Examining non-cardiac surgical procedures in patients supported with extracorporeal membrane oxygenation (original) (raw)
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European Journal of Cardio-Thoracic Surgery, 2014
OBJECTIVES: To describe the clinical results (both early and at follow-up) of patients currently receiving extracorporeal membrane oxygenation (ECMO) therapy for cardiac and/or pulmonary failure. To assess the effect of indications, clinical presentations and ECMO modalities on early/late clinical outcomes. To identify baseline factors associated with worse survival at follow-up. METHODS: We reviewed the prospectively collected data of 325 patients receiving ECMO therapy at a tertiary referral centre during the 2005-2013 period. Follow-up was prospectively conducted by dedicated personnel (average: 84 ± 86 days, 100% complete). Survival was analysed by stratified Kaplan-Meier curves. RESULTS: Veno-arterial (VA) ECMO was employed in 80% of cases (due to early graft failure (EGF) in 13% of cases, post-cardiotomy in 29%, primary cardiogenic shock in 42% for miscellaneous aetiologies, other indications in 15.4%) and veno-venous (VV) ECMO in the remainders (adult respiratory distress syndrome). In the VA and VV groups, weaning rates were 59 and 53%, survival at 30th postimplantation day was 44 and 45% and survival at the end of the follow-up was 41 and 45%, respectively. Implantation under advanced life support (ALS) occurred in 15% of cases (26% survival at 30 days). VA patients had a higher rate of thrombotic/haemorrhagic complications and of transfusion of blood products and shorter ventilation time. Worse early and follow-up survival were observed among patients aged ≥65 years, having pH ≤ 7, lactates >12 mmol/l, creatinine >200 μmol/l at implantation or receiving ECMO under ALS. No difference in survival was noted among VA vs VV patients. Patients receiving ECMO for EGF displayed better early and late survival (64% at 30 days and 53% at 6 months) than post-cardiotomy (36 and 34%, respectively), post-acute myocardial infarction (48 and 40%) and the remaining patients (46 and 45%). CONCLUSIONS: Despite most critical baseline conditions, ECMO therapy is confirmed useful for the treatment of patients with acute cardiopulmonary failure refractory to conventional treatments. The ECMO modality (VA vs VV), as well as indications to support, identifies different patient profiles and dissimilar outcomes. Preimplantation markers of gravity and end-organ damage are useful in the stratification of expected survival. These may facilitate clinical decision-making and appropriate allocation of hospital resources.
The Turkish Journal of Pediatrics, 2020
Extracorporeal membrane oxygenation (ECMO) is used in pediatric patients with severe cardiopulmonary failure who do not respond to conventional therapy; only a few studies have been conducted in Turkey. We present the experience of pediatric ECMO with the aim of showing factors affecting mortality. We retrospectively reviewed our ECMO database to identify patients who received ECMO from October 2015 to March 2018. Our population comprised 30 pediatric patients. The mean patient age was 41.31±53.35 months and 17 (56.7%) patients were male. The median duration of ECMO support was 8.9 (6.6-10.8) days. The rates of successful ECMO weaning and survival to discharge were 70.0% (n=21) and 66.7% (n=20), respectively. Indications for ECMO were respiratory failure (40.0%), cardiac failure (33.3%), and sepsis (26.7%). We found that pre-cannulation values of pH (p=0.034), leukocytes (p=0.029), C-reactive protein (p=0.045), creatinine (p=0.047), chloride (p=0.001) and post-cannulation pH (p=0.0001), bicarbonate (p=0.014), lactate (p=0.002), chloride (p=0.0001) were associated with mortality. The results showed that preexisting sepsis and renal conditions contributed to poor outcomes. Indications, ECMO onset time, and pre-and post-cannulation laboratory values such as leukocytes, CRP, creatinine, bicarbonate, lactate, and chloride are factors that affect outcomes.
Critical Care, 2017
Background: Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an effective rescue therapy for severe cardiorespiratory failure, but morbidity and mortality are high. We hypothesised that survival decreases with longer VA ECMO treatment. We examined the Extracorporeal Life Support Organization (ELSO) registry for a relationship between VA ECMO duration and in-hospital mortality, and covariates including indication for support. Methods: All VA runs from the ELSO database from 2002 to 2012 were extracted. Multiple runs and non-VA runs were excluded. Runs were categorized into diagnostic groups. Logistic regression for analysis of the effect of duration on outcome, and multivariate regression for diagnosis and other baseline factors were performed. Non-linear models including piecewise logistic models were fitted. Results: There were 2699 runs analysed over 14,747 days. Logistic regression analysis of the effect of duration on outcome, and multivariate regression analysis of diagnosis and other baseline factors were performed. In-hospital survival was 41.4% (95% CI 39.6-43.3). 75% of patients were supported for less than 1 week and 96% for less than 3 weeks. Median duration (4 days IQR 2.0-6.8) was greater in survivors (4.1 (IQR 2.5-6.7) vs 3.8 (IQR 1.7-7.0) p = 0.002). The final multivariate model demonstrated increasing survival to day 4 (OR 1.53 (95% CI 1.37-1.71) p < 0.001), decreasing from day 4 to 12 (OR 0.86 (95% CI 0.81-0.91), p < 0.001) with no significant change thereafter (OR 0.98 (95% CI 0.94-1.02), p = 0.400). Conclusions: ECMO for 4 days or less is associated with higher mortality, likely reflecting early treatment failure. Survival is highest when patients are weaned on the fourth day of ECMO but likely decreases into the second week. While this does not suggest weaning at this point will produce better outcomes, it does reflect the likely time course of ECMO as a bridge in severe shock. Patients with some underlying conditions (like myocarditis and heart transplantation) achieve better outcomes despite longer support duration. These findings merit prospective study for the development of prognostic models and weaning strategies.
Predictors of Mortality in Patients Successfully Weaned from Extracorporeal Membrane Oxygenation
PLoS ONE, 2012
Purpose: Extracorporeal membrane oxygenation (ECMO) has been utilized for critically ill patients, such as those with lifethreatening respiratory failure or post-cardiotomy cardiogenic shock. This study compares the predictive value of Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), and Organ System Failure (OSF) obtained on the first day of ECMO removal, and the Acute Kidney Injury Network (AKIN) stages obtained at 48 hours post-ECMO removal (AKIN 48-hour) in terms of hospital mortality for critically ill patients. Methods: This study reviewed the medical records of 119 critically ill patients successfully weaned from ECMO at the specialized intensive care unit of a tertiary-care university hospital between July 2006 and October 2010. Demographic, clinical, and laboratory data were collected retrospectively as survival predictors. Results: Overall mortality rate was 26%. The most common condition requiring ECMO support was cardiogenic shock. By using the areas under the receiver operating characteristic (AUROC) curve, the Sequential Organ Failure Assessment (SOFA) score displayed good discriminative power (AUROC 0.80560.055, p,0.001). Furthermore, multiple logistic regression analysis indicated that daily urine output on the second day of ECMO removal (UO 24-48 hour), mean arterial pressure (MAP), and SOFA score on the day of ECMO removal were independent predictors of hospital mortality. Finally, cumulative survival rates at 6-month follow-up differed significantly (p,0.001) for a SOFA score#13 relative to those for a SOFA score.13. Conclusions: Following successful ECMO weaning, the SOFA score proved a reproducible evaluation tool with good prognostic abilities.
