Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study

Cecile Aubron, Allen C Cheng, David Pilcher, Tim Leong, Geoff Magrin, D Jamie Cooper, Carlos Scheinkestel, Vince Pellegrino, Cecile Aubron, Allen C Cheng, David Pilcher, Tim Leong, Geoff Magrin, D Jamie Cooper, Carlos Scheinkestel, Vince Pellegrino

Abstract

Introduction: Mortality of patients on extracorporeal membrane oxygenation (ECMO) remains high. The objectives of this study were to assess the factors associated with outcome of patients undergoing ECMO in a large ECMO referral centre and to compare veno-arterial ECMO (VA ECMO) with veno-venous ECMO (VV ECMO).

Methods: We reviewed a prospectively obtained ECMO database and patients' medical records between January 2005 and June 2011. Demographic characteristics, illness severity at admission, ECMO indication, organ failure scores before ECMO and the ECMO mode and configuration were recorded. Bleeding, neurological, vascular and infectious complications that occurred on ECMO were also collected. Demographic, illness, ECMO support descriptors and complications associated with hospital mortality were analysed.

Results: ECMO was initiated 158 times in 151 patients. VA ECMO (66.5%) was twice as common as VV ECMO (33.5%) with a median duration significantly shorter than for VV ECMO (7 days (first and third quartiles: 5; 10 days) versus 10 days (first and third quartiles: 6; 16 days)). The most frequent complications during ECMO support were bleeding and bloodstream infections regardless of ECMO type. More than 70% of the ECMO episodes were successfully weaned in each ECMO group. The overall mortality was 37.3% (37.1% for the patients who underwent VA ECMO, and 37.7% for the patients who underwent VV ECMO). Haemorrhagic events, assessed by the total of red blood cell units received during ECMO, were associated with hospital mortality for both ECMO types.

Conclusions: Among neurologic, vascular, infectious and bleeding events that occurred on ECMO, bleeding was the most frequent and had a significant impact on mortality. Further studies are needed to better investigate bleeding and coagulopathy in these patients. Interventions that reduce these complications may improve outcome.

Figures

Figure 1
Figure 1
Primary indications of the 158 extracorporeal membrane oxygenation (ECMO) procedures. AMI, acute myocardial infarction; ARDS, acute respiratory distress syndrome; CABG, coronary artery bypass surgery; CM/FM, cardiomyopathy/myocarditis; PE, pulmonary emboli; Tx, transplantation.
Figure 2
Figure 2
Comparison of the number of red blood cell (RBC) units transfused during extracorporeal membrane oxygenation (ECMO) procedures between survivors and non-survivors in different types of ECMO. VA ECMO, veno-arterial ECMO; VV ECMO, veno-venous ECMO.

References

    1. Chen YS, Lin JW, Yu HY, Ko WJ, Jerng JS, Chang WT, Chen WJ, Huang SC, Chi NH, Wang CH, Chen LC, Tsai PR, Wang SS, Hwang JJ, Lin FY. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;17:554–561. doi: 10.1016/S0140-6736(08)60958-7.
    1. Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med. 2009;17:2105–2114. doi: 10.1007/s00134-009-1661-7.
    1. Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators. Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest P, Gattas D, Granger E, Herkes R, Jackson A, McGuinness S, Nair P, Pellegrino V, Pettilä V, Plunkett B, Pye R, Torzillo P, Webb S, Wilson M, Ziegenfuss M. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;17:1888–1895.
    1. Allen S, Holena D, McCunn M, Kohl B, Sarani B. A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients. J Intensive Care Med. 2011;17:13–26. doi: 10.1177/0885066610384061.
    1. Mirabel M, Luyt CE, Leprince P, Trouillet JL, Leger P, Pavie A, Chastre J, Combes A. Outcomes, long-term quality of life, and psychologic assessment of fulminant myocarditis patients rescued by mechanical circulatory support. Crit Care Med. 2011;17:1029–1035. doi: 10.1097/CCM.0b013e31820ead45.
    1. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D. CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;17:1351–1363. doi: 10.1016/S0140-6736(09)61069-2.
    1. Combes A, Pellegrino V. Extracorporeal membrane oxygenation for 2009 influenza A (H1N1)-associated acute respiratory distress syndrome. Semin Respir Crit Care Med. 2011;17:188–194. doi: 10.1055/s-0031-1275531.
    1. Patroniti N, Zangrillo A, Pappalardo F, Peris A, Cianchi G, Braschi A, Iotti GA, Arcadipane A, Panarello G, Ranieri VM, Terragni P, Antonelli M, Gattinoni L, Oleari F, Pesenti A. The Italian ECMO network experience during the 2009 influenza A(H1N1) pandemic: preparation for severe respiratory emergency outbreaks. Intensive Care Med. 2011;17:1447–1457. doi: 10.1007/s00134-011-2301-6.
    1. Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart, lung & circulation. 2008. pp. S41–47.
    1. Marasco SF, Vale M, Pellegrino V, Preovolos A, Leet A, Kras A, Schulberg E, Bergin P, Esmore DS. Extracorporeal membrane oxygenation in primary graft failure after heart transplantation. Ann Thorac Surg. 2010;17:1541–1546. doi: 10.1016/j.athoracsur.2010.05.066.
    1. Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL, Leger P, Pavie A, Chastre J. Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med. 2008;17:1404–1411. doi: 10.1097/CCM.0b013e31816f7cf7.
    1. Camboni D, Philipp A, Lubnow M, Bein T, Haneya A, Diez C, Schmid C, Muller T. Support time-dependent outcome analysis for veno-venous extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 2011;17:341–346.
    1. Kumar TK, Zurakowski D, Dalton H, Talwar S, Allard-Picou A, Duebener LF, Sinha P, Moulick A. Extracorporeal membrane oxygenation in postcardiotomy patients: factors influencing outcome. J Thorac Cardiovasc Surg. 2010;17:330–336. doi: 10.1016/j.jtcvs.2010.02.034.
    1. Steiner CK, Stewart DL, Bond SJ, Hornung CA, McKay VJ. Predictors of acquiring a nosocomial bloodstream infection on extracorporeal membrane oxygenation. J Pediatr Surg. 2001;17:487–492. doi: 10.1053/jpsu.2001.21609.
    1. Hsu MS, Chiu KM, Huang YT, Kao KL, Chu SH, Liao CH. Risk factors for nosocomial infection during extracorporeal membrane oxygenation. J Hosp Infect. 2009;17:210–216. doi: 10.1016/j.jhin.2009.07.016.
    1. Burket JS, Bartlett RH, Vander Hyde K, Chenoweth CE. Nosocomial infections in adult patients undergoing extracorporeal membrane oxygenation. Clin Infect Dis. 1999;17:828–833. doi: 10.1086/515200.
    1. Schutze GE, Heulitt MJ. Infections during extracorporeal life support. J Pediatr Surg. 1995;17:809–812. doi: 10.1016/0022-3468(95)90753-X.
    1. O'Neill JM, Schutze GE, Heulitt MJ, Simpson PM, Taylor BJ. Nosocomial infections during extracorporeal membrane oxygenation. Intensive Care Med. 2001;17:1247–1253. doi: 10.1007/s001340101029.
    1. Sun HY, Ko WJ, Tsai PR, Sun CC, Chang YY, Lee CW, Chen YC. Infections occurring during extracorporeal membrane oxygenation use in adult patients. J Thorac Cardiovasc Surg. 2010;17:1125–1132. doi: 10.1016/j.jtcvs.2010.07.017.
    1. Brown KL, Ridout DA, Shaw M, Dodkins I, Smith LC, O'Callaghan MA, Goldman AP, Macqueen S, Hartley JC. Healthcare-associated infection in pediatric patients on extracorporeal life support: The role of multidisciplinary surveillance. Pediatr Crit Care Med. 2006;17:546–550. doi: 10.1097/01.PCC.0000243748.74264.CE.
    1. Lidegran MK, Mosskin M, Ringertz HG, Frenckner BP, Linden VB. Cranial CT for diagnosis of intracranial complications in adult and pediatric patients during ECMO: Clinical benefits in diagnosis and treatment. Acad Radiol. 2007;17:62–71. doi: 10.1016/j.acra.2006.10.004.
    1. Montgomery VL, Strotman JM, Ross MP. Impact of multiple organ system dysfunction and nosocomial infections on survival of children treated with extracorporeal membrane oxygenation after heart surgery. Crit Care Med. 2000;17:526–531. doi: 10.1097/00003246-200002000-00040.
    1. Aubron C, Cheng AC, Pilcher D, Leong T, Magrin G, Cooper DJ, Scheinkestel C, Pellegrino V. Infections acquired by adults who receive extracorporeal membrane oxygenation: risk factors and outcome. Infect Control Hosp Epidemiol. 2013;17:24–30. doi: 10.1086/668439.
    1. Balasubramanian SK, Tiruvoipati R, Amin M, Aabideen KK, Peek GJ, Sosnowski AW, Firmin RK. Factors influencing the outcome of paediatric cardiac surgical patients during extracorporeal circulatory support. J Cardiothorac Surg. 2007;17:4. doi: 10.1186/1749-8090-2-4.
    1. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;17:707–710. doi: 10.1007/BF01709751.
    1. Schmidt M, Tachon G, Devilliers C, Muller G, Hekimian G, Bréchot N, Merceron S, Luyt CE, Trouillet JL, Chastre J, Leprince P, Combes A. Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med. 2013;17:838–846. doi: 10.1007/s00134-012-2785-8.
    1. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988;17:128–140. doi: 10.1016/0196-6553(88)90053-3.
    1. Bartlett RH, Gattinoni L. Current status of extracorporeal life support (ECMO) for cardiopulmonary failure. Minerva Anestesiol. 2010;17:534–540.
    1. Hemmila MR, Rowe SA, Boules TN, Miskulin J, McGillicuddy JW, Schuerer DJ, Haft JW, Swaniker F, Arbabi S, Hirschl RB, Bartlett RH. Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg. 2004;17:595–605. discussion 605-607.
    1. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;17:409–417. doi: 10.1056/NEJM199902113400601.
    1. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008;17:2667–2674. doi: 10.1097/CCM.0b013e3181844677.
    1. Kasirajan V, Smedira NG, McCarthy JF, Casselman F, Boparai N, McCarthy PM. Risk factors for intracranial hemorrhage in adults on extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 1999;17:508–514. doi: 10.1016/S1010-7940(99)00061-5.
    1. Wang J, Han J, Jia Y, Zeng W, Shi J, Hou X, Meng X. Early and intermediate results of rescue extracorporeal membrane oxygenation in adult cardiogenic shock. Ann Thorac Surg. 2009;17:1897–1903. doi: 10.1016/j.athoracsur.2009.08.009.
    1. Bisdas T, Beutel G, Warnecke G, Hoeper MM, Kuehn C, Haverich A, Teebken OE. Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support. Ann Thorac Surg. 2011;17:626–631. doi: 10.1016/j.athoracsur.2011.02.018.
    1. Kolovos NS, Bratton SL, Moler FW, Bove EL, Ohye RG, Bartlett RH, Kulik TJ. Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery. Ann Thorac Surg. 2003;17:1435–1441. doi: 10.1016/S0003-4975(03)00898-1. discussion 1441-1442.
    1. Thiagarajan RR, Brogan TV, Scheurer MA, Laussen PC, Rycus PT, Bratton SL. Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation in adults. Ann Thorac Surg. 2009;17:778–785. doi: 10.1016/j.athoracsur.2008.12.079.
    1. Investigators TBOS. Transfusion practice and guidelines in Australian and New Zealand intensive care units. Intensive Care Med. 2010;17:1138–1146.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe