Abstract Background Use of Extracorporeal Membrane Oxygenation during cardiopulmonary resuscitation (ECPR) is increasingly being deployed as an adjunct to conventional CPR. It is unknown if this has ...been associated with improved outcomes. Aims To describe trends in survival and patient demographics for ECPR patients in the international Extracorporeal Life Support Organisation (ELSO) database over the past 12 years and identify factors associated with changes in survival. Methods Patients greater than 16 years of age who received ECPR between January 2003 and December 2014 were extracted from the ELSO registry and were divided into three 4-year cohorts (Cohort 1: 2003–2006, Cohort 2: 2007–2010, Cohort 3: 2011–2014). Univariable analysis was performed to compare demographics and outcomes of patients across the three cohorts. Univariable and multivariable analyses were then performed to identify factors independently associated with survival. Results 1796 patients treated with ECPR were extracted from the registry, aged 50 (±18.5) years. Annual ECPR episodes increased over 10-fold, from 35 to over 400 per year. Survival to hospital discharge was 29% overall (27% cohort 1, 28% cohort 2, 30% cohort 3 (p = 0.71)). Age, body weight and documented comorbidities increased over time. There was a reduction in complications associated with ECMO usage. After adjusting for confounders there was no change in the odds of survival over the time period examined. Interpretation Over the period 2003–2014, survival to hospital discharge was 29% for patients who require ECPR. Despite advances in provision of ECMO care and increasing co-morbidities of patients, there has been no change in risk-adjusted survival over time.
Background
Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and ...returns blood from the venous system and provides non‐pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump‐driven and pump‐free systems are in use. Use of ECMO is associated with several risks. Patient‐related adverse events include haemorrhage or extremity ischaemia; circuit‐related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain.
Objectives
The primary objective of this systematic review was to determine whether use of veno‐venous (VV) or venous‐arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting s, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications.
Selection criteria
We included randomized controlled trials (RCTs), quasi‐RCTs and cluster‐RCTs that compared adult ECMO versus conventional support.
Data collection and analysis
Two review authors independently screened the titles and s of all retrieved citations against the inclusion criteria. We independently reviewed full‐text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias.
Main results
We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all‐cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.
Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health‐related quality of life.
In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non‐brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.
Clinical heterogeneity between studies prevented meta‐analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest).
Authors' conclusions
Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta‐analysis.
We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.
Abstract The use of extracorporeal membrane oxygenation (ECMO) support for cardiac and respiratory failure has increased in recent years. Improvements in ECMO oxygenator and pump technologies have ...aided this increase in utilization. Additionally, reports of successful outcomes in supporting patients with respiratory failure during the 2009 H1N1 pandemic and reports of ECMO during cardiopulmonary resuscitation have led to increased uptake of ECMO. Patients requiring ECMO are a heterogenous group of critically ill patients with cardiac and respiratory failure. Bleeding and thrombotic complications remain a leading cause of morbidity and mortality in patients on ECMO. In this review, we describe the mechanisms and management of hemostatic, thrombotic and hemolytic complications during ECMO support.
Muscle weakness is common in patients requiring extracorporeal membrane oxygenation (ECMO), but early identification is challenging. This study aimed to 1) quantify the change in quadriceps size and ...quality (echogenicity) from baseline to day 10 using ultrasound in patients requiring ECMO, 2) determine the relationship between ultrasound measures, muscle strength and highest mobility level.
Prospective cohort study involving ultrasound measurement of quadriceps at baseline, days 10 and 20. Muscle strength and highest mobility level were assessed at days 10 and 20 using the Medical Research Council sum-score (MRC), hand-held dynamometry (HHD) and the ICU mobility scale (IMS).
25 patients (age 49 ± 14 years, 44% male) received ECMO. There was a significant reduction (−19%, p < .001) in rectus femoris cross-sectional area by day 10. Echogenicity did not change over time. There was a negative correlation between echogenicity and MRC at day 10 (r = −0.66) and HHD at day 20 (r = −0.81). At day 20, there was a moderate correlation between total muscle thickness and IMS (rho = 0.59) and MRC (rho = 0.56).
In patients requiring ECMO there was marked wasting of the quadriceps over the first 10 days. Ultrasound measures were related to muscle strength and highest mobility level.
•There was marked wasting of the quadriceps muscle from day 1 to day 10, and this continued to day 20.•Quadriceps muscle size and echogenicity were associated with measures of muscle strength and highest mobility level.•Premorbid frailty was associated with quadriceps size at day 1, however by day 10 and 20 there was little correlation.
Research evaluating outcomes in critically ill patients with acute respiratory and cardiac failure supported with extracorporeal membrane oxygenation has increased significantly. The objective was to ...identify a core set of outcomes that are essential to include in all clinical research evaluating the use of either venoarterial or venovenous extracorporeal membrane oxygenation in critically ill patients, particularly regarding safety and adverse events.
A three-round modified Delphi process.
Patients, caregivers, multidisciplinary clinicians, researchers, industry partners, and research funders were included.
Participants represented key extracorporeal membrane oxygenation organizations, including the Extracorporeal Life Support Organization, the International Extracorporeal Membrane Oxygenation Network, clinicians from high volume extracorporeal membrane oxygenation centers, and extracorporeal membrane oxygenation researchers or former extracorporeal membrane oxygenation patients from five continents.
We used recommended standards for the development of a core outcome set. Outcome measures identified from systematic reviews of the literature and from qualitative studies of survivors were mapped to the domains identified by the Core Outcome Measures in Effectiveness Trials initiative separately for venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation.
Participant response rates were 40 of 47 (85%), 35 of 37 (95%), and 64 of 69 (93%) for survey rounds 1, 2, and 3, respectively, with participants representing 10 different countries on five continents. After the third round survey, 8 outcome measures met consensus for both venovenous extracorporeal membrane oxygenation and venoarterial extracorporeal membrane oxygenation.
This study identified core outcomes to assess in all research evaluating the use of extracorporeal membrane oxygenation, including adverse events specific to this intervention, permitting standardization of outcome reporting for the first time. Identifying appropriate measurement instruments to evaluate these outcomes is an important next step to enable synthesis of extracorporeal membrane oxygenation research.
•Thrombosis is a severe complication during VA ECMO therapy.•Inferiorly positioned single-stage cannulae exhibited highest risk of thrombosis.•Positioning cannulae inferiorly may lead to blood ...stagnation.•Varying tip positions impacted flow dynamics, thereby influencing thrombosis risk.•Tip position and cannula design should be carefully considered prior to cannulation.
Venoarterial extracorporeal membrane oxygenation (VA ECMO) is able to support critically ill patients undergoing refractory cardiopulmonary failure. It relies on drainage cannulae to extract venous blood from the patient, but cannula features and tip position may impact flow dynamics and thrombosis risk. Therefore, this study aimed to investigate the effect of tip position of single-stage (SS) and multi-stage (MS) VA ECMO drainage cannulae on the risk of thrombosis.
Computational fluid dynamics was used to model flow dynamics within patient-specific geometry of the venous vasculature. The tip of the SS and MS cannula was placed in the superior vena cava (SVC), SVC-Right atrium (RA) junction, mid-RA, inferior vena cava (IVC)-RA junction, and IVC. The risk of thrombosis was assessed by measuring several factors. Blood residence time was measured via an Eulerian approach through the use of a scalar source term. Regions of stagnant volume were recognised by identifying regions of low fluid velocity and shear rate. Rate of blood washout was calculated by patching the domain with a scalar value and measuring the rate of fluid displacement. Lastly, wall shear stress values were determined to provide a qualitative understanding of potential blood trauma.
Thrombosis risk varied substantially with position changes of the SS cannula, which was less evident with the MS cannula. The SS cannula showed reduced thrombosis risk arising from stagnant regions when placed in the SVC or SVC-RA junction, whereas an MS cannula was predicted to create stagnant regions during all tip positions. When positioned in the IVC-RA junction or IVC, the risk of thrombosis was higher in the SS cannula than in the MS cannula due to both high and low shear flow.
Tip position of the drainage cannula impacts cannula flow dynamics and, subsequently, the risk of thrombosis. The use of MS cannulae can reduce high shear-related thrombosis, but SS cannulae can eliminate stagnant regions when advanced into the SVC. Therefore, the choice of cannula design and tip position should be carefully considered during cannulation.
Out-of-hospital cardiac arrest is a leading cause of mortality with survival rates of less than 10%. In selected patients, survival may be improved via timely application of extracorporeal ...cardiopulmonary resuscitation (ECPR). However, ECPR is a complex and resource intensive intervention with a high risk of complications that impair widespread clinical adoption. This study employed a mixed approach of qualitative interview analysis embedded with quantitative data collection to uncover the major hurdles faced by clinicians during ECPR initiation. We conducted semi-structured interviews with eight ECPR intensive care specialists with 2-10 years of experience working at a large, tertiary ECPR center in Australia. Clinicians identified dilation as the most time-consuming step, followed by draping, and decision-making during extracorporeal membrane oxygenation patient selection. The most challenging step was the decision-making for patient selection, followed by dilation and imaging. These findings uncovered key barriers to ECPR, and identified priority areas for further research and clinical training. Major logistical hindrances will require well-defined protocols and improved clinical training. Engineering innovations in the identified areas may improve the delivery of ECPR, making it simpler and faster to deliver.
Abstract Objective To describe physical function, leg complications and health-related quality of life (HRQOL) in the three months following extracorporeal membrane oxygenation (ECMO) pre- or ...post-heart transplantation (HTx). Background Little is known about functional recovery following ECMO before or after HTx. Methods A 2-year retrospective study in patients who received ECMO pre or post HTx. Strength, mobility, leg complications and HRQOL were recorded to hospital discharge. Six-minute walk distance (6MWD) was assessed at hospital discharge and 3 months. Results 25 patients were included, with 80% (20/25) survival to hospital discharge. At ICU discharge, strength and mobility were poor but improved by hospital discharge ( p < 0.001) despite leg complications in 44% (11/25) of patients. The 6MWD improved over time (mean 203 m, 95% confidence interval 140–265). HRQOL scores were lower than Australian norms ( p < 0.05). Conclusion Patients requiring ECMO pre or post HTx had impaired physical function at ICU discharge and leg complications were common.
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