Venovenous extracorporeal membrane oxygenation for respiratory failure in inotrope dependent neonates

It is often stated that venovenous extracorporeal membrane oxygenation (VV ECMO) should not be used in inotrope dependent patients. It is our practice to use VV ECMO in most patients with respiratory failure even though many of these patients are receiving significant doses of inotropes. Our objective was to review the mode of ECMO in relation to precannulation doses of inotropes administered to neonates treated with ECMO for respiratory failure. Forty-three consecutive case notes were reviewed. Data were collected for basic demographic and ECMO parameters. Inotropic doses were converted to a single score for ease of comparison, with one point equivalent to 1 microg/kg/min dopamine. Forty-three neonates were studied; 37(86%) were treated with VV ECMO and 6 (14%) were treated with VA ECMO. Significant pre-ECMO inotropic support (score > 10) was present in 30 (70%) of the 43 cases. Of these patients, 26 were treated via VV ECMO with a survival rate of 84%, while 4 were treated with VA ECMO with a survival of 75%. Inotrope scores fell to nonsignificant levels (< 10) within 24 hours, regardless of ECMO mode. Mean arterial blood pressure remained above precannulation levels in both groups. VV ECMO allows safe treatment of neonatal respiratory failure in the presence of significant inotropic support. We recommend VV ECMO for neonatal respiratory failure in all cases except where double lumen cannulation is impossible or when septic shock is refractory to inotropic support (i.e., mean blood pressure < 35 mm Hg despite inotrope score of > 100).     

Extracorporeal life support: first year of experience implementing the technique in Slovenia

Extracorporeal life support (ELS) is emerging as a standard treatment option for acute respiratory and/or cardiac failure. In this article we describe our first year of experience with ELS activity in adult medical patients in our center. Veno-venous extracorporeal membrane oxygenation (VV ECMO) support was applied in cases of severe acute respiratory distress syndrome (ARDS) not responsive to conventional treatments. The use of veno-arterial (VA) ECMO support was reserved for cases of cardiac shock refractory to standard treatment and cardiac arrests not responding to conventional resuscitation. A total of 19 patients were treated with ELS during the first year of activity. Eight of these received VV ECMO for ARDS of various etiologies, with a survival rate of 63%. Eleven patients received VA ECMO support due to cardiac failure (2 post-resuscitation). Survival in this group was 45%. We report our results, including complications and organizational issues that we encountered, and describe protocol improvements developed over the short period of time since ELS treatment has been implemented in our center.     

Ease of conversion from venovenous extracorporeal membrane oxygenation to cardiopulmonary bypass and venoarterial extracorporeal membrane oxygenation with a bicaval dual lumen catheter

Extracorporeal circulatory support revolutionized the field of cardiothoracic surgery, initially in the form of cardiopulmonary bypass (CPB) and then in its modified form, extracorporeal membrane oxygenation (ECMO). Although initial cannulation techniques involved open intrathoracic approaches, the increased prevalence of reoperative sternotomies and the emergence of minimally invasive surgery encouraged the development of peripheral cannulation methods and configurations. The Avalon Elite Bicaval Dual Lumen catheter (Avalon Laboratories, LLC, CA) can be placed in the right internal jugular vein to provide venovenous (VV) ECMO. However, some patients on VV ECMO then develop compromised cardiac performance. We describe two ways in which the Avalon Elite was used, first for complete venous drainage through a single peripheral site for CPB and in the other to convert a patient on VV ECMO to axillary artery venoarterial (VA) ECMO.     

Hemolysis in patients with Extracorporeal Membrane Oxygenation therapy for severe Acute Respiratory Distress Syndrome - a systematic review of the literature

The Acute Respiratory Distress Syndrome (ARDS) is common in patients on the Intensive Care Unit and associated with significant mortality rates. In situations of severe respiratory insufficiency and failure of all possible conservative therapeutic approaches, veno-venous extracorporeal membrane oxygenation (VV ECMO) is used as a final option for temporary replacement of pulmonary function. ARDS as well as sepsis and VV ECMO treatment are all associated with intravascular hemolysis. The extent and relevance of intravascular hemolysis in the context of ARDS therapy is unclear. This systematic review aims to summarize the current evidence on the incidence and associated complications of intravascular hemolysis in adult patients with ARDS and treatment with VV ECMO. The databases MEDLINE, EMBASE and Web of Science were systematically searched and 19 publications fulfilled inclusion criteria. The incidence of hemolysis in patients with ARDS and treatment with VV ECMO ranged from 0 to 41% with survivors showing lower incidences and less severe hemolysis. A pump head thrombosis and high blood flows (≥3 l/min) as well as use of dual-lumen cannulas but not different pump models were associated with increased hemolysis. In conclusion, intravascular hemolysis in patients with ARDS and treatment with VV ECMO is a common and relevant complication that appears associated with increased mortality. Apart from ECMO hardware-settings, no additional possible causes for increased red cell breakdown such as disease severity, duration of ECMO therapy, or number and quality of red blood cell transfusions were investigated. Further research is needed to determine the origin and relevance of intravascular hemolysis in patients with ARDS and treatment with VV ECMO.     

