https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(09)61069-2.pdf

Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial.

Rationale: Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers.Objectives: To determine if higher annual ECMO patient volume is associated with lower case-mix–adjusted hospital mortality rate.Methods: We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0–28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group–specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008–2013.Measurements and Main Results: From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquar...

/pdf/association-of-hospital-level-volume-of-extracorporeal-v3bq37hcq1.pdf

Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality: Analysis of the extracorporeal life support organization registry

Objective: To comprehensively assess published peerreviewed studies related to extracorporeal membrane oxygenation (ECMO), focusing on outcomes and complications of ECMO in adult patients. Design: Systematic review and meta-analysis. Data sources: MEDLINE/PubMed was searched for articles on complications and mortality occurring during or after ECMO. Data extraction: Included studies had more than 100 patients receiving ECMO and reported in detail fatal or nonfatal complications occurring during or after ECMO. Primary outcome was mortality at the longest follow-up available; secondary outcomes were fatal and non-fatal complications. Data synthesis: Twelve studies were included (1763 patients), mostly reporting on venoarterial ECMO. Criteria for applying ECMO were variable, but usually comprised acute respiratory failure, cardiogenic shock or both. After a median follow-up of 30 days (1st-3rd quartile, 30-68 days), overall mortality was 54% (95% CI, 47%-61%), with 45% (95% CI, 42%-48%) of fatal events occurring during ECMO and 13% (95% CI, 11%-15%) after it. The most common complications associated with ECMO were: renal failure requiring continuous venovenous haemofiltration (occurring in 52%), bacterial pneumonia (33%), any bleeding (33%), oxygenator dysfunction requiring replacement (29%), sepsis (26%), haemolysis (18%), liver dysfunction (16%), leg ischaemia (10%), venous thrombosis (10%), central nervous system complications (8%), gastrointestinal bleeding (7%), aspiration pneumonia (5%), and disseminated intravascular coagulation (5%). Conclusions: Even with conditions usually associated with a high chance of death, almost 50% of patients receiving ECMO survive up to discharge. Complications are frequent and most often comprise renal failure, pneumonia or sepsis, and Crit Care Resusc 2013; 15: 172-178 bleeding.

/pdf/a-meta-analysis-of-complications-and-mortality-of-4iluqdfbvb.pdf

A meta-analysis of complications and mortality of extracorporeal membrane oxygenation

The use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure (ARF) in adults is growing rapidly given recent advances in technology, even though there is controversy regarding the evidence justifying its use. Because ECMO is a complex, high-risk, and costly modality, at present it should be conducted in centers with sufficient experience, volume, and expertise to ensure it is used safely. This position paper represents the consensus opinion of an international group of physicians and associated health-care workers who have expertise in therapeutic modalities used in the treatment of patients with severe ARF, with a focus on ECMO. The aim of this paper is to provide physicians, ECMO center directors and coordinators, hospital directors, health-care organizations, and regional, national, and international policy makers a description of the optimal approach to organizing ECMO programs for ARF in adult patients. Importantly, this will help ensure that ECMO is delivered safely and...

/pdf/position-paper-for-the-organization-of-extracorporeal-3y0bjrcwjh.pdf

Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients

The University of Michigan experience with extracorporeal life support
(ECLS) in 1000 consecutive patients between 1980 and 1998 is the largest series
at one institution in the world. Among this patient population, survival to
hospital discharge in moribund patients with respiratory failure was 88% in
586 neonates, 70% in 132 children, and 56% in 146 adults. Survival in moribund
patients with cardiac failure was 48% in 105 children and 33% in 31 adults.
This article describes the University of Michigan's overall ECLS patient experience,
the progression of ECLS from laboratory experiments to clinical application
at the bedside, the expansion of the technology to other centers, and current
ECLS technology and outcomes. Despite the challenges faced in clinical research
in this field, our experience and that of others has shown that ECLS saves
lives of patients with acute cardiac or pulmonary failure in a variety of
clinical settings.

https://jamanetwork.com/journals/jama/articlepdf/192408/JSC90349.pdf

Extracorporeal Life Support: The University of Michigan Experience

Between May 1990 and January 1999, 100 patients (68 adult, 32 pediatric) with severe respiratory or cardiac instability were successfully transported to the University of Michigan Medical Center on extracorporeal life support. Diagnoses included adult respiratory distress syndrome (n = 78), cardiac failure (n = 7), sepsis (n = 7), asthma (n = 5), respiratory distress syndrome (of newborn) (n = 2), and airway compromise (n = 1). Of the patients, 53 were supported with venovenous bypass and 47 with venoarterial bypass. Patients were transported by ground ambulance (n = 80), helicopter (n = 15), or fixed-wing aircraft (n = 5). The median transport distance was 44 miles (range 2-790 miles), and the median transport time was 5 hours and 30 minutes (range: 1 h 33 min to 16 h 6 min). Sixty-six patients (66%) survived to discharge. One death occurred during cannulation, and two patients died before cannulation began. Complications that occurred during transport included 10 cases of electrical failure, 3 cases of circuit tubing leakage, and 1 case each of circuit rupture, membrane lung thrombosis, and membrane lung leakage. None of the complications occurring during transport had an adverse effect on outcome. We conclude that the long distance transport of patients on extracorporeal life support can be safely accomplished and is an effective option for the unstable patient with severe respiratory or cardiac failure.

A review of 100 patients transported on extracorporeal life support.

http://lib.ajaums.ac.ir/booklist/1-s2.0-S0003497514013083-main.pdf

Two decades' experience with interfacility transport on extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) was introduced to clinical medicine over 40 years ago. While initially used as a treatment for acute respiratory failure in infants, the use of ECMO has grown to include respiratory and circulatory failure in both children and adults, cardiogenic shock, pulmonary embolism, sepsis, trauma, malignancy, pulmonary hemorrhage and as a treatment for hypothermic drowning.(1) Recent technological improvements in ECMO circuitry make it possible to minimize anticoagulation of the ECMO patient, decreasing the incidence of bleeding. Thrombus deposition within the ECMO circuit can be a life-threating complication. ECMO circuit thrombus can be contained in the circuit, adherent to cannula and deposited within the patient. The ability to remove thrombus while the patient remains on ECMO support could be a life-saving measure for some patients. The present case report outlines use of the AngioVac(®) thrombus removal system in concert with ECMO to remove a large thrombus adherent to an ECMO cannula.

William Copenhaver

Papers

A review of 100 patients transported on extracorporeal life support.

Two decades' experience with interfacility transport on extracorporeal membrane oxygenation.

Novel use of the AngioVac® system to remove thrombus during simultaneous extracorporeal membrane oxygenation life support: