Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock.
TL;DR: Patients who tolerated a full ECMO weaning trial and had aortic VTI ≥10 cm, LVEF >20–25%, and TDSa ≥6 cm/s at minimal ECMO flow were all successfully weaned, and further studies are needed to validate these simple and easy-to-acquire Doppler echocardiography parameters as predictors of subsequent EC MO weaning success in patients recovering from severe cardiogenic shock.
Abstract: Purpose
Detailed extracorporeal membrane oxygenation (ECMO) weaning strategies and specific predictors of ECMO weaning success are lacking. This study evaluated a weaning strategy following support for refractory cardiogenic shock to identify clinical, hemodynamic, and Doppler echocardiography parameters associated with successful ECMO removal.
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University of Washington1, University of Florida2, University of Düsseldorf3, University of Iowa4, Oregon Health & Science University5, University of California, Irvine6, Thomas Jefferson University7, Alfred I. duPont Hospital for Children8, University of Texas Southwestern Medical Center9, St Thomas' Hospital10, Columbia University11, Maastricht University12, University of Regensburg13, Emory University14
TL;DR: These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.
Abstract: Disclaimer: The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.
294 citations
TL;DR: For severe ARDS patients receiving femoro–jugular vv-ECMO, blood flow was the main determinant of arterial oxygenation, while CO2 elimination depended on sweep gas flow through the oxygenator.
Abstract: Purpose
This study was designed to optimize the latest generation venovenous (vv)-extracorporeal membrane oxygenation (ECMO)-circuit configuration and settings based on the evaluation of blood oxygenation and CO2 removal determinants in patients with severe acute respiratory distress syndrome (ARDS) on ultraprotective mechanical ventilation.
251 citations
Cites background from "Predictors of successful extracorpo..."
...can cause excessive depression and cavitation in the inflow line, resulting in massive intravascular hemolysis [16, 17]....
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...However, when refractory hypoxemia does develop, recourse to vv-ECMO is a reasonable therapeutic option [10, 12, 13, 16, 17]....
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...To minimize blood recirculation, the circuit can be configured in several ways [16, 17]....
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TL;DR: Venoarterial extracorporeal membrane oxygenation rescued more than 70% of the patients who developed refractory cardiovascular dysfunction during severe bacterial septic shock and reported good health-related quality of life at long-term follow-up.
Abstract: Objectives:Profound myocardial depression can occur during severe septic shock. Although good outcomes of venoarterial extracorporeal membrane oxygenation–treated children with refractory septic shock have been reported, little is known about adults’ outcomes. This study was designed to assess the o
224 citations
TL;DR: Restoring pulsatility and decreasing left ventricular afterload with intra-aortic balloon pump was associated with smallerleft ventricular dimensions and lower pulmonary artery pressures but did not affect microcirculation variables in cardiogenic shock patients with little/no residual left vent cardiac ejection while on peripheral venoarterial extracorporeal membrane oxygenation.
Abstract: Objectives:This study was designed to assess the effects on macrocirculation and microcirculation of adding an intra-aortic balloon pump to peripheral venoarterial extracorporeal membrane oxygenation in patients with severe cardiogenic shock and little/no residual left ventricular ejection.Design:A
154 citations
Cites background from "Predictors of successful extracorpo..."
...org 2077 (LVEF), aortic VTI, cardiac output and cardiac index, transmitral early peak (E) and late (A) diastolic velocities, and spectral tissue Doppler lateral mitral annulus peak systolic (TDSa) and early diastolic (Ea) velocities (14), with E/Ea estimating LV-filling pressures (15, 16)....
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TL;DR: Early ECMO implantation may improve outcomes in out-of-hospital cardiac arrest patients and the initial rhythm and ROSC may help select patients for extracorporeal-CPR.
Abstract: Aims Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes. Methods and results We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8-2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5-1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5-10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1-4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5-5.9; P = 0.002). Conclusions In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.
151 citations
References
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TL;DR: The ESICM developed a so-called sepsis-related organ failure assessment (SOFA) score to describe quantitatively and as objectively as possible the degree of organ dysfunction/failure over time in groups of patients or even in individual patients.
Abstract: Multiple organ failure (MOF) is a major cause of morbidity and mortali ty in the critically ill patient. Emerging in the 1970s, the concept of MOF was linked to modern developments in intensive care medicine [1]. Although an uncontrolled infection can lead to MOF [2], such a phenomenon is not always found. A number of mediators and the persistence of tissue hypoxia have been incriminated in the development of MOF [3]. The gut has been cited as a possible \"moto r \" of MOF [4]. Nevertheless, our knowledge regarding the pathophysiology of MOF remains limited. Furthermore, the development of new therapeutic interventions aiming at a reduction of the incidence and severity of organ failure calls for a better definition of the severity of organ dysfunction/failure to quantify the severity of illness. Accordingly, it is important to set some simple but objective criteria to define the degree of organ dysfunction/failure. The evolution of our knowledge of organ dysfunction/failure led us to establish several principles: 1. Organ dysfunction/failure is a process rather than an event. Hence, it should be seen as a continuum and should not be described simply as \"present\" or \"absent~' Hence, the assessment should be based on a scale. 2. The time factor is fundamental for several reasons: (a) Development and similarly resolution of organ failure may take some time. Patients dying early may not have time to develop organ dysfunction/failure. (b) The time course of organ dysfunction/failure can be mult imodal during a complex clinical course, what is sometimes referred to as a \"multiple-hit\" scenario. (c) Time evaluation allows a greater understanding of the disease process as a natural process or under the influence of therapeutic interventions. The collection of data on a daily basis seems adequate. 3. The evaluation of organ dysfunction/failure should be based on a limited number of simple but objective variables that are easily and routinely measured in every institution. The collection of this information should not impose any intervention beyond what is routinely performed in every ICU. The variables used should as much as possible be independent of therapy, since therapeutic management may vary from one institution to another and even from one patient to another (Table 1). Until recently, none of the existing systems describing organ failure met these criteria, since they were based on categorial definitions or described organ failure as present or absent [5-7] . The ESICM organized a consensus meeting in Paris in October 1994 to create a so-called sepsis-related organ failure assessment (SOFA) score, to describe quantitatively and as objectively as possible the degree of organ dysfunction/failure over time in groups of patients or even in individual patients (Fig. 1). There are two major applications of such a SOFA score: 1. To improve our Understanding of the natural history of organ dysfunction/failure and the interrelation between the failure of the various organs.
8,538 citations
TL;DR: The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis, and is a starting point for future evaluation of the efficiency of intensive care units.
Abstract: Objective. —To develop and validate a new Simplified Acute Physiology Score, the SAPS II, from a large sample of surgical and medical patients, and to provide a method to convert the score to a probability of hospital mortality. Design and Setting. —The SAPS II and the probability of hospital mortality were developed and validated using data from consecutive admissions to 137 adult medical and/or surgical intensive care units in 12 countries. Patients. —The 13 152 patients were randomly divided into developmental (65%) and validation (35%) samples. Patients younger than 18 years, burn patients, coronary care patients, and cardiac surgery patients were excluded. Outcome Measure. —Vital status at hospital discharge. Results. —The SAPS II includes only 17 variables: 12 physiology variables, age, type of admission (scheduled surgical, unscheduled surgical, or medical), and three underlying disease variables (acquired immunodeficiency syndrome, metastatic cancer, and hematologic malignancy). Goodness-of-fit tests indicated that the model performed well in the developmental sample and validated well in an independent sample of patients (P=.883 andP=.104 in the developmental and validation samples, respectively). The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample. Conclusion. —The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis. This is a starting point for future evaluation of the efficiency of intensive care units. (JAMA. 1993;270:2957-2963)
5,836 citations
TL;DR: Mitral E velocity, corrected for the influence of relaxation (i.e., the E/Ea ratio), relates well to mean PCWP and may be used to estimate LV filling pressures.
2,911 citations
"Predictors of successful extracorpo..." refers methods in this paper
...LV filling pressures were estimated with the E/Ea ratio [22, 23]....
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TL;DR: Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin and this study was a 3-year prospective observational study.
928 citations
"Predictors of successful extracorpo..." refers background in this paper
...However, to date, detailed weaning strategies following ECMO initiation for refractory cardiogenic shock have never been reported, and only a few studies have evaluated outcome predictors following ECMO institution [1, 2, 4, 7, 9, 15, 17, 18]....
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..., acute myocardial infarction [7, 11], end-stage dilated cardiomyopathy [9], viral or toxic myocarditis [12–14], complications of cardiac surgery [8, 15, 16], or cardiac arrest [1, 2]....
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TL;DR: ECMO support can rescue 40% of otherwise fatal cardiogenic shock patients but its initiation under cardiac massage or after renal or hepatic failure carried higher risks of intensive care unit death, while fulminant myocarditis had a better prognosis.
Abstract: Objective:To assess the outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock.Design, Setting, and Patients:Refractory cardiogenic shock is almost always lethal without emergency circulatory support, e.g., ECMO. EC
557 citations
"Predictors of successful extracorpo..." refers background in this paper
...However, to date, detailed weaning strategies following ECMO initiation for refractory cardiogenic shock have never been reported, and only a few studies have evaluated outcome predictors following ECMO institution [1, 2, 4, 7, 9, 15, 17, 18]....
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..., acute myocardial infarction [7, 11], end-stage dilated cardiomyopathy [9], viral or toxic myocarditis [12–14], complications of cardiac surgery [8, 15, 16], or cardiac arrest [1, 2]....
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