Safe transport of critically ill adult patients on extracorporeal membrane oxygenation support to a regional extracorporeal membrane oxygenation center

Patients with severe cardiac or pulmonary failure who require transport to specialized hospitals currently pose a challenge. Mechanical support in the form of extracorporeal membrane oxygenation (ECMO) may increase the safety of transporting such patients to an institution where they will have access to advanced medical therapy. Over 2.5 years, 17 patients were successfully cannulated and placed on a simplified ECMO circuit at other institutions and transported via ambulance to our hospital. Fourteen patients with acute respiratory distress syndrome (ARDS) were placed on venovenous (VV) ECMO. Two patients with isolated cardiogenic shock and one patient with ARDS were placed on venoarterial (VA) ECMO. The two cardiogenic shock patients were converted to a biventricular assist device shortly after arrival. The median unit-to-unit transport time was 60 minutes (interquartile range 50-92 minutes), and the median distance traveled was 23 miles (interquartile range 17-55 miles). There was no transport-related morbidity or mortality. The median duration of ECMO support was 8 days (interquartile range 4-11 days). Thirteen patients (76%) were successfully decannulated. Ten patients (59%) were weaned from the ventilator, and nine patients (53%) survived up to 3 months and were discharged from the hospital. Critically ill patients with severe ARDS or cardiogenic shock can be safely transported on VV or VA ECMO support to regional ECMO centers. As the indications and demands for ECMO support expand, so will the role for transporting patients on ECMO.     

Efficacy of Veno-Venous Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Failure

Purpose

The objective of this study was to evaluate our institutional experience with veno-venous (VV) extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory failure (ARF).

Materials and Methods

From January 2007 to August 2013, 31 patients with severe ARF that was due to various causes and refractory to mechanical ventilation with conventional therapy were supported with VV ECMO. A partial pressure of arterial oxygen (PaO₂)/inspired fraction of oxygen (FiO₂) <100 mm Hg at an FiO₂ of 1.0 or a pH <7.25 due to CO₂ retention were set as criteria for VV ECMO.

Results

Overall, 68% of patients survived among those who had received VV ECMO with a mean PaO₂/FiO₂ of 56.8 mm Hg. Furthermore, in trauma patients, early use of ECMO had the best outcome with a 94% survival rate.

Conclusion

VV ECMO is an excellent, life-saving treatment option in patients suffering from acute and life-threatening respiratory failure due to various causes, especially trauma, and early use of VV ECMO therapy improved outcomes in these patients.     

48 h cessation of mechanical ventilation during venovenous extracorporeal membrane oxygenation in severe trauma: a case report

A 32-year-old motorcyclist who was hit by a tram subsequently presented with blunt force thoracic trauma, a pelvic fracture and a penetrating injury to the left lower extremity. Coagulopathy persisted following surgery of the leg and pelvic vascular intervention. Bedside thoracotomy was performed to treat pneumothorax and pneumopericardium. Severe hypoxemia secondary to lung failure ensued, which required venovenous extracorporeal membrane oxygenation (VV ECMO) support. On the third day after the trauma, ultra-protective mechanical ventilation was not possible due to non-existent lung compliance; thus, the ventilator was disconnected, and the T-piece was connected to the blocked tracheal tube left in the airway. Gas exchange occurred via VV ECMO separately. After 48 h of cessation of ventilator support, the patient was weaned from sedation. At this time, respiratory effort was observed, and assisted ventilation was initiated. The patient ultimately recovered and experienced an excellent outcome. The clinical significance of zero end-expiratory pressure (ZEEP) and the complete cessation of open lung strategy during ECMO remains controversial. In cases of reduced lung compliance, if VV ECMO can facilitate adequate gas exchange, the discontinuation of ventilation is an option that can be used to prevent ventilator-induced lung damage and to allow the lungs to rest. VV ECMO is feasible as lung support with no mechanical ventilation in case of severe lung failure after major trauma.     

Oxygenation index for extracorporeal membrane oxygenation: is there predictive significance?