Vox Sanguinis, 2009
Background/Objectives More adults undergo extracorporeal membrane oxygenation (ECMO) now. They have high transfusion requirements. This study described transfusion requirements of adults during ECMO in a single institution, and determined factors associated with high transfusion requirements. Materials/Methods Retrospective analysis was done on the amount of blood products received by adults during ECMO. Predictors of increased average daily transfusion requirements during ECMO and increased ECMO duration (which correlated positively with total transfusion requirements) were determined. Results Forty-one patients (median age 50 years) underwent 42 ECMO sessions for respiratory failure (16•7%), cardiogenic shock (76•2%) or massive pulmonary embolism (7•1%). They received 569 red blood cells, 852 platelets, 126 fresh-frozen plasma (FFP) and 220 cryoprecipitate in total during median ECMO duration of 5 (1-15) days. On multivariate analysis, average daily red blood cell transfusion increased with nadir haemoglobin (Hb) during ECMO (Hb nadir) of < 7•5 g/dl (P < 0•001). Average daily platelet transfusion increased with recent antiplatelet agents (P = 0•015) and maximum Hb decline of > 5•5 g/dl during ECMO (P = 0•011). Average daily platelet transfusion > 3 units was also associated with increased ECMO duration (P = 0•024). Average daily FFP transfusion was increased in patients with hypertension (P = 0•007) and Hb nadir < 7•5 g/dl (P = 0•050). Patients with sepsis (P = 0•009) or without surgery (P = 0•009) had increased ECMO duration, which correlated positively with total transfusion requirements during the entire ECMO session. ECMO improved mortality of patients with fulminant myocarditis, respiratory failure and massive pulmonary embolism. Conclusion Adult ECMO patients with lower Hb nadir require more daily red blood cell and FFP. Hypertension increases daily FFP requirements. Recent antiplatelet agents, larger Hb decline and longer ECMO duration increase daily platelet requirements. Patients with sepsis or on ECMO for medical reasons have longer ECMO duration, which is associated with total transfusion requirements. Some of these factors may be identified early to optimize blood product support.
International Journal of Advance Study and Research Work, 2021
The review mainly focuses on the goals to evaluate the viability of ECMO in a decrease of mortality, length of stay, and other complications in adults above 18 years. Introduction: Inclusion criteria: This review is conducted in adult patients above 18 years who were included with cardiac or respiratory failure, or both. Respiratory, Neurological disease, Cardiac arrest, acute respiratory distress syndrome (ARDS), COVID-19, Haemorrhagic Stroke, Pneumonia, Bleeding, Renal replacement therapy, organ Failure primary graft dysfunction following lung Transplant, H1N1 Influenza, and other comorbidities. Methods: The databases of web indexes like PubMed, Google researcher, and Cochrane were utilized for this review. The titles and abstracts are screened and evaluated based on the inclusion criteria of the review. Depending on inclusion criteria the full-text articles were assessed exhaustively and chosen studies were recovered by methodological quality. Results: In this review among the retrieved articles forty-six studies met the inclusion criteria and those studies were pooled statistically and their outcomes were measured. All those studies explain the effectiveness of ECMO by reducing mortality, length of stay, and other complications. Conclusion: Currently with limited evidence suggests that ECMO reduces mortality, length of stay, and other complications in adult patients with respiratory, cardiac failure, and other comorbidities.
Perioperative Management of Adult Surgical Patients on Extracorporeal Membrane Oxygenation Support
Journal of Cardiothoracic and Vascular Anesthesia, 2013
E XTRACORPOREAL MECHANICAL support devices are used as an adjunct in the management of critically ill patients who are refractory to more conventional modes of therapy. Extracorporeal membrane oxygenation (ECMO) is one such device that has been used mainly in the management of patients in cardiogenic shock or respiratory failure who failed therapy on maximal ventilator settings and maximal pharmacologic support. ECMO has the advantage of being rapidly deployable, both at the bedside and in the operating room, and can be initiated without the need for general anesthesia. ECMO has been used as a bridging device to recovery or to more definitive therapy. In patients who are awaiting lung transplantation, ECMO has been used as a bridge to transplant when decompensation occurs and also as an adjunct in physical rehabilitation before transplant.