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Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO)

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Intensive Care".

Deadline for manuscript submissions: closed (31 August 2024) | Viewed by 18945

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Dr. Martin Balik

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1. Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
2. General University Hospital in Prague, U Nemocnice 2, 12808 Prague, Czech Republic
Interests: extracorporeal oxygenation; respiratory failure; adult respiratory distress syndrome; intensive care; extracorporeal circulation; critical care

Special Issue Information

Dear Colleagues,

Extracorporeal membrane oxygenation (ECMO) has gained popularity as a rescue tool in severe circulatory and/or respiratory failure. Various ECMO modalities are applied to bridge patients in critical states, yet evidence regarding the effectivness of these modalities is missing in the literature. Nonetheless, we are entering a stage of a routine application by qualified staff in highly specialised centres in which launching a trial with a control group denied ECMO would seem unethical. At the same time, intensive care practitioners are searching for outcomes for their demanding patients and continuously strive to avoid complications related to very invasive and costly methods of treatment. The application of ECMO entered a new stage during the SARS-CoV-2 pandemic. The nature of COVID-19-related severe pneumonitis and ARDS changed a paradigm of mechanical ventilation, with the stress factors and inflammation of the endothelium leading to novel findings in ECMO-related coagulation and homeostatic side effects. In this Special Issue, we plan to gather up-to-date publications on important ECMO-related complications as well as on factors outlining the prognosis of patients.

Dr. Martin Balik
Guest Editor

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Keywords

extracorporeal membrane oxygenation
obesity
ARDS
COVID-19
cardiogenic shock
anticoagulation
cardiac arrest

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Published Papers (10 papers)

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Research

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13 pages, 998 KiB

Open AccessArticle

Fit-for-Future: Lessons Learned from the COVID-19 Pandemic in Primary Extracorporeal Membrane Oxygenation (ECMO) Transports of Acute Respiratory Distress Syndrome (ARDS) Patients

by Stefan Muenster, Silvia Schumacher, Mathias Schmandt, Stefan Kreyer, Jens Martin Poth, Christian Putensen, Jens-Christian Schewe and Stefan Felix Ehrentraut

J. Clin. Med. 2024, 13(18), 5391; https://doi.org/10.3390/jcm13185391 - 12 Sep 2024

Viewed by 952

Abstract

(1) Background: The COVID-19 pandemic presented significant challenges in managing acute respiratory distress syndrome (ARDS), with extracorporeal membrane oxygenation (ECMO) being a critical but resource-intensive intervention. (2) Methods: This retrospective study analyzed veno-venous (VV) ECMO therapy in ARDS patients before and during the pandemic at a high-volume ECMO center in Germany. The study used a reduced ECMO team (one medical and one nursing specialist) to optimize patient care with limited resources, aiming to offer insights for future pandemic management. Data from 181 adult patients (age ≥ 18) with severe ARDS were analyzed: 57 pre-pandemic and 124 during the pandemic. (3) Results: Despite increased isolation measures during the pandemic (25% pre-COVID-19 vs. 79% during COVID-19, p < 0.0001), there was no significant change in transportation mode (ground vs. air) or ECMO implantation times at local hospitals. Similarly, time and distance for primary ECMO transport remained unchanged between the two periods. Complication rates related to ECMO circuit placement and prolonged transport were also insignificant across groups. However, ECMO therapy duration (median 12 days pre-COVID-19 vs. 19 days during COVID-19, p < 0.0001) and hospital stays (median 3 days pre-COVID-19 vs. 7 days during COVID-19, p < 0.01) were longer during the pandemic. Mortality rates were also higher during the pandemic (49% pre-COVID-19 vs. 65% during COVID-19, p < 0.05). (4) Conclusions: In conclusion, a reduced ECMO team proved to be an effective resource-saving strategy that maintained high-quality care with low complication rates, despite the additional challenges posed by pandemic-related isolation measures. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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10 pages, 1438 KiB

Open AccessArticle

Polyuria in COVID-19 Patients Undergoing Extracorporeal Membrane Oxygenation

by Johannes Rausch, Andrea U. Steinbicker, Benjamin Friedrichson, Armin N. Flinspach, Kai Zacharowski, Elisabeth H. Adam and Florian Piekarski