Although extracorporeal membrane oxygenation (ECMO) is known to improve survival in neonates with respiratory failure, there has been a significant decrease in the use of ECMO in recent years. Alternative modalities such as high-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), and surfactant therapy are associated with this decline. The criteria for the initiation of ECMO, developed about 20 years ago, are likely no longer relevant. We examined the predictive significance of the oxygenation index (OI) as a patient entry criterion for ECMO use. We sought a critical OI level predicting death or chronic lung disease (CLD) with and without ECMO use. We also examined whether patients with certain OIs are more likely to have worse outcomes. One hundred and seventy-four term-newborn admissions between 1995 and 2000 requiring mechanical ventilation were enrolled in the study. Receiver operating curve analysis was performed to find a cutoff value of OI for ECMO initiation. Mortality rates and CLD probability were compared to the worst OIs. Our 6-year ECMO administration experience showed that an OI of 33.2 is a suitable cutoff value for ECMO initiation with high sensitivity and specificity as a predictive criterion. The critical OI value associated with the CLD risk when ECMO is not used is in the 40s. OI is a good predictor of CLD; the probability of CLD increases with higher OIs. Our data support the trend toward the use of new interventions over ECMO, especially for patients with OI scores of less than 33.2. Only when the probability of ventilator-associated lung injury becomes significant is it better to consider ECMO than conventional modalities.     

Heparin-induced thrombocytopenia in COVID-19 patients with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation: two case reports

Journal of Artificial Organs - Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is increasingly used in Coronavirus disease-19 (COVID-19) patients with the most severe forms of acute...     

Veno–veno–arterial extracorporeal membrane oxygenation for acute respiratory distress syndrome with septic-induced cardiomyopathy due to severe pulmonary tuberculosis

We describe the rare experience of veno–veno–arterial (VVA) extracorporeal membrane oxygenation (ECMO) in a patient with acute respiratory distress syndrome and septic-induced cardiomyopathy due to pulmonary tuberculosis (TB). A 24-year-old male patient who developed septic-induced cardiomyopathy secondary to pulmonary TB was administered veno-arterial (VA) ECMO for cardiac support. Six days later, the ECMO configuration mode was changed from VA to VVA to improve hypoxemia of the upper body and to prevent further lung injury. The patient was then successfully managed using an appropriate alternative ECMO strategy.     

Soluble fibrin is a useful marker for predicting extracorporeal membrane oxygenation circuit exchange because of circuit clots

A circuit clot is one of the most frequent complications during extracorporeal membrane oxygenation (ECMO) support. We identify coagulation/fibrinolysis markers for predicting ECMO circuit exchange because of circuit clots during ECMO support. Ten patients with acute pulmonary failure who underwent veno-venous ECMO were enrolled between January 2014 and December 2016. ECMO support lasted 106 days. The 6 days on which the ECMO circuits were exchanged were considered as circuit clot (+) group, while the remaining 100 days were considered as circuit clot (?) group. The predictors of ECMO circuit exchange because of circuit clots were identified. The mean duration of ECMO support was 10?±?13 days, and the mean number of ECMO circuit exchange was 0.6?±?1.1 times per patient. Thrombin-antithrombin complex (TAT) and soluble fibrin (SF) were higher in the circuit clot (+) group than in the circuit clot (?) group (both P?<?0.01). According to a multivariate analysis, SF was the only independent predictor of ECMO circuit exchange (P?<?0.01). The odds ratio (confidence intervals) for SF (10 µg/ml) was 1.20 (1.06–1.36). The area under the curve and optimal cut-off value were 0.95 and 101 ng/ml for SF (sensitivity, 100%; specificity, 89%). SF may be useful in predicting ECMO circuit exchange because of circuit clots.     

Prolonged extracorporeal membrane oxygenation for pediatric necrotizing pneumonia due to <Emphasis Type="Italic">Streptococcus pneumonia</Emphasis> and influenza H1N1 co-infection: how long should we wait for native lung recovery?

Most children with severe respiratory failure require extracorporeal membrane oxygenation (ECMO) for 7–10 days. However, some may need prolonged duration ECMO (>?14 days). To date, no consensus exists on how long to wait for native lung recovery. Here we report the case of a 3-year-old boy who developed severe necrotizing pneumonia requiring venovenous (VV) ECMO after 19 days of mechanical ventilation. In the first 4 weeks of his ECMO run, he showed no lung aeration, requiring total extracorporeal support. However, after we started strategies for promoting lung recovery such as daily prone positioning and regular use of toilet bronchoscopy and inhalative DNAse to clear secretions, by week five his tidal volumes gradually increased and he was successfully decannulated after 43 days. Moreover, we decided not to proceed to a surgical removal of the necrotic lung area. At present, he is 1-year post discharge and has fully recovered. This report shows that unexpected native lung recovery is possible even after prolonged loss of lung function and that a previous healthy lung can recover from apparent irreversible lung injury.     

