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Ravi R. Thiagarajan - One of the best experts on this subject based on the ideXlab platform.
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hospital acquired infection in pediatric subjects with congenital heart disease postcardiotomy supported on Extracorporeal membrane oxygenation
Pediatric Critical Care Medicine, 2020Co-Authors: Elizabeth A Herrup, Peter Rycus, Ravi R. Thiagarajan, Mahsun Yuerek, Heather Griffis, James T Connelly, Joshua J BlinderAbstract:Objective To determine prevalence of and risk factors for infection in pediatric subjects with congenital heart disease status postcardiotomy supported on Extracorporeal membrane oxygenation, as well as outcomes of these subjects. Design Retrospective cohort from the Extracorporeal Life Support Organization. Setting U.S. and international medical centers providing care to children with congenital heart disease status postcardiotomy. Patients Critically ill pediatric subjects less than 8 years old admitted to medical centers between January 1, 2013, and December 31, 2015, who underwent cardiac surgery for congenital heart disease and required Extracorporeal membrane oxygenation support within the first 14 postoperative days. Subjects were excluded if they underwent orthotopic heart transplantation, required preoperative Extracorporeal membrane oxygenation, and had more than one postoperative Extracorporeal membrane oxygenation run. Interventions None. Measurements and main results A total of 1,314 Extracorporeal membrane oxygenation subject encounters in the Extracorporeal Life Support Organization registry met inclusion criteria. Neonates comprised 53% (n = 696) of the cohort, whereas infants made up 33% (n = 435). Of the 994 subjects with Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categorizable surgery, 33% (n = 325) were in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 23% (n = 231) in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 5. While on Extracorporeal membrane oxygenation, 229 subjects (17%) acquired one or more Extracorporeal membrane oxygenation-related infections, which represents an occurrence rate of 67 infections per 1,000 Extracorporeal membrane oxygenation days. Gram-negative (62%) and Gram-positive (42%) infections occurred most commonly. Forty percent had positive blood cultures. Infants and children were at higher infection risk compared with neonatal subjects; subjects undergoing less complex surgery had higher infection rates. Unadjusted survival to hospital discharge was lower in infected subjects compared with noninfected subjects (43% vs 51%; p = 0.01). After adjusting for confounders via propensity matching, we identified no significant mortality difference between infected and noninfected subjects. Conclusions Neonatal and pediatric subjects in this study have a high rate of acquired infection. Infants and children were at higher infection risk compared with neonatal subjects. There was not, however, a significant association between Extracorporeal membrane oxygenation-related infection and survival to hospital discharge after propensity matching.
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outcomes of infants supported with Extracorporeal membrane oxygenation using centrifugal versus roller pumps an analysis from the Extracorporeal life support organization registry
Pediatric Critical Care Medicine, 2019Co-Authors: Conor P Ohalloran, Peter Rycus, Ryan P Barbaro, Ravi R. Thiagarajan, Vamsi V Yarlagadda, Viviane G Nasr, Marc Anders, Peta M A AlexanderAbstract:OBJECTIVES To determine whether mortality differs between roller and centrifugal pumps used during Extracorporeal membrane oxygenation in infants weighing less than 10 kg. DESIGN Retrospective propensity-matched cohort study. SETTING All Extracorporeal membrane oxygenation centers reporting to the Extracorporeal Life Support Organization. PATIENTS All patients less than 10 kg supported on Extracorporeal membrane oxygenation during 2011-2016 within Extracorporeal Life Support Organization Registry. INTERVENTIONS Centrifugal and roller pump recipients were propensity matched (1:1) based on predicted probability of receiving a centrifugal pump using demographic variables, indication for Extracorporeal membrane oxygenation, central versus peripheral cannulation, and pre-Extracorporeal membrane oxygenation patient management. MEASUREMENTS AND MAIN RESULTS A total of 12,890 patients less than 10 kg were supported with Extracorporeal membrane oxygenation within the Extracorporeal Life Support Organization registry during 2011-2016. Patients were propensity matched into a cohort of 8,366. Venoarterial and venovenous Extracorporeal membrane oxygenation runs were propensity matched separately. The propensity-matched cohorts were similar except earlier year of Extracorporeal membrane oxygenation (standardized mean difference, 0.49) in the roller pump group. Within the propensity-matched cohort, survival to discharge was lower in the centrifugal pump group (57% vs 59%; odds ratio, 0.91; 95% CI, 0.83-0.99; p = 0.04). Hemolytic, infectious, limb injury, mechanical, metabolic, neurologic, pulmonary, and renal complications were more frequent in the centrifugal pump group. Hemorrhagic complications were similar between groups. Hemolysis mediated the relationship between centrifugal pumps and mortality (indirect effect, 0.023; p < 0.001). CONCLUSIONS In this propensity score-matched cohort study of 8,366 Extracorporeal membrane oxygenation recipients weighing less than 10 kg, those supported with centrifugal pumps had increased mortality and Extracorporeal membrane oxygenation complications. Hemolysis was evaluated as a potential mediator of the relationship between centrifugal pump use and mortality and met criteria for full mediation.