J. Clin. Med. 2024, 13(14), 4081; https://doi.org/10.3390/jcm13144081 - 12 Jul 2024

Viewed by 1108

Abstract

Background: The COVID-19 pandemic caused an unprecedented number of patients requiring veno-venous extracorporeal membrane oxygenation (VV ECMO) therapy. Clinical polyuria was observed at our ECMO center during the pandemic. This study aims to investigate the incidence, potential causes, and implications of polyuria in COVID-19 patients undergoing VV ECMO therapy. Methods: Here, 68 SARS-CoV-2 positive patients receiving VV ECMO were stratified into the following two groups: polyuria (PU), characterized by an average urine output of ≥3000 mL/day within seven days following initiation, and non-polyuria (NPU), defined by <3000 mL/day. Polyuria in ECMO patients occurred in 51.5% (n = 35) within seven days after ECMO initiation. No significant difference in mortality was observed between PU and NPU groups (60.0% vs. 60.6%). Differences were found in the fluid intake (p < 0.01) and balance within 24 h (p = 0.01), creatinine (p < 0.01), plasma osmolality (p = < 0.01), lactate (p < 0.01), urea (p < 0.01), and sodium levels (p < 0.01) between the groups. Plasma osmolality increased (p < 0.01) after ECMO initiation during the observation period. Results: Diuresis and plasma osmolality increased during VV ECMO treatment, while mortality was not affected by polyuria. Conclusions: Polyuria does not appear to impact mortality. Further investigations are warranted to elucidate its underlying mechanisms and clinical implications in the context of VV ECMO therapy and COVID-19 management. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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11 pages, 1779 KiB

Open AccessArticle

Injection Site Matters: A Comparative Analysis of Transpulmonary Thermodilution via Simultaneous Femoral and Jugular Indicator Injections under Veno-Venous Extracorporeal Membrane Oxygenation Therapy

by Sabrina Kopp, Johannes Windschmitt, Lena Schnauder, Thomas Münzel, Karsten Keller, Susanne Karbach, Lukas Hobohm, Philipp Lurz, Ingo Sagoschen and Johannes Wild

J. Clin. Med. 2024, 13(8), 2334; https://doi.org/10.3390/jcm13082334 - 17 Apr 2024

Viewed by 1267

Abstract

Background: The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) in acute lung failure has witnessed a notable increase. The PiCCO system is frequently used for advanced hemodynamic monitoring in this cohort. Our study aimed to investigate whether the choice of indicator injection site (jugular vs. femoral) in patients undergoing vv-ECMO therapy affects transpulmonary thermodilution (TPTD) measurements using the PiCCO^® device (Pulsion Medical Systems SE, Munich, Germany). Methods: In a retrospective single-center analysis, we compared thermodilution-derived hemodynamic parameters after simultaneous jugular and femoral injections in 28 measurements obtained in two patients with respiratory failure who were undergoing vv-ECMO therapy. Results: Elevated values of the extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end-diastolic volume index (GEDVI) were observed following femoral indicator injection compared to jugular indicator injection (EVLWI: 29.3 ± 10.9 mL/kg vs. 18.3 ± 6.71 mL/kg, p = 0.0003; ITBVI: 2163 ± 631 mL/m² vs. 806 ± 125 mL/m², p < 0.0001; GEDVI: 1731 ± 505 mL/m² vs. 687 ± 141 mL/m², p < 0.0001). The discrepancy between femoral and jugular measurements exhibited a linear correlation with extracorporeal blood flow (ECBF). Conclusions: In a PiCCO®-derived hemodynamic assessment of patients on vv-ECMO, the femoral indicator injection, as opposed to the jugular injection, resulted in an overestimation of all index parameters. This discrepancy can be attributed to mean transit time (MTt) and downslope time-dependent (DSt) variations in GEDVI and cardiac function index and is correlated with ECBF. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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8 pages, 772 KiB

Open AccessCommunication

Predictive Value of Serial Model of End-Stage Liver Disease Score Determination in Patients with Postcardiotomy Extracorporeal Membrane Oxygenation

by Oliver Sommerfeld, Caroline Neumann, Marcel-Dominic Pfeifer, Gloria Faerber, Hristo Kirov, Christian von Loeffelholz, Torsten Doenst and Christoph Sponholz

J. Clin. Med. 2024, 13(7), 1856; https://doi.org/10.3390/jcm13071856 - 23 Mar 2024

Viewed by 819

Abstract

(1) Background: The use of extracorporeal membrane oxygenation (ECMO) in low cardiac output states after cardiac surgery may aid in patient recovery. However, in some patients, the clinical state may worsen, resulting in multiple organ failure and high mortality rates. In these circumstances, calculating a model of end-stage liver disease (MELD) score was shown to determine organ dysfunction and predicting mortality. (2) Methods: We evaluated whether serial MELD score determination increases mortality prediction in patients with postcardiotomy ECMO support. (3) Results: Statistically, a cutoff of a 2.5 MELD score increase within 48 h of ECMO initiation revealed an AUC of 0.722. Further, we found a significant association between hospital mortality and 48 h MELD increase (HR: 2.5, 95% CI: 1.33–4.75, p = 0.005) after adjustment for possible confounders. (4) Conclusions: Therefore, serial MELD score determinations on alternate days may be superior to single measurements in this special patient cohort. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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10 pages, 851 KiB

Open AccessArticle

Bleeding Complications in COVID-19 Critically Ill ARDS Patients Receiving VV-ECMO Therapy

by Armin Niklas Flinspach, Dorothée Bobyk, Kai Zacharowski, Vanessa Neef and Florian Jürgen Raimann

J. Clin. Med. 2023, 12(19), 6415; https://doi.org/10.3390/jcm12196415 - 9 Oct 2023

Cited by 2 | Viewed by 1412

Abstract

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) therapy is rapidly expanding worldwide, yet this therapy has a serious risk of bleeding. Whether coagulation-activating viral infections such as COVID-19 may have an impact on the risk of bleeding is largely unknown. This study conducted a monocentric investigation of severely affected COVID-19 patients receiving VV-ECMO therapy with regard to the occurrence and possible influences of minor and major bleeding and transfusion requirements. Among the 114 included study patients, we were able to assess more than 74,000 h of VV-ECMO therapy. In these, 103 major bleeding events and 2283 minor bleeding events were detected. In total, 1396 red blood concentrates (RBCs) were administered. A statistically significant correlation with the applied anticoagulation or demographic data of the patients was not observed. Contrary to the frequently observed thromboembolic complications among COVID-19 patients, patients with VV-ECMO therapy, even under low-dose anticoagulation, show a distinct bleeding profile, especially of minor bleeding, with a substantial need for blood transfusions. COVID-19 patients show a tendency to have frequent bleeding and require repeated RBC transfusions during VV-ECMO. This fact might not be solely explained by the mechanical alteration of ECMO or anticoagulation. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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10 pages, 3696 KiB

Open AccessArticle

Prognostic Impact of Serial Imaging in Severe Acute Respiratory Distress Syndrome on the Extracorporeal Membrane Oxygenation

by Martin Balik, Michal Maly, Michal Huptych, Masego Candy Mokotedi and Lukas Lambert

J. Clin. Med. 2023, 12(19), 6367; https://doi.org/10.3390/jcm12196367 - 5 Oct 2023

Cited by 1 | Viewed by 1188

Abstract

Background: The impact of serial imaging on the outcome of ICU patients has not been studied specifically in patients with high illness severity. Methods: The authors sought a relationship between the numbers of antero-posterior supine chest X-rays (CXR), computed tomography (CT) examinations, and outcome in a cohort of 292 patients with severe COVID-19 ARDS collected over 24 months in a high-volume ECMO center with established ultrasound and echocardiographic diagnostics. Of the patients, 172 (59%) were obese or morbidly obese, and 119 (41%) were treated with ECMO. Results: The median number of CXRs was eight per 14 days of the length of stay in the ICU. The CXR rate was not related to ICU survival (p = 0.37). Patients required CT scanning in 26.5% of cases, with no relationship to the outcome except for the better ICU survival of the ECMO patients without a need for a CT scan (p = 0.01). The odds ratio for survival associated with ordering a CT scan in an ECMO patient was 0.48, p = 0.01. The calculated savings for not routinely requesting a whole-body CT scan in every patient were 98.685 EUR/24 months. Conclusions: Serial imaging does not impact the survival rates of patients with severe ARDS. Extracorporeal membrane oxygenation patients who did not need CT scanning had significantly better ICU outcomes. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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Review

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13 pages, 1877 KiB

Open AccessReview

The Role of Extracorporeal Membrane Oxygenation ECMO in Accidental Hypothermia and Rewarming in Out-of-Hospital Cardiac Arrest Patients—A Literature Review

by Hubert Hymczak, Aleksandra Gołąb, Sylweriusz Kosiński, Paweł Podsiadło, Dorota Sobczyk, Rafał Drwiła, Bogusław Kapelak, Tomasz Darocha and Dariusz Plicner

J. Clin. Med. 2023, 12(21), 6730; https://doi.org/10.3390/jcm12216730 - 25 Oct 2023

Viewed by 2034

Abstract

Accidental hypothermia, defined as an unintentional drop of the body core temperature below 35 °C, is one of the causes of cardiocirculatory instability and reversible cardiac arrest. Currently, extracorporeal life support (ECLS) rewarming is recommended as a first-line treatment for hypothermic cardiac arrest patients. The aim of the ECLS rewarming is not only rapid normalization of core temperature but also maintenance of adequate organ perfusion. Veno-arterial extracorporeal membrane oxygenation (ECMO) is a preferred technique due to its lower anticoagulation requirements and potential to prolong circulatory support. Although highly efficient, ECMO is acknowledged as an invasive treatment option, requiring experienced medical personnel and is associated with the risk of serious complications. In this review, we aimed to discuss the clinical aspects of ECMO management in severely hypothermic cardiac arrest patients. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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18 pages, 2825 KiB

Open AccessReview

Extracorporeal Membrane Oxygenation for Septic Shock in Adults and Children: A Narrative Review

by Lars Mikael Broman, Olga Dubrovskaja and Martin Balik

J. Clin. Med. 2023, 12(20), 6661; https://doi.org/10.3390/jcm12206661 - 20 Oct 2023

Cited by 2 | Viewed by 4422

Abstract

Refractory septic shock is associated with a high risk of death. Circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) may function as a bridge to recovery, allowing for the treatment of the source of the sepsis. Whilst VA ECMO has been accepted as the means of hemodynamic support for children, in adults, single center observational studies show survival rates of only 70–90% for hypodynamic septic shock. The use of VA ECMO for circulatory support in hyperdynamic septic shock with preserved cardiac output or when applied late during cardio-pulmonary resuscitation is not recommended. With unresolving septic shock and a loss of ventriculo–arterial coupling, stress cardiomyopathy often develops. If the cardiac index (CI) approaches subnormal levels (CI < 2.5 L/min m⁻²) that do not match low systemic vascular resistance with a resulting loss of vital systemic perfusion pressure, VA ECMO support should be considered. A further decrease to the level of cardiogenic shock (CI < 1.8 L/min m⁻²) should be regarded as an indication for VA ECMO insertion. For patients who maintain a normal-to-high CI as part of their refractory vasoparalysis, VA ECMO support is justified in children and possibly in patients with a low body mass index. Extracorporeal support for septic shock should be limited to high-volume ECMO centers. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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10 pages, 1304 KiB

Open AccessReview

Growing Evidence for LV Unloading in VA ECMO

by Jan Soltes, Daniel Rob, Petra Kavalkova, Jan Bruthans and Jan Belohlavek

J. Clin. Med. 2023, 12(18), 6069; https://doi.org/10.3390/jcm12186069 - 20 Sep 2023

Cited by 1 | Viewed by 3130

Abstract

Impressively increasing availability of mechanical circulatory/cardiac support systems (MCSs) worldwide, together with the deepening of the knowledge of critical care medical practitioners, has inevitably led to the discussion about further improvements of intensive care associated to MCS. An appealing topic of the left ventricle (LV) overload related to VA ECMO support endangering myocardial recovery is being widely discussed within the scientific community. Unloading of LV leads to the reduction in LV end-diastolic pressure, reduction in pressure in the left atrium, and decrease in the LV thrombus formation risk. Consequently, better conditions for myocardial recovery, with comfortable filling pressures and a better oxygen delivery/demand ratio, are achieved. The combination of VA ECMO and Impella device, also called ECPELLA, seems to be a promising strategy that may bring the improvement of CS mortality rates. The series of presented trials and meta-analyses clearly showed the potential benefits of this strategy. However, the ongoing research has brought a series of new questions, such as whether Impella itself is the only appropriate unloading modality, or any other approach to unload LV would be beneficial in the same way. Benefits and potential risks of LV unloading and its timing are being discussed in this current review. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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12 pages, 682 KiB

Open AccessReview

Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure

by Filip Burša, Michal Frelich, Peter Sklienka, Ondřej Jor and Jan Máca

J. Clin. Med. 2023, 12(16), 5196; https://doi.org/10.3390/jcm12165196 - 9 Aug 2023

Cited by 4 | Viewed by 1632

Abstract

Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid–base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure. Full article

(This article belongs to the Special Issue Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation (ECMO))

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