Venoarterial extracorporeal membrane oxygenation support for neonatal and pediatric refractory septic shock

Objective:To report our institutional experience of veno-arterial extracorporeal membrane oxygenation (VA ECMO) in children with refractory septic shock.Conclusion:ECMO can be safely used to resuscitate and support children with refractory septic shock. We recommend that patients with oliguria whose lactate level has not decreased within 6 h of starting maximum drug therapy be transferred to an ECMO referral center.     

Use of dilutional ultrasound monitoring to detect changes in recirculation during venovenous extracorporeal membrane oxygenation in swine

Since recirculation during venovenous extracorporeal membrane oxygenation (VV ECMO) reduces oxygen delivery to the patient, monitoring recirculation is necessary to guide clinicians in interventions that may reduce recirculation and thereby optimize patient care. The use of dilutional ultrasound may be a clinically practical way to quantify recirculation during VV ECMO. This study evaluates in a swine model of VV ECMO a dilutional ultrasound techniques ability to provide accurate recirculation data under changing conditions. One 16-kg swine was cannulated with a dual-lumen cannula and placed on VV ECMO. Recirculation measured by using blood oxygen saturations (r = S(preox) - SVO2/S(postox) - SVO2) was compared with recirculation measured by a saline dilution ultrasound technique. Dilutional ultrasound was then used to measure changes in baseline recirculation in the face of (a) cannula repositioning and (b) a drug-induced cardiac output change. The comparison of recirculation calculations between the saturation method and dilutional ultrasound were similar at all flow rates measured. The time for results was much faster with the use of dilutional ultrasound. Induction of recirculation changes by repositioning the cannula or changing cardiac output was rapidly detected using dilutional ultrasound and showed significant differences from baseline recirculation. Dilutional ultrasound provides a clinically practical method to quantify and monitor recirculation in VV ECMO applications and may aid in assessing interventions to improve oxygen delivery.     

Pediatric outcomes after extracorporeal membrane oxygenation for cardiac disease and for cardiac arrest: a review

We reviewed reported survival and neurological outcomes, and predictors of these outcomes for pediatric cardiac extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR). We searched PubMed from 2000 to April 2011. Cumulative survival after cardiac ECMO in children was 788/1755 (45%); renal dysfunction, dialysis, neurologic complication, lactate, and ECMO duration consistently predicted this outcome, whereas single ventricle and ECPR did not. Neurological outcomes after cardiac ECMO were based on poorly described telephone questions in two studies for 47 patients with 51% significantly impaired and detailed follow-up testing for 42 patients in three studies with mental delay in 38% and mental score >85 (average or above) in 33%. Cumulative survival after ECPR in children was 371/762 (49%); noncardiac disease, renal dysfunction, neurologic complication, and pH on extracorporeal life support consistently predicted this outcome, whereas duration of CPR did not. Neurological outcomes after ECPR were based predominantly on the pediatric cerebral performance category (PCPC) score by chart review, with 161/181 (79%) having PCPC <2. No study reported detailed follow-up testing for survivors of ECPR. Survival outcomes of most cardiac subgroups were similar, except for concerning mortality in cavopulmonary connection patients. Priority areas for study include identification of potentially modifiable predictors of long-term outcomes.     

Venovenous ECMO as a bridge to lung transplant and a protective strategy for subsequent primary graft dysfunction

Extracorporeal membrane oxygenation (ECMO) is an established therapy for primary graft dysfunction (PGD) in adults after lung transplant, while venovenous (VV) ECMO is an evolving therapy that can bridge patients to lung transplantation. This report describes a case of relatively quick improvement of grade 3 PGD, based on the PaO₂/FIO₂ (P/F) ratio, in a 17-year-old patient with cystic fibrosis who was bridged to lung transplantation with ambulatory VV ECMO and then received support with VV ECMO as a protective strategy during the initial phases of PGD after lung transplantation.     