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outcomes after Extracorporeal cardiopulmonary resuscitation of pediatric in hospital cardiac arrest a report from the get with the guidelines resuscitation and the Extracorporeal life support organization registries
Critical Care Medicine, 2019Co-Authors: Melania M Bembea, Peter Rycus, Heidi J Dalton, Ravi R. Thiagarajan, Javier J Lasa, Alexis A Topjian, Vinay M Nadkarni, Derek K Ng, Nicole Rizkalla, Elizabeth A HuntAbstract:Objectives:The aim of this study was to determine cardiac arrest– and Extracorporeal membrane oxygenation–related risk factors associated with unfavorable outcomes after Extracorporeal cardiopulmonary resuscitation.Design:We performed an analysis of merged data from the Extracorporeal Life Support O
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Extracorporeal Life Support Organization Registry International Report 2016.
ASAIO journal (American Society for Artificial Internal Organs : 1992), 2017Co-Authors: Ravi R. Thiagarajan, Ryan P Barbaro, James D. Fortenberry, Peter T. Rycus, Steven A. Conrad, D. Michael Mcmullan, Matthew L. PadenAbstract:Data on Extracorporeal life support (ECLS) use and survival submitted to the Extracorporeal Life Support Organization's data registry from the inception of the registry in 1989 through July 1, 2016, are summarized in this report. The registry contained information on 78,397 ECLS patients with 58% survival to hospital discharge. Extracorporeal life support use and centers providing ECLS have increased worldwide. Extracorporeal life support use in the support of adults with respiratory and cardiac failure represented the largest growth in the recent time period. Extracorporeal life support indications are expanding, and it is increasingly being used to support cardiopulmonary resuscitation in children and adults. Adverse events during the course of ECLS are common and underscore the need for skilled ECLS management and appropriately trained ECLS personnel and teams.
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Extracorporeal membrane oxygenation for the support of adults with acute myocarditis
Critical Care Medicine, 2015Co-Authors: Wesley J Diddle, Satish K. Rajagopal, Peter T. Rycus, Melvin C Almodovar, Ravi R. ThiagarajanAbstract:Objectives: To characterize survival outcomes for adult patients with acute myocarditis supported with Extracorporeal membrane oxygenation and identify risk factors for in-hospital mortality. Design: Retrospective review of Extracorporeal Life Support Organization registry database. Setting: Data reported to Extracorporeal Life Support Organization by 230 Extracorporeal membrane oxygenation centers. Patients: Patients 16 years old or older supported with Extracorporeal membrane oxygenation for myocarditis during 1995 to 2011. Interventions: None. Measurements and Main Results: There were 150 separate runs of Extracorporeal membrane oxygenation for 147 patients with a diagnosis of acute myocarditis in the Extracorporeal Life Support Organization database from 1995 through 2011. Survival to hospital discharge was 61%. Nine patients underwent heart transplantation, and transplant-free survival to discharge was 56%. Extracorporeal membrane oxygenation was deployed during Extracorporeal cardiopulmonary resuscitation in 31 patients (21% of the cohort). In a multivariate model evaluating pre–Extracorporeal membrane oxygenation and Extracorporeal membrane oxygenation support factors, pre–Extracorporeal membrane oxygenation arrest (adjusted odds ratio, 2.4; 95% CI, 1.1–5.0) and need for higher Extracorporeal membrane oxygenation flows at 4 hours post–Extracorporeal membrane oxygenation cannulation (odds ratio, 2.8; 95% CI, 1.1–7.3) were associated with increased odds of in-hospital mortality. In a second multivariate model evaluating adverse events while on Extracorporeal membrane oxygenation, central nervous system injury (odds ratio, 26.5; 95% CI, 7.3–96.6), renal failure (odds ratio, 3.6; 95% CI, 1.4–9.3), arrhythmia (odds ratio, 5.8; 95% CI, 2.2–15.1), and hyperbilirubinemia (odds ratio, 9.1; 95% CI, 2.6–31.8) were associated with increased odds of in-hospital mortality. Conclusions: Extracorporeal membrane oxygenation can be used effectively in adults with myocarditis to support the circulation while awaiting myocardial recovery. Early Extracorporeal membrane oxygenation deployment prior to cardiac arrest may be associated with better outcomes.
Peter T. Rycus - One of the best experts on this subject based on the ideXlab platform.
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risk factors of ischemic and hemorrhagic strokes during venovenous Extracorporeal membrane oxygenation analysis of data from the Extracorporeal life support organization registry
Critical Care Medicine, 2021Co-Authors: Sung-min Cho, Peter T. Rycus, Joe Canner, Giorgio Caturegli, Chun Woo Choi, Eric Etchill, Katherine Giuliano, Giovanni Chiarini, Kate Calligy, Roberto LorussoAbstract:OBJECTIVES Stroke is commonly reported in patients receiving venovenous Extracorporeal membrane oxygenation, but risk factors are not well described. We sought to determine preExtracorporeal membrane oxygenation and on-Extracorporeal membrane oxygenation risk factors for both ischemic and hemorrhagic strokes in patients with venovenous Extracorporeal membrane oxygenation support. DESIGN Retrospective analysis. SETTING Data reported to the Extracorporeal Life Support Organization by 366 Extracorporeal membrane oxygenation centers from 2013 to 2019. PATIENTS Patients older than 18 years supported with a single run of venovenous Extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 15,872 venovenous Extracorporeal membrane oxygenation patients, 812 (5.1%) had at least one type of acute brain injury, defined as ischemic stroke, hemorrhagic stroke, or brain death. Overall, 215 (1.4%) experienced ischemic stroke and 484 (3.1%) experienced hemorrhagic stroke. Overall inhospital mortality was 36%, but rates were higher in those with ischemic or hemorrhagic stroke (68% and 73%, respectively). In multivariable analysis, preExtracorporeal membrane oxygenation pH (adjusted odds ratio = 0.10; 95% CI, 0.03-0.35; p < 0.001), hemolysis (adjusted odds ratio = 2.27; 95% CI, 1.22-4.24; p = 0.010), gastrointestinal hemorrhage (adjusted odds ratio = 2.01; 95% CI 1.12-3.59; p = 0.019), and disseminated intravascular coagulation (adjusted odds ratio = 3.61; 95% CI, 1.51-8.66; p = 0.004) were independently associated with ischemic stroke. Pre-Extracorporeal membrane oxygenation pH (adjusted odds ratio = 0.28; 95% CI, 0.12-0.65; p = 0.003), preExtracorporeal membrane oxygenation Po2 (adjusted odds ratio = 0.96; 95% CI, 0.93-0.99; p = 0.021), gastrointestinal hemorrhage (adjusted odds ratio = 1.70; 95% CI, 1.15-2.51; p = 0.008), and renal replacement therapy (adjusted odds ratio=1.57; 95% CI, 1.22-2.02; p < 0.001) were independently associated with hemorrhagic stroke. CONCLUSIONS Among venovenous Extracorporeal membrane oxygenation patients in the Extracorporeal Life Support Organization registry, approximately 5% had acute brain injury. Mortality rates increased two-fold when ischemic or hemorrhagic strokes occurred. Risk factors such as lower pH and hypoxemia during the pericannulation period and markers of coagulation disturbances were associated with acute brain injury. Further research on understanding preExtracorporeal membrane oxygenation and on-Extracorporeal membrane oxygenation risk factors and the timing of acute brain injury is necessary to develop appropriate prevention and management strategies.
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modifiable risk factors and mortality from ischemic and hemorrhagic strokes in patients receiving venoarterial Extracorporeal membrane oxygenation results from the Extracorporeal life support organization registry
Critical Care Medicine, 2020Co-Authors: Sung-min Cho, Ryan P Barbaro, Peter T. Rycus, Roberto Lorusso, Joe Canner, Giorgio Caturegli, Giovanni Chiarini, Kate Calligy, Joseph E Tonna, Ahmet KilicAbstract:OBJECTIVES Although acute brain injury is common in patients receiving Extracorporeal membrane oxygenation, little is known regarding the mechanism and predictors of ischemic and hemorrhagic stroke. We aimed to determine the risk factors and outcomes of each ischemic and hemorrhagic stroke in patients with venoarterial Extracorporeal membrane oxygenation support. DESIGN Retrospective analysis. SETTING Data reported to the Extracorporeal Life Support Organization by 310 Extracorporeal membrane oxygenation centers from 2013 to 2017. PATIENTS Patients more than 18 years old supported with a single run of venoarterial Extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 10,342 venoarterial Extracorporeal membrane oxygenation patients, 401 (3.9%) experienced ischemic stroke and 229 (2.2%) experienced hemorrhagic stroke. Reported acute brain injury during venoarterial Extracorporeal membrane oxygenation decreased from 10% to 6% in 5 years. Overall in-hospital mortality was 56%, but rates were higher when ischemic stroke and hemorrhagic stroke were present (76% and 86%, respectively). In multivariable analysis, lower pre-Extracorporeal membrane oxygenation pH (adjusted odds ratio, 0.21; 95% CI, 0.09-0.49; p < 0.001), higher PO2 on first day of Extracorporeal membrane oxygenation (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.009), higher rates of Extracorporeal membrane oxygenation circuit mechanical failure (adjusted odds ratio, 1.33; 95% CI, 1.02-1.74; p = 0.03), and renal replacement therapy (adjusted odds ratio, 1.49; 95% CI, 1.14-1.94; p = 0.004) were independently associated with ischemic stroke. Female sex (adjusted odds ratio, 1.61; 95% CI, 1.16-2.22; p = 0.004), Extracorporeal membrane oxygenation duration (adjusted odds ratio, 1.01; 95% CI, 1.00-1.03; p = 0.02), renal replacement therapy (adjusted odds ratio, 1.81; 95% CI, 1.30-2.52; p < 0.001), and hemolysis (adjusted odds ratio, 1.87; 95% CI, 1.11-3.16; p = 0.02) were independently associated with hemorrhagic stroke. CONCLUSIONS Despite a decrease in the prevalence of acute brain injury in recent years, mortality rates remain high when ischemic and hemorrhagic strokes are present. Future research is necessary on understanding the timing of associated risk factors to promote prevention and management strategy.
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Extracorporeal membrane oxygenation in pregnancy an analysis of the Extracorporeal life support organization registry
Critical Care Medicine, 2020Co-Authors: Kollengode Ramanathan, Peter T. Rycus, Marc Anders, Chuen Seng Tan, Roberto Lorusso, John J Y Zhang, Graeme MaclarenAbstract:Objectives We examined data from the International Registry of the Extracorporeal Life Support Organization to identify risk factors for mortality in pregnant and peripartum patients receiving Extracorporeal membrane oxygenation. Design Retrospective analysis. Setting International Registry of Extracorporeal Life Support Organization. Patients We collected de-identified data on all peripartum patients who needed Extracorporeal membrane oxygenation between 1997 and 2017 using International Classification of Diseases, 9th and 10th Edition criteria. Interventions Our primary outcome measure was in-hospital mortality. We also collected data on demographics, preExtracorporeal membrane oxygenation ventilator, hemodynamic and biochemical parameters, Extracorporeal membrane oxygenation mode, duration, and complications. Initial bivariate analysis assessed potential associations between survival and various preExtracorporeal membrane oxygenation as well as Extracorporeal membrane oxygenation-related factors. Variables with p values of less than 0.1 were considered for logistic regression analysis which identified predictors of mortality. Measurements and main results There were 280 peripartum patients who received Extracorporeal membrane oxygenation. Overall maternal survival was 70%, with observed mortality for these patients decreasing over the 21-year time period. Multivariate regression identified Extracorporeal cardiopulmonary resuscitation (odds ratio, 3.674; 95% CI, 1.425-9.473; overall p = 0.025), duration of Extracorporeal membrane oxygenation ( 232 hr: odds ratio, 1.084; 95% CI, 0.429-2.737; p = 0.864; overall p = 0.017), and renal complications on Extracorporeal membrane oxygenation (odds ratio, 2.346; 95% CI, 1.203-4.572; p = 0.012) as significant risk factors for mortality. There was no statistically significant difference in mortality between venovenous versus venoarterial versus mixed group Extracorporeal membrane oxygenation (23.9 vs 34.4 vs 29.4%; p = 0.2) or between pulmonary versus cardiac indications (1.634; 95% CI, 0.797-3.352; p = 0.18) for Extracorporeal membrane oxygenation. Conclusions On analysis of this multicenter database, pregnant and peripartum patients with refractory cardiac or respiratory failure supported on Extracorporeal membrane oxygenation had survival rates of 70%. We identified preExtracorporeal membrane oxygenation as well as Extracorporeal membrane oxygenation-related factors that are associated with mortality.
