Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database

Background Single- (SL) and double-lumen (DL) catheters are used in clinical practice for veno-venous extracorporeal membrane oxygenation (V-V ECMO) therapy. However, information is lacking regarding the effects of the cannulation on neurological complications. Methods A retrospective observational study based on data from the Extracorporeal Life Support Organization (ELSO) registry. All adult patients included in the ELSO registry from 2011 to 2018 submitted to a single run of V-V ECMO were analyzed. Propensity score (PS) inverse probability of treatment weighting estimation for multiple treatments was used. The average treatment effect (ATE) was chosen as the causal effect estimate of outcome. The aim of the study was to evaluate differences in the occurrence and the type of neurological complications in adult patients undergoing V-V ECMO when treated with SL or DL cannulas. Results From a population of 6834 patients, the weighted propensity score matching included 6245 patients (i.e., 91% of the total cohort; 4175 with SL and 20,270 with DL cannulation). The proportion of patients with at least one neurological complication was similar in the SL (306, 7.2%) and DL (189, 7.7%; odds ratio 1.10 [95% confidence intervals 0.91–1.32]; p = 0.33). After weighted propensity score, the ATE for the occurrence of least one neurological complication was 0.005 (95% CI − 0.009 to 0.018; p = 0.50). Also, the occurrence of specific neurological complications, including intracerebral hemorrhage, acute ischemic stroke, seizures or brain death, was similar between groups. Overall mortality was similar between patients with neurological complications in the two groups. Conclusions In this large registry, the occurrence of neurological complications was not related to the type of cannulation in patients undergoing V-V ECMO

Large Dual-Lumen Extracorporeal Membrane Oxygenation Cannulas Are Associated with More Intracranial Hemorrhage

Large dual-lumen veno-venous (VV) extracorporeal membrane oxygenation (ECMO) cannulas may increase venous pressure in the brain, contributing to intracranial hemorrhage (ICH). A retrospective cohort study was performed using the extracorporeal life support organization (ELSO) registry. Propensity score matching was used to control for confounding. The rate of ICH and rates of hemolysis, cannula complications, and mortality were compared between patients with a 27 French dual-lumen cannula and patients with a 31 French dual-lumen cannula. Seven hundred forty-four patients were included in the propensity score-matched cohort. Patients were well matched except there was some residual imbalance in body weight and sex. Patients with a 31 French cannula had an ICH rate of 4.3% compared with 1.6% in patients with a 27 French cannula (p = 0.03). There were no differences in hemolysis, cannula complications, or mortality between groups. After controlling for body weight and sex in the matched cohort, ICH odds remained higher in patients with a 31 French cannula; odds ratio = 2.74, (95% CI = 1.06–7.09, p = 0.03). Our study data suggest that large dual-lumen VV ECMO cannulas are associated with more ICH, and thus, smaller cannulas may be preferable when feasible

The HAT Score—A Simple Risk Stratification Score for Coagulopathic Bleeding During Adult Extracorporeal Membrane Oxygenation

Objective The study objective was to create an adult extracorporeal membrane oxygenation (ECMO) coagulopathic bleeding risk score. Design Secondary analysis was performed on an existing retrospective cohort. Pre-ECMO variables were tested for association with coagulopathic bleeding, and those with the strongest association were included in a multivariable model. Using this model, a risk stratification score was created. The score\u27s utility was validated by comparing bleeding and transfusion rates between score levels. Bleeding also was examined after stratifying by nadir platelet count and overanticoagulation. Predictive power of the score was compared against the risk score for major bleeding during anti-coagulation for atrial fibrillation (HAS-BLED). Setting Tertiary care academic medical center. Participants The study comprised patients who received venoarterial or venovenous ECMO over a 3-year period, excluding those with an identified source of surgical bleeding during exploration. Interventions None. Measurements and Main Results Fifty-three (47.3%) of 112 patients experienced coagulopathic bleeding. A 3-variable score—hypertension, age greater than 65, and ECMO type (HAT)—had fair predictive value (area under the receiver operating characteristic curve [AUC] = 0.66) and was superior to HAS-BLED (AUC = 0.64). As the HAT score increased from 0 to 3, bleeding rates also increased as follows: 30.8%, 48.7%, 63.0%, and 71.4%, respectively. Platelet and fresh frozen plasma transfusion tended to increase with the HAT score, but red blood cell transfusion did not. Nadir platelet count less than 50×103/µL and overanticoagulation during ECMO increased the AUC for the model to 0.73, suggesting additive risk. Conclusions The HAT score may allow for bleeding risk stratification in adult ECMO patients. Future studies in larger cohorts are necessary to confirm these findings

Single-Center Experience With Venovenous ECMO for Influenza-Related ARDS

Objectives: This study was designed to determine whether venovenous extracorporeal membrane oxygenation (VV ECMO) reduced mortality in patients with influenza-related acute respiratory distress syndrome (ARDS). Design: A retrospective cohort study was performed. Baseline characteristics of participants were compared and Kaplan-Meier survival analysis was used to compare survival at last medical center follow-up. Cox proportional hazards modeling also was performed to test for univariate associations between salient variables and mortality. Setting: A single-center ECMO referral university hospital. Participants: All patients admitted with influenza-related ARDS during the 2015 to 2016 influenza season. Interventions: Mechanical ventilation alone versus mechanical ventilation and ECMO cannulation. Measurements and Main Results: A total of 26 patients with influenza-related ARDS were included in the cohort. Thirteen patients were treated with VV ECMO while 13 were not. Twelve of the ECMO patients and 8 of the non-ECMO patients were transferred from outside hospitals. Patients treated with ECMO were younger and had less hypertension and diabetes mellitus. There was no difference in baseline sequential organ failure assessment score between the 2 groups. In-hospital mortality for ECMO patients was 15.4% versus 46.7% for patients not treated with ECMO. Survival at last medical center follow-up was better in patients treated with ECMO (p = 0.02). Age, highest blood carbon dioxide level, and treatment without ECMO were all associated with increased mortality. Conclusions: Influenza-related ARDS has a high mortality rate and patients treated only with mechanical ventilation have worse outcome than those managed with VV ECMO. More liberal use of ECMO should be considered in patients with influenza-related ARDS

Long term veno-venous extracorporeal life support without intravenous anticoagulation for diffuse alveolar hemorrhage

Introduction: Diffuse alveolar damage is the histologic hallmark for the acute phase of acute respiratory distress syndrome and can occasionally present as diffuse alveolar hemorrhage. Case report: We report a patient with diffuse alveolar hemorrhage and acute respiratory distress syndrome requiring veno-venous extracorporeal life support for 210 days, who was successfully treated for a period of 130 consecutive days without intravenous anticoagulation. Discussion: Although there are a few brief reports detailing long extracorporeal life support runs, the literature is largely devoid of data regarding long-term extracorporeal life support without full systemic anticoagulation. Regular inspection of the extracorporeal membrane oxygenation circuit is critical because externally visible thrombi may predict internal thrombus generation with the potential for systemic embolization or abrupt oxygenator failure. In our case, multiple circuit and oxygenators changes were required. Conclusion: We have demonstrated that a patient with a contraindication for systemic anticoagulation can safely have veno-venous extracorporeal life support for prolonged periods without catastrophic thrombotic complications

Does weight matter? Outcomes in adult patients on venovenous extracorporeal membrane oxygenation when stratified by obesity class

BACKGROUND: Many believe obesity is associated with higher rates of mortality in the critically ill. The purpose of this retrospective observational study is to evaluate the association between body mass index (BMI) and survival in patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) for acute hypoxic or hypercarbic respiratory failure. METHODS: All of the patients admitted to a dedicated VV ECMO unit were included. Patients \u3c18 years of age, listed for lung transplant, or underweight were excluded. ECMO outcomes, including hospital length of stay and survival to discharge, were analyzed after stratification according to BMI. Multivariate logistic and linear regression techniques were used to assess variables associated with the outcomes of death and length of stay, respectively. RESULTS: One hundred ninety-four patients with a median BMI of 35.7 kg/m2(33-42 kg/m2) were included. Obese patients were older, had higher creatinine levels, and required higher levels of positive end-expiratory pressure and mean airway pressure at time of cannulation. Survival to discharge in any group did not differ when stratified by BMI classification (P =.36). Multivariable regression did not reveal any association with greater odds of death or longer length of stay when controlling for BMI and other variables. CONCLUSIONS: We did not detect an association between obesity and increased mortality in patients requiring VV ECMO for acute hypoxic or hypercarbic respiratory failure. These data suggest that obesity alone should not exclude candidacy for VV ECMO. Evidence for the obesity paradox in this population of VV ECMO patients may be supported by these data