Impact of varied center volume categories on volume–outcome relationship in children receiving ECMO for heart operations

To study the volume–outcome relationship among children receiving extracorporeal membrane oxygenation (ECMO), different studies from different databases use different volume categories. The objective of this study was to evaluate if different center volume categories impact the volume–outcome relationship among children receiving ECMO for heart operations. We performed a post hoc analysis of data from an existing national database, the Pediatric Health Information System. Centers were classified into five different volume categories using different cut-offs and different variables. Mortality rates were compared between the varied volume categories using a mixed effects logistic regression model after adjusting for patient- and center-level risk factors. Data collection included demographic information, baseline characteristics, pre-ECMO risk factors, operation details, patient diagnoses, and center data. In unadjusted analysis, there was a significant relationship between center volume and mortality, with low-and medium-volume centers associated with higher mortality rates compared to high-volume centers in all volume categories, except the hierarchical clustering volume category. In contrast, there was no significant association between center-volume and mortality among all volume categories in adjusted analysis. We concluded that high-volume centers were not associated with improved outcomes for the majority of the categorization schemes despite using different cut-offs and different variables for volume categorization.     

Subclavian artery cannulation for venoarterial extracorporeal membrane oxygenation

Femoral artery cannulation for venoarterial extracorporeal membrane oxygenation (ECMO) can be associated with ischemic and neurologic complications. The subclavian artery offers an alternative cannulation site, which is helpful in patients with peripheral vascular disease, in those who have sustained pelvic trauma, or when ambulation is anticipated. This is a single-institution review of 20 adults who were placed on venoarterial ECMO using subclavian arterial cannulation over a 2 year period. Technical success with subclavian venoarterial ECMO was 100%. Median ECMO time was 168 hours (2.4-720 hours). Sufficient flows (median 4.24 L/min), oxygenation (median postcannulation PaO2 315 mm Hg), and ventricular unloading confirmed with intraoperative transesophageal echocardiogram were achieved in all patients. Seventy-five percent of patients were decannulated, 50% were extubated, and 45% were discharged. Seven patients (35%) had an entirely upper body ECMO configuration with the internal jugular vein serving as the venous drainage site. Complications included arterial cannula site hematoma and infection, as well as ipsilateral arm swelling. Each required conversion to femoral artery cannulation. There were no ischemic or neurologic complications. Patients with acute cardiopulmonary failure can safely be placed on subclavian venoarterial ECMO for prolonged periods with full flows, adequate oxygenation, and sufficient ventricular unloading.     

Use of nafamostat mesilate as an anticoagulant during extracorporeal membrane oxygenation

Although the incidence of bleeding complications during extracorporeal membrane oxygenator (ECMO) support has decreased in various trials, bleeding is still the most fatal complication. We investigated the ideal dosage and efficacy of nafamostat mesilate for use with ECMO in patients with acute cardiac or respiratory failure. We assessed 73 consecutive patients who received ECMO due to acute cardiac or respiratory failure between January 2006 and December 2009. To evaluate the efficacy of nafamostat mesilate, we divided the patients into 2 groups according to the anticoagulants used during ECMO support. All patients of nafamostat mesilate group were male with a mean age of 49.2 yr. Six, 3, 5, and 3 patients were diagnosed with acute myocardial infarction, cardiac arrest, septic shock, and acute respiratory distress syndrome, respectively. The mean dosage of nafamostat mesilate was 0.64 mg/kg/hr, and the mean duration of ECMO was 270.7 hr. The daily volume of transfused packed red blood cells, fresh frozen plasma, and cryoprecipitate and the number of complications related to hemorrhage and thrombosis was lower in the nafamostat mesilate group than in the heparin group. Nafamostat mesilate should be considered as an alternative anticoagulant to heparin to reduce bleeding complications during ECMO.     

Continuous Renal Replacement Therapy (CRRT) Attenuates Myocardial Inflammation and Mitochondrial Injury Induced by Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) in a Healthy Piglet Model

In this study, we investigated the myocardial inflammation and mitochondrial function during venovenous extracorporeal membrane oxygenation (VV ECMO) and further evaluated the effects of continuous renal replacement therapy (CRRT) on them. Eighteen piglets were assigned to the control group, ECMO group, and ECMO+CRRT group. Myocardial inflammation was assessed by the activity of myeloperoxidase (MPO), myocardial concentrations, and mRNA expression of TNF-α, IL-1β, and IL-6; mitochondrial function was assessed by activities of mitochondrial complexes I–V. VV ECMO elicited a general activation of serum and myocardial inflammation and significantly decreased the activities of mitochondrial complexes I and IV. After being combined with CRRT, serum and myocardial concentrations of IL-1β and IL-6, myocardial mRNA expression of IL-6, and the activity of MPO were decreased significantly; the activities of mitochondrial complexes were increased. We conclude that myocardial inflammation was activated during ECMO therapy, inducing mitochondrial injury; moreover, CRRT reduced myocardial inflammation and partially ameliorated mitochondrial function.