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Sung-min Cho - 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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Brain Injury Is More Common in Venoarterial Extracorporeal Membrane Oxygenation Than Venovenous Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis.
Critical care medicine, 2020Co-Authors: Aaron Shoskes, Ibrahim Migdady, Cory Rice, Catherine Hassett, Abhishek Deshpande, Carrie Price, Adrian V. Hernandez, Sung-min ChoAbstract:OBJECTIVES Despite the common occurrence of brain injury in patients undergoing extracorporeal membrane Oxygenation, it is unclear which cannulation method carries a higher risk of brain injury. We compared the prevalence of brain injury between patients undergoing venoarterial and venovenous extracorporeal membrane Oxygenation. DATA SOURCES PubMed and six other databases from inception to April 2020. STUDY SELECTION Observational studies and randomized clinical trials in adult patients undergoing venoarterial extracorporeal membrane Oxygenation or venovenous extracorporeal membrane Oxygenation reporting brain injury. DATA EXTRACTION Two independent reviewers extracted the data from the studies. Random-effects meta-analyses were used to pool data. DATA SYNTHESIS Seventy-three studies (n = 16,063) met inclusion criteria encompassing 8,211 patients (51.2%) undergoing venoarterial extracorporeal membrane Oxygenation and 7,842 (48.8%) undergoing venovenous extracorporeal membrane Oxygenation. Venoarterial extracorporeal membrane Oxygenation patients had more overall brain injury compared with venovenous extracorporeal membrane Oxygenation (19% vs 10%; p = 0.002). Venoarterial extracorporeal membrane Oxygenation patients had more ischemic stroke (10% vs 1%; p < 0.001), hypoxic-ischemic brain injury (13% vs 1%; p < 0.001), and brain death (11% vs 1%; p = 0.001). In contrast, rates of intracerebral hemorrhage (6% vs 8%; p = 0.35) did not differ. Survival was lower in venoarterial extracorporeal membrane Oxygenation (48%) than venovenous extracorporeal membrane Oxygenation (64%) (p < 0.001). After excluding studies that included extracorporeal cardiopulmonary resuscitation, no significant difference was seen in the rate of overall acute brain injury between venoarterial extracorporeal membrane Oxygenation and venovenous extracorporeal membrane Oxygenation (13% vs 10%; p = 0.4). However, ischemic stroke (10% vs 1%; p < 0.001), hypoxic-ischemic brain injury (7% vs 1%; p = 0.02), and brain death (9% vs 1%; p = 0.005) remained more frequent in nonextracorporeal cardiopulmonary resuscitation venoarterial extracorporeal membrane Oxygenation compared with venovenous extracorporeal membrane Oxygenation. CONCLUSIONS Brain injury was more common in venoarterial extracorporeal membrane Oxygenation compared with venovenous extracorporeal membrane Oxygenation. While ischemic brain injury was more common in venoarterial extracorporeal membrane Oxygenation patients, the rates of intracranial hemorrhage were similar between venoarterial extracorporeal membrane Oxygenation and venovenous extracorporeal membrane Oxygenation. Further research on mechanism, timing, and effective monitoring of acute brain injury and its management is necessary.
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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, Peter T. Rycus, Ryan P Barbaro, 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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understanding characteristics of acute brain injury in adult extracorporeal membrane Oxygenation an autopsy study
Critical Care Medicine, 2020Co-Authors: Sung-min Cho, Giorgio Caturegli, Chun Woo Choi, Romergryko G Geocadin, Vanessa Chan, Bartholomew White, Jeffrey M Doddo, Bo Soo Kim, Marc Sussman, Glenn J R WhitmanAbstract:Objectives Current studies lack information on characteristics of acute brain injury in patients with extracorporeal membrane Oxygenation. We sought to characterize the types, timing, and risk factors of acute brain injury in extracorporeal membrane Oxygenation. Design Retrospective analysis. Setting We reviewed the extracorporeal membrane Oxygenation patients who had undergone brain autopsy with gross and microscopic examinations from January 2009 to December 2018 from a single tertiary center. Patients Twenty-five patients (median age 53 yr) had postmortem brain autopsy. Interventions Description and analysis of neuropathologic findings. Measurