Anticoagulation and Transfusions Management in Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Assessment of Factors Associated With Transfusion Requirements and Mortality

2017 ◽  
Vol 34 (8) ◽  
pp. 630-639 ◽  
Author(s):  
Gennaro Martucci ◽  
Giovanna Panarello ◽  
Giovanna Occhipinti ◽  
Veronica Ferrazza ◽  
Fabio Tuzzolino ◽  
...  
Keyword(s):  
Septic Shock ◽  
Acute Respiratory Distress Syndrome ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Factors Associated ◽  
Membrane Oxygenation ◽  
Transfusion Requirements ◽  
Vv Ecmo

Purpose: We describe an approach for anticoagulation and transfusions in veno-venous–extracorporeal membrane oxygenation (VV-ECMO), evaluating factors associated with higher transfusion requirements, and their impact on mortality. Methods: Observational study on consecutive adults supported with VV-ECMO for acute respiratory distress syndrome (ARDS). We targeted an activated partial thromboplastin time of 40 to 50 seconds and a hematocrit of 24% to 30%. Univariate and multiple analyses were done to evaluate factors associated with transfusion requirements and the influence of increasing transfusions on mortality during ECMO. Results: In a cohort of 82 VV-ECMO patients (PRedicting dEath for SEvere ARDS on VV-ECMO [PRESERVE] score: 4, Interquartile range [IQR]: 3-5, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction [RESP] score: 2, IQR: 2-4), 76 (92.7%) patients received at least 1 unit of packed red blood cells (PRBCs) during the intensive care unit stay related to ECMO (median PRBC/d 156 mL, IQR: 93-218; median ECMO duration 14 days, IQR: 8-22). A higher requirement of PRBC transfusions was associated with pre-ECMO hematocrit, and with the following conditions during ECMO: platelet nadir, antithrombin III (ATIII), and stage 3 of acute kidney injury (all P < .05). Sixty-two (75.6%) patients survived ECMO. Pre-ECMO hospital stay, PRBC transfusion, and septic shock were associated with mortality (all P < .05). The adjusted odds ratio for each 100mL/d increase in PRBC transfusion was 1.9 (95% confidence interval [CI]: 1.1-3.2, P = .01); for the development of septic shock it was 15.4 (95% CI: 1.7-136.8, P = .01), and for each day of pre-ECMO stay it was 1.1 (95% CI: 1-1.2, P = .04). Conclusion: Implementation of a comprehensive protocol for anticoagulation and transfusions in VV-ECMO for ARDS resulted in a low PRBC requirement, and an ECMO survival comparable to data in the literature. Lower ATIII emerged as a factor associated with increased need for transfusions. Higher PRBC transfusions were associated with ECMO mortality. Further investigations are needed to better understand the right level of anticoagulation in ECMO, and the factors to take into account in order to manage personalized transfusion practice in this select setting.

Does acute kidney injury affect survival in adults with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation?

Perfusion ◽  
2018 ◽  
Vol 33 (5) ◽  
pp. 375-382 ◽  
Author(s):  
Richard Devasagayaraj ◽  
Nicholas C. Cavarocchi ◽  
Hitoshi Hirose
Keyword(s):  
Acute Kidney Injury ◽  
Renal Failure ◽  
Acute Respiratory Distress Syndrome ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Kidney Injury ◽  
Membrane Oxygenation ◽  
Vv Ecmo

Introduction: Patients who develop severe acute respiratory distress syndrome (ARDS) despite full medical management may require veno-venous extracorporeal membrane oxygenation (VV ECMO) to support respiratory function. Survival outcomes remain unclear in those who develop acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) during VV ECMO for isolated severe respiratory failure in adult populations. Methods: A retrospective chart review (2010-2016) of patients who underwent VV ECMO for ARDS was conducted with university institutional review board (IRB) approval. Patients supported by veno-arterial ECMO were excluded. AKI was defined by acute renal failure receiving CRRT and the outcomes of patients on VV ECMO were compared between the AKI and non-AKI groups. Results: We identified 54 ARDS patients supported by VV ECMO (mean ECMO days 12 ± 6.7) with 16 (30%) in the AKI group and 38 (70%) in the non-AKI group. No patient had previous renal failure and the serum creatinine was not significantly different between the two groups at the time of ECMO initiation. The AKI group showed a greater incidence of complications during ECMO, including liver failure (38% vs. 5%, p=0.002) and hemorrhage (94% vs. 45%, p=0.0008). ECMO survival of the AKI group (56% [9/16]) was inferior to the non-AKI group (87% [33/38], p=0.014). Conclusions: Our study demonstrated that VV ECMO successfully manages patients with severe isolated lung injury. However, once patients develop AKI during VV ECMO, they are likely to further develop multi-organ dysfunction, including hepatic and hematological complications, leading to inferior survival.

Does Earlier Cannulation With Veno-Venous Extracorporeal Membrane Oxygenation in Adult Patients With Acute Respiratory Distress Syndrome Decrease Duration of Artificial Mechanical Ventilation?

2020 ◽  
Vol 13 (2) ◽  
pp. 148-155
Author(s):  
Christine Hartner ◽  
Jacqueline Ochsenreither ◽  
Kenneth Miller ◽  
Michael Weiss
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Lung Injury ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Adult Patients ◽  
Membrane Oxygenation ◽  
Vv Ecmo

BackgroundAcute respiratory distress syndrome (ARDS) is characterized by an acute, diffuse, inflammatory lung injury, leading to increased alveolar capillary permeability, increased lung weight, and loss of aerated lung tissue (Fan, Brodie, & Slutsky, 2018). Primary treatment for ARDS is artificial mechanical ventilation (AMV) (Wu, Huang, Wu, Wang, & Lin, 2016). Given recent advances in technology, the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) to treat severe ARDS is growing rapidly (Combes et al., 2014).ObjectiveThis 49-month quantitative, retrospective inpatient EMR chart review compared if cannulation with VV-ECMO up to and including 48 hours of admission and diagnosis in adult patients 30 to 65 years of age diagnosed with ARDS, decreased duration on AMV, as compared to participants who were cannulated after 48 hours of admission and diagnosis with ARDS.MethodsA total of 110 participants were identified as receiving VV-ECMO during the study timeframe. Of the 58 participants who met all inclusion criteria, 39 participants were cannulated for VV-ECMO within 48 hours of admission and diagnosis with ARDS, and 19 participants were cannulated with VV-ECMO after 48 hours of admission and diagnosis with ARDS.ResultsData collected identified no statistically significant (p < 0.579) difference in length of days on AMV between participant groups.ConclusionsFurther studies are needed to determine if earlier initiation of VV-ECMO in adult patients with ARDS decrease time on AMV.Implications for NursingAlthough the results related to length of time on AMV did not produce statistical significance, the decreased duration of AMV in the participants who were cannulated within 48 hours (21 days vs. 27 days) may support several benefits associated with this participant population including increased knowledge of healthcare providers, decreased lung injury, earlier discharge which decreases hospital and patient cost, ability for patients to communicate sooner, decreased risk of pulmonary infection, decreased length of stay, decreased cost, and improved patient and family satisfaction.

Sedation and analgesia requirements during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome patients

Perfusion ◽  
2021 ◽  
pp. 026765912110521
Author(s):  
Xingshu Ren ◽  
Yuhang Ai ◽  
Lina Zhang ◽  
Chunguang Zhao ◽  
Li Li ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Linear Correlation ◽  
Distress Syndrome ◽  
Membrane Oxygenation ◽  
Venovenous Extracorporeal Membrane Oxygenation ◽  
Sedation And Analgesia ◽  
Vv Ecmo

Introduction: The purpose of this study is to describe sedation and analgesia management, and identify the factors associated with increased demand for medication in acute respiratory distress syndrome (ARDS) patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO). Methods: This retrospective, single-center study included consecutive adult ARDS patients who received VV-ECMO for at least 24 hours from January 2018 to December 2020 in a comprehensive intensive care unit. The electronic medical records were retrospectively reviewed to collect data. Results: Forty-two adult patients meeting the inclusion criteria were included in the study. Midazolam, sufentanil, and remifentanil were main sedatives and analgesics used in the patient population. The morphine equivalents, representative of the demand for opioids, was 512.9 (IQR, 294.5, 798.2) mg/day. The midazolam equivalents, representative of benzodiazepine requirement, was 279.6 (IQR, 208.8, 384.5) mg/day. The levels of serum creatinine, total bilirubin, lactic acid, SOFA score, and APACHE Ⅱ score at cannulation were found to be associated with opiate or benzodiazepine requirements. Multiple linear regression analysis revealed a linear correlation between midazolam equivalents and morphine equivalents (p < 0.001). In addition, there was a negative linear correlation between Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score and midazolam equivalents (p = 0.024). Conclusions: The sedation and analgesia requirements of ARDS patients receiving VV-ECMO often increase simultaneously. More large-scale studies are needed to confirm the risk factors for increased sedation and analgesia needs in patients supported on VV-ECMO.

scholarly journals Use of hemoadsorption in sepsis-associated ECMO-dependent severe ARDS: A case series

2019 ◽  
Vol 21 (2) ◽  
pp. 183-190 ◽  
Author(s):  
Klaus Kogelmann ◽  
Morten Scheller ◽  
Matthias Drüner ◽  
Dominik Jarczak
Keyword(s):  
Septic Shock ◽  
Acute Respiratory Distress Syndrome ◽  
Renal Replacement Therapy ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Continuous Renal Replacement Therapy ◽  
Distress Syndrome ◽  
Case Series ◽  
Membrane Oxygenation

Introduction Acute respiratory distress syndrome in the context of severe sepsis and septic shock represents a serious clinical disorder. A recent case series in patients with septic shock and renal failure receiving hemoadsorption treatment showed rapid hemodynamic stabilization and increased survival, particularly in pneumonia patients and in those where therapy was started early. We hypothesized that patients suffering from pneumonia and refractory acute respiratory distress syndrome to the extent that they required extracorporeal membrane oxygenation support could possibly demonstrate the most pronounced benefit from the treatment. Methods We assessed the association of hemoadsorption treatment with hemodynamics, ventilation, and outcome variables in a set of patients with septic shock, acute respiratory distress syndrome, need for veno-venous extracorporeal membrane oxygenation, and continuous renal replacement therapy. Results Key observations include a significant stabilization in hemodynamics as evidenced by a marked decrease in catecholamine need, which was paralleled by a clear reduction in hyperlactatemia. Respiratory variables improved significantly. In addition, severity of illness and overall organ dysfunction showed a considerable decrease during the course of treatment. Observed mortality was approximately half as predicted by APACHE II. Treatment with CytoSorb was safe and well tolerated with no device-related adverse events. Discussion This is the first case series reporting on outcome variables associated to CytoSorb therapy in critically ill patients with septic shock, acute respiratory distress syndrome, veno-venous extracorporeal membrane oxygenation, and continuous renal replacement therapy. Based on our observations in this small case series, CytoSorb might represent a potentially promising therapy option for patients with refractory extracorporeal membrane oxygenation-dependent acute respiratory distress syndrome in the context of septic shock.

scholarly journals Application of veno-venous extracorporeal membrane oxygenation in lymphoma patients with severe acute respiratory distress syndrome

2021 ◽  
Vol 57 (1) ◽  
pp. 109-113
Author(s):  
Dorian Tokmadžić ◽  
Kazimir Juričić ◽  
Matilda Novosel ◽  
Alen Protić
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Hodgkin’S Lymphoma ◽  
Distress Syndrome ◽  
Ecmo Support ◽  
Hodgkin's Lymphoma ◽  
Membrane Oxygenation ◽  
Vv Ecmo

Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.

scholarly journals Association of COVID-19 with Intracranial Hemorrhage during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A 10-Year Retrospective Observational Study

2021 ◽  
Vol 11 (1) ◽  
pp. 28
Author(s):  
Tobias Pantel ◽  
Kevin Roedl ◽  
Dominik Jarczak ◽  
Yuanyuan Yu ◽  
Daniel Peter Frings ◽  
...  
Keyword(s):  
Acute Respiratory Distress Syndrome ◽  
Extracorporeal Membrane Oxygenation ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Intracranial Hemorrhage ◽  
Distress Syndrome ◽  
Cranial Computed Tomography ◽  
Cox Regression Analysis ◽  
Membrane Oxygenation ◽  
Vv Ecmo

Extracorporeal membrane oxygenation (ECMO) is potentially lifesaving for patients with acute respiratory distress syndrome (ARDS) but may be accompanied by serious adverse events, including intracranial hemorrhage (ICRH). We hypothesized that ICRH occurs more frequently in patients with COVID-19 than in patients with ARDS of other etiologies. We performed a single-center retrospective analysis of adult patients treated with venovenous (vv-) ECMO for ARDS between January 2011 and April 2021. Patients were included if they had received a cranial computed tomography (cCT) scan during vv-ECMO support or within 72 h after ECMO removal. Cox regression analysis was used to identify factors associated with ICRH. During the study period, we identified 204 patients with vv-ECMO for ARDS, for whom a cCT scan was available. We observed ICRH in 35.4% (n = 17/48) of patients with COVID-19 and in 16.7% (n = 26/156) of patients with ARDS attributable to factors other than COVID-19. COVID-19 (HR: 2.945; 95%; CI: 1.079–8.038; p = 0.035) and carboxyhemoglobin (HR: 0.330; 95%; CI: 0.135–0.806; p = 0.015) were associated with ICRH during vv-ECMO. In patients receiving vv-ECMO, the incidence of ICRH is doubled in patients with COVID-19 compared to patients suffering from ARDS attributable to other causes. More studies on the association between COVID-19 and ICRH during vv-ECMO are urgently needed to identify risk patterns and targets for potential therapeutic interventions.

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