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neurologic injury in adults supported with veno venous Extracorporeal membrane oxygenation for respiratory failure findings from the Extracorporeal life support organization database
Critical Care Medicine, 2017Co-Authors: Roberto Lorusso, Peter T. Rycus, Sandro Gelsomino, Orlando Parise, Michele Di Mauro, Fabio Barili, Gijs Geskes, Enrico Vizzardi, Raf Muellenbach, Thomas MuellerAbstract:Objectives:To assess in-hospital neurologic (CNS) complications in adult patients undergoing veno-venous Extracorporeal membrane oxygenation for respiratory failure.Design:Retrospective analysis of the Extracorporeal Life Support Organization’s data registry.Setting:Data reported to Extracorporeal L
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Extracorporeal Life Support Organization Registry International Report 2016.
ASAIO journal (American Society for Artificial Internal Organs : 1992), 2017Co-Authors: Ravi R. Thiagarajan, Ryan P Barbaro, James D. Fortenberry, Peter T. Rycus, Steven A. Conrad, D. Michael Mcmullan, Matthew L. PadenAbstract:Data on Extracorporeal life support (ECLS) use and survival submitted to the Extracorporeal Life Support Organization's data registry from the inception of the registry in 1989 through July 1, 2016, are summarized in this report. The registry contained information on 78,397 ECLS patients with 58% survival to hospital discharge. Extracorporeal life support use and centers providing ECLS have increased worldwide. Extracorporeal life support use in the support of adults with respiratory and cardiac failure represented the largest growth in the recent time period. Extracorporeal life support indications are expanding, and it is increasingly being used to support cardiopulmonary resuscitation in children and adults. Adverse events during the course of ECLS are common and underscore the need for skilled ECLS management and appropriately trained ECLS personnel and teams.
Brian C Bridges - One of the best experts on this subject based on the ideXlab platform.
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the use of an Extracorporeal membrane oxygenation anticoagulation laboratory protocol is associated with decreased blood product use decreased hemorrhagic complications and increased circuit life
Pediatric Critical Care Medicine, 2015Co-Authors: Michael S Northrop, Sharon E Phillips, Hardison C Daphne, Andrew H Smith, John B. Pietsch, Robert F. Sidonio, Brian C BridgesAbstract:Abstract To determine if a comprehensive Extracorporeal membrane oxygenation anticoagulation monitoring protocol results in fewer hemorrhagic complications, reduced blood product usage, and increased circuit life. In September 2011, we augmented our standard Extracorporeal membrane oxygenation laboratory protocol to include anti-factor Xa assays, thromboelastography, and antithrombin measurements. We performed a retrospective chart review to determine outcomes for patients placed on Extracorporeal membrane oxygenation prior to and after the initiation of our anticoagulation laboratory protocol. Tertiary care, academic children's hospital. All patients who were placed on Extracorporeal membrane oxygenation at our institution from January 1, 2007, to September 30, 2013. None. There were 261 Extracorporeal membrane oxygenation runs before the initiation of the protocol and 105 Extracorporeal membrane oxygenation runs after the initiation of the protocol. There were no major changes to our Extracorporeal membrane oxygenation circuit or changes to our transfusion threshold during the study period. The indication for Extracorporeal membrane oxygenation, age, and severity of illness of the patients were similar before and after protocol initiation. Median blood product usage for packed RBCs, fresh frozen plasma, platelets, and cryoprecipitate decreased significantly after protocol initiation. The occurrence of cannula site bleeding decreased from 22% to 12% (p = 0.04), and surgical site bleeding decreased from 38% to 25% (p = 0.02). Median Extracorporeal membrane oxygenation circuit life increased from 3.6 to 4.3 days (p = 0.02). A trend toward increased patient survival was noted, but it did not reach statistical significance. We demonstrate an association between an Extracorporeal membrane oxygenation anticoagulation laboratory protocol using anti-factor Xa assays, thromboelastography, and antithrombin measurements and a decrease in blood product transfusion, a decrease in hemorrhagic complications, and an increase in circuit life. To our knowledge, this is the first study to demonstrate clinical benefit associated with the use of these laboratory values for patients on Extracorporeal membrane oxygenation.
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the use of an Extracorporeal membrane oxygenation anticoagulation laboratory protocol is associated with decreased blood product use decreased hemorrhagic complications and increased circuit life
Pediatric Critical Care Medicine, 2015Co-Authors: Michael S Northrop, Sharon E Phillips, Hardison C Daphne, Andrew H Smith, John B. Pietsch, Robert F. Sidonio, Brian C BridgesAbstract:OBJECTIVES To determine if a comprehensive Extracorporeal membrane oxygenation anticoagulation monitoring protocol results in fewer hemorrhagic complications, reduced blood product usage, and increased circuit life. DESIGN In September 2011, we augmented our standard Extracorporeal membrane oxygenation laboratory protocol to include anti-factor Xa assays, thromboelastography, and antithrombin measurements. We performed a retrospective chart review to determine outcomes for patients placed on Extracorporeal membrane oxygenation prior to and after the initiation of our anticoagulation laboratory protocol. SETTING Tertiary care, academic children's hospital. PATIENTS All patients who were placed on Extracorporeal membrane oxygenation at our institution from January 1, 2007, to September 30, 2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 261 Extracorporeal membrane oxygenation runs before the initiation of the protocol and 105 Extracorporeal membrane oxygenation runs after the initiation of the protocol. There were no major changes to our Extracorporeal membrane oxygenation circuit or changes to our transfusion threshold during the study period. The indication for Extracorporeal membrane oxygenation, age, and severity of illness of the patients were similar before and after protocol initiation. Median blood product usage for packed RBCs, fresh frozen plasma, platelets, and cryoprecipitate decreased significantly after protocol initiation. The occurrence of cannula site bleeding decreased from 22% to 12% (p = 0.04), and surgical site bleeding decreased from 38% to 25% (p = 0.02). Median Extracorporeal membrane oxygenation circuit life increased from 3.6 to 4.3 days (p = 0.02). A trend toward increased patient survival was noted, but it did not reach statistical significance. CONCLUSIONS We demonstrate an association between an Extracorporeal membrane oxygenation anticoagulation laboratory protocol using anti-factor Xa assays, thromboelastography, and antithrombin measurements and a decrease in blood product transfusion, a decrease in hemorrhagic complications, and an increase in circuit life. To our knowledge, this is the first study to demonstrate clinical benefit associated with the use of these laboratory values for patients on Extracorporeal membrane oxygenation.
Alain Combes - One of the best experts on this subject based on the ideXlab platform.
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Extracorporeal cardiopulmonary resuscitation in out of hospital cardiac arrest a registry study
European Heart Journal, 2020Co-Authors: Wulfran Bougouin, Alain Combes, Florence Dumas, Lionel Lamhaut, Eloi Marijon, Pierre Carli, Romain Pirracchio, Nadia Aissaoui, Nicole KaramAbstract: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.
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practice patterns and ethical considerations in the management of venovenous Extracorporeal membrane oxygenation patients an international survey
Critical Care Medicine, 2019Co-Authors: Darryl Abrams, Alain Combes, Tai Pham, Karen E A Burns, Randall J Curtis, Thomas Mueller, Kenneth PragerAbstract:Objectives To characterize physicians' practices and attitudes toward the initiation, limitation, and withdrawal of venovenous Extracorporeal membrane oxygenation for severe respiratory failure and evaluate factors associated with these attitudes. Design Electronic, cross-sectional, scenario-based survey. Setting Extracorporeal membrane oxygenation centers affiliated with the Extracorporeal Life Support Organization and the International Extracorporeal Membrane Oxygenation Network. Subjects Attending-level physicians with experience managing adult patients receiving venovenous Extracorporeal membrane oxygenation. Interventions None. Measurements and main results Five-hundred thirty-nine physicians in 39 countries across six continents completed the survey. Factors that influenced the decision to limit Extracorporeal membrane oxygenation initiation included older patient age (46.9%), additional organ failures (37.7%), and prolonged mechanical ventilation (35.1%). Patient comorbidities (70.5%), patient's wishes (56.0%), and etiology of respiratory failure (37.7%) were factors that influenced the decision to withdraw Extracorporeal membrane oxygenation. In multivariable analysis, factors associated with increased odds of withdrawing life-sustaining therapies included pulmonary fibrosis, stroke, surrogate's desire to withdraw, lack of knowledge regarding patient's or surrogate's wishes in the setting of fibrosis, not initiating Extracorporeal membrane oxygenation in the baseline scenario, and respondent religiosity. Factors associated with decreased odds of withdrawal included practicing in an environment where it is not legally possible to make decisions against patient or surrogate wishes. Most respondents (90.5%) involved other physicians in treatment decisions for Extracorporeal membrane oxygenation patients, whereas only 53.2%, 45.3%, and 29.5% of respondents involved surrogates, awake patients, or bedside nurses, respectively. Conclusions Patient and physician-level factors were associated with decision-making regarding Extracorporeal membrane oxygenation initiation and withdrawal, including patient prognosis and knowledge of patient or surrogate wishes. Respondents reported low rates of engaging in shared decision-making when managing patients receiving Extracorporeal membrane oxygenation.
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Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review.
JAMA, 2019Co-Authors: Daniel Brodie, Arthur S. Slutsky, Alain CombesAbstract:Importance The substantial growth over the last decade in the use of Extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made Extracorporeal life support more widely accepted in clinical practice. Observations Clinical trials of Extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in Extracorporeal support made it safer to use. Interest in Extracorporeal life support increased with the confluence of 2 events in 2009: (1) the publication of a randomized clinical trial of Extracorporeal life support for acute respiratory failure and (2) the use of Extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that Extracorporeal life support was beneficial for patients with very severe acute respiratory distress syndrome. As the evidence supporting the use of Extracorporeal life support increases, its indications are expanding to being a bridge to lung transplantation and the management of patients with pulmonary vascular disease who have right-sided heart failure. Extracorporeal life support is now an acceptable form of organ support in clinical practice. Conclusions and Relevance The role of Extracorporeal life support in the management of adults with acute respiratory failure is being redefined by advances in technology and increasing evidence of its effectiveness. Future developments in the field will result from technological advances, an increased understanding of the physiology and biology of Extracorporeal support, and increased knowledge of how it might benefit the treatment of a variety of clinical conditions.
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Extracorporeal gas exchange for acute respiratory failure in adult patients a systematic review
Critical Care, 2015Co-Authors: Matthieu Schmidt, Carol L Hodgson, Alain CombesAbstract:Mechanical ventilation remains the cornerstone of respiratory support for patients with acute respiratory failure. However, high pressure and volume associated with tidal ventilation are known to aggravate lung injury in this setting [1]. Furthermore, profound gas-exchange abnormalities threatening patients’ lives can occur in the most severe forms of the disease despite recourse to conventional salvage therapies [2, 3]. Extracorporeal gas exchange devices, i. e., venovenous Extracorporeal membrane oxygenation (ECMO) and Extracorporeal carbon dioxide removal (ECCO2R), were developed more than 40 years ago [4, 5] to rescue these dying patients. Whereas venovenous ECMO provides complete Extracorporeal blood oxygenation and decarboxylation using high blood flows (4–6 l/min) and large (20–30 Fr) cannulas [6–9], efficient Extracorporeal CO2 removal (with minimal blood oxygenation) can be achieved with ECCO2R devices using limited Extracorporeal blood flow (0.4–1 l/min) and thin double lumen venous catheters (14–18 Fr) [10, 11], because CO2 clearance is more effective than oxygenation due to the greater solubility and more rapid diffusion of CO2 [12]. Extracorporeal gas exchange devices also permit ‘ultraprotective’ mechanical ventilation with further reduction of volume and pressure, which may ultimately enhance lung protection and improve clinical outcomes for patients with acute respiratory distress syndrome (ARDS). However, results of trials evaluating Extracorporeal gas exchange for respiratory failure performed in the 1970s, 80s and 90s were often disappointing [13, 14]. In recent years, major technological advances have occurred and the latest generation Extracorporeal gas exchange devices, with polymethylpentene hollow-fiber membrane lungs and Mendler-designed centrifugal pumps offer lower resistance to blood flow, have smaller priming volumes, higher effective gas exchange properties and are coated with more biocompatible materials.
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acute lung injury after mechanical circulatory support implantation in patients on Extracorporeal life support an unrecognized problem
European Journal of Cardio-Thoracic Surgery, 2013Co-Authors: David Boulate, Alain Combes, Charlesedouard Luyt, Matteo Pozzi, M Niculescu, Pascal Leprince, Matthias KirschAbstract:OBJECTIVES: We observed early acute lung injury (ALI) after a switch from veno-arterial Extracorporeal life support (VA-ECLS) to longterm mechanical circulatory support (MCS). The aim of our study was to analyse the frequency, impact on mortality and characteristics of patients presenting ALI after MCS implantation in the bridge-to-bridge (BTB) strategy. METHODS: We retrospectively analysed data from 55 consecutive cardiogenic shock patients who underwent a BTB strategy between January 2004 and March 2012 in our centre. ALI was defined as severe acute respiratory failure (PaO2/FiO2 <200) with or without need for iterative VA-ECLS or veno-venous (VV)-exracorporeal membrane oxygenation (ECMO) occurring within 48 h of MCS implantation. RESULTS: ALI was observed in 15 of 55 (27%) patients. Eleven patients required VV-ECMO or VA-ECLS and 4 were treated medically. The median (interquartile range) duration of support under a long-term device was 47.5 (168.8) days. Mortality while on long-term support was significantly higher in patients who developed ALI (13 of 15, 87%) than in those who did not (21 of 40, 53%; P=0.03). Hazard ratio for death while on support in patients who developed ALI when compared with those who did not was 3.390 (95% confidence interval, 1.636–7.026, P=0.001). Univariate risk factors for postimplant ALI included: signs of pulmonary oedema while under Extracorporeal life support (ECLS) during the week preceding long-term device implantation; mechanical ventilation, the incomplete recovery of renal and hepatic functions and the number of red blood cell units transfused at the time of long-term device implantation, and use of pulsatile, biventricular support. CONCLUSIONS: Implantation of a long-term MCS device in patients on ECLS can result in severe ALI, which is associated with ominous outcomes. Various preimplant risk factors for ALI have been identified and might allow devising strategies to prevent this complication.
Thomas H Schneider - One of the best experts on this subject based on the ideXlab platform.
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Extracorporeal shockwave lithotripsy of gallstones in cystic duct remnants and mirizzi syndrome
Gastrointestinal Endoscopy, 2004Co-Authors: J Benninger, Thomas Rabenstein, M J Farnbacher, Eckhart G Hahn, J. Keppler, Thomas H SchneiderAbstract:Abstract Background Although the efficacy of Extracorporeal shockwave lithotripsy for treatment of bile duct calculi is established, there are few studies of the value of Extracorporeal shockwave lithotripsy for cystic duct remnant stones and for Mirizzi syndrome. Methods Patients who required Extracorporeal shockwave lithotripsy for cystic duct stones were identified in a cohort of 239 patients with bile duct stones treated by Extracorporeal shockwave lithotripsy between January 1989 and December 2001 at a single institution. The medical records of these patients were reviewed. Follow-up information was obtained by telephone contact. Observations Six women (age range 19-85 years) underwent Extracorporeal shockwave lithotripsy for cystic duct stones after failure of endoscopic treatment measures. Three of the patients presented with retained cystic duct remnant calculi (one also had Mirizzi syndrome type I), and 3 presented with Mirizzi syndrome type I. The stones were fragmented successfully by Extracorporeal shockwave lithotripsy in all patients; the fragments were extracted endoscopically in 5 patients. Endoscopy plus Extracorporeal shockwave lithotripsy was definitive treatment for all patients except one who subsequently underwent cholecystectomy. Conclusions Gallstones in a cystic duct remnant and in Mirizzi syndrome can be successfully treated by Extracorporeal shockwave lithotripsy in conjunction with endoscopic measures. Extracorporeal shockwave lithotripsy is especially useful when surgery is contraindicated.
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Extracorporeal shockwave lithotripsy of gallstones in cystic duct remnants and mirizzi syndrome
Gastrointestinal Endoscopy, 2004Co-Authors: J Benninger, Thomas Rabenstein, M J Farnbacher, Eckhart G Hahn, J. Keppler, Thomas H SchneiderAbstract:Abstract Background Although the efficacy of Extracorporeal shockwave lithotripsy for treatment of bile duct calculi is established, there are few studies of the value of Extracorporeal shockwave lithotripsy for cystic duct remnant stones and for Mirizzi syndrome. Methods Patients who required Extracorporeal shockwave lithotripsy for cystic duct stones were identified in a cohort of 239 patients with bile duct stones treated by Extracorporeal shockwave lithotripsy between January 1989 and December 2001 at a single institution. The medical records of these patients were reviewed. Follow-up information was obtained by telephone contact. Observations Six women (age range 19-85 years) underwent Extracorporeal shockwave lithotripsy for cystic duct stones after failure of endoscopic treatment measures. Three of the patients presented with retained cystic duct remnant calculi (one also had Mirizzi syndrome type I), and 3 presented with Mirizzi syndrome type I. The stones were fragmented successfully by Extracorporeal shockwave lithotripsy in all patients; the fragments were extracted endoscopically in 5 patients. Endoscopy plus Extracorporeal shockwave lithotripsy was definitive treatment for all patients except one who subsequently underwent cholecystectomy. Conclusions Gallstones in a cystic duct remnant and in Mirizzi syndrome can be successfully treated by Extracorporeal shockwave lithotripsy in conjunction with endoscopic measures. Extracorporeal shockwave lithotripsy is especially useful when surgery is contraindicated.
