients were older, sicker, and experienced a different clinical context. Unlike with other critical illnesses, neurologic injury was not a primary reason for WLST in ECMO patients.

Successful extracorporeal membrane oxygenation support for severe acute diquat and glyphosate poisoning: A case report

RATIONALE

Because of the lack of an antidote or effective treatment, patients with severe acute diquat and glyphosate poisoning always died within a few hours. Extracorporeal membrane pulmonary oxygenation (ECMO), as an artificial heart-lung supporting system, can be applied to support lung that is expected to recover from reversible pathological damage. However, to our knowledge, the application of ECMO for patients with diquat and glyphosate poisoning has not been reported.

PATIENT CONCERNS

A 40-year-old man ingested in 100 ml of diquat (20 g/100 ml) and 400 ml glyphosate (41 g/100 ml) was admitted to the intensive care unit (ICU), immediately complicated by the development of ventricular fibrillation, respiratory failure, renal failure, and multi-organ failure.

DIAGNOSIS

Diquat and glyphosate poisoning were diagnosed by stated ingestion history, and the diagnostic criteria for acute respiratory distress syndrome (ARDS) and multi-organ dysfunction syndrome were also met.

INTERVENTIONS

He was treated with veno-venous ECMO.

OUTCOMES

He was successfully transferred out of the ICU on day 46 and discharged on day 67. The computed tomography scan showed no obvious pulmonary fibrosis 2 months after poisoning.

LESSONS

ECMO may be effective in the treatment of patients with severe ARDS caused by diquat and glyphosate poisoning when conventional management does not work.

Effects of Nutritional Intervention on the Survival of Patients with Cardiopulmonary Failure Undergoing Extracorporeal Membrane Oxygenation Therapy

BACKGROUND/AIM

This study aimed to examine the effects of nutritional intervention on the prognosis of patients with cardiopulmonary failure undergoing extracorporeal membrane oxygenation (ECMO) therapy in Taiwan.

MATERIALS AND METHODS

An institutional review board-approved retrospective study was conducted on patients receiving ECMO therapy in the intensive care unit of the China Medical University Hospital, Taiwan, from January 2013 to December 2013. The study included 102 patients with cardiopulmonary failure receiving ECMO therapy.

RESULTS

The data indicated that higher survival rates were closely related to lower age and APACHE II scores among the patients. In addition, compared to patients who deceased, those who survived had a higher total calorie intake. Most patients could tolerate bolus feeding and polymeric formulas. Furthermore, patients who underwent nutritional therapy with nutritional goals greater than 80% achieved a better outcome and lower mortality than other patients.

CONCLUSION

Early nutritional intervention could benefit patients undergoing ECMO, and those who reached the delivery goal of 80% had significantly better outcomes than other patients. Enteral feeding can begin early and was well tolerated by patients receiving ECMO therapy. Following individual nutrition goals is critical for better outcomes, and this analysis might be useful in establishing individualized nutrition goals for oriental population when caring for critically ill patients.

Effects of Nutritional Intervention on the Survival of Patients with Cardiopulmonary Failure Undergoing Extracorporeal Membrane Oxygenation Therapy

BACKGROUND/AIM

This study aimed to examine the effects of nutritional intervention on the prognosis of patients with cardiopulmonary failure undergoing extracorporeal membrane oxygenation (ECMO) therapy in Taiwan.

MATERIALS AND METHODS

An institutional review board-approved retrospective study was conducted on patients receiving ECMO therapy in the intensive care unit of the China Medical University Hospital, Taiwan, from January 2013 to December 2013. The study included 102 patients with cardiopulmonary failure receiving ECMO therapy.

RESULTS

The data indicated that higher survival rates were closely related to lower age and APACHE II scores among the patients. In addition, compared to patients who deceased, those who survived had a higher total calorie intake. Most patients could tolerate bolus feeding and polymeric formulas. Furthermore, patients who underwent nutritional therapy with nutritional goals greater than 80% achieved a better outcome and lower mortality than other patients.

CONCLUSION

Early nutritional intervention could benefit patients undergoing ECMO, and those who reached the delivery goal of 80% had significantly better outcomes than other patients. Enteral feeding can begin early and was well tolerated by patients receiving ECMO therapy. Following individual nutrition goals is critical for better outcomes, and this analysis might be useful in establishing individualized nutrition goals for oriental population when caring for critically ill patients.

Cerebral Perfusion After Repair of Congenital Diaphragmatic Hernia with Common Carotid Artery Occlusion After ECMO Therapy

AIM

To prospectively evaluate cerebral perfusion after repair of congenital diaphragmatic hernia (CDH) and right-common-carotid-artery (rCCA) occlusion after extracorporeal membrane oxygenation (ECMO) therapy.

PATIENTS AND METHODS

A total of 29 2-year-old-children with a history of CDH repair underwent cerebral magnetic resonance perfusion imaging. In 14 patients, the rCCA was occluded after ECMO therapy. Fifteen patients with CDH without ECMO served as controls. Regional cerebral-blood-flow (rCBF) was measured cortically and subcortically in both hemispheres and compared intra-individually and between both groups.

RESULTS

Patients with rCCA-occlusion showed intra-individual side differences between hemispheres, with significantly lower subcortical perfusion of the right hemisphere and reduced cortical perfusion. In one-third of patients with rCCA-occlusion, rCBF of the right-hemisphere was reduced by more than 20% when compared to the left hemisphere. Despite intra-individual side differences, mean rCBF in patients with rCCA occlusion was not reduced compared to controls.

CONCLUSION

Beside intra-individual side differences, overall right hemisphere perfusion is sufficient after rCCA-occlusion due to collateral blood supply.

Successful extracorporeal membrane oxygenation therapy as a bridge to sequential bilateral lung transplantation for a patient after severe paraquat poisoning

CONTEXT

Paraquat is a widely used herbicide that can cause severe to fatal poisoning in humans. The irreversible and rapid progression of pulmonary fibrosis associated with respiratory failure is the main cause of death in the later stages of poisoning. There are infrequent reports of successful lung transplants for cases of severe paraquat poisoning. We expect that this successful case will provide a reference for other patients in similar circumstances.

CASE DETAILS

A 24-year-old female was sent to the hospital approximately 2 hours after ingesting 50 ml of paraquat. She experienced rapidly aggravated pulmonary fibrosis and severe respiratory failure. On the 34th day after ingestion, she underwent intubation and invasive mechanical ventilation. The patient was evaluated for lung transplantation, and veno-venous extracorporeal membrane oxygenation (ECMO) was established as a bridge to lung transplantation on the 44th day. On the 56th day, she successfully underwent a bilateral sequential lung transplantation. Through respiratory and physical rehabilitation and nutrition support, the patient was weaned from mechanical ventilation and extubated on the 66th day. On the 80th day, she was discharged. During the 1-year follow-up, the patient was found to be in good condition, and her pulmonary function improved gradually.

CONCLUSION

We suggest that lung transplantation may be an effective treatment in the end stages of paraquat-induced pulmonary fibrosis and consequential respiratory failure. For patients experiencing a rapid progression to a critical condition in whom lung transplantation cannot be performed immediately (e.g., while awaiting a viable donor or toxicant clearance), ECMO should be a viable bridge to lung transplantation.

Extracorporeal membrane oxygenation: experience in acute graft failure after heart transplantation

INTRODUCTION

Acute graft failure is the leading cause of early mortality after heart transplantation (HTx). Extracorporeal membrane oxygenation (ECMO) is an efficient therapeutic option to treat various pathologies, unburden the left and right ventricle, and allow for functional recovery of the transplanted heart. We reviewed our ECMO experience and outcomes in HTx patients.

METHODS

Retrospectively, we analyzed all patients who received an orthotopic HTx (n = 298) in our department over a 15-yr period (1997 through 2011) to assess the incidence of post-HTx ECMO implantation, perioperative complications, early and one-yr mortality as well as causes of death.

RESULTS

ECMO therapy was utilized to treat graft failure in 28 patients (10.6%) with a mean duration of ECMO support of 4.2 d (six h to 9.4 d). Multivariate analysis revealed as independent predictors for mortality low cardiac output (p = 0.028; odds ratio (OR) = 11.3) and stroke (p = 0.008; OR = 19.7). Cumulative survival rates were 46.4 ± 9.4% within 30 d and 25.0 ± 8.2% at one yr. Causes of death were multiorgan failure (n = 9), sepsis (n = 9), lung failure (n = 2), and intracerebral bleeding (n = 2). ECMO was implanted due to primary graft failure (PGF, n = 16), sepsis (n = 4), and right heart failure (n = 6).

CONCLUSION

Temporary ECMO support for postoperative output failure is an acceptable option as a last resort for otherwise doomed patients with fatal graft failure after HTx. The small fraction of patients surviving appear to have a decent long-term prognosis.

The effect of priming solutions and storage time on plasticizer migration in different PVC tubing types--implications for wet storage of ECMO systems

The wet priming of extracorporeal membrane oxygenation systems and storage of these systems for rapid deployment is common practice in many clinical centers. This storage policy is, however, seen by many to be controversial due to the potential adverse effects associated with the migration of the di(2-ethylhexyl) phthalate plasticizer (DEHP) from the polyvinyl chloride (PVC) circuit tubing and issues surrounding the maintenance of sterility. This study was performed to evaluate the effects of both short and long-term storage and priming fluid type on plasticizer migration from four commonly used PVC tubes in extracorporeal membrane oxygenation therapy circuits. The four tubes incorporating three plasticizers, two DEHP, one tri(2-ethylhexyl) trimellitate (TOTM), and one dioctyl adipate (DOA) were exposed to each of the three priming fluids for a period of 28 days. Samples were taken at time intervals of 1, 4, 8, 24, and 48 hours, followed by samples at 7, 14, and 28 days. Each sample was processed using a spectrophotomer and the concentration of plasticizer leaching into each solution at each time-point determined. There was a time dependent increase in plasticizer leached from each tube. The migration was greatly affected by both the priming fluid and tubing type. The migration of DEHP was higher than that of TOTM and DOA over both the short and long-term exposure levels. Plasticizer migration occurs from all of the tubes tested over the long term. The TOTM and DOA tubes performed better than the DEHP counterparts in the short term. Selection of priming fluid has a major bearing on plasticizer migration with significant lipid and protein containing fluids promoting higher migration than simple sodium chloride .9% solution prime. The results suggest that DOA tubing and sodium chloride. 9% solution priming fluid should be selected if wet primed perfusion circuits are to be used over short terms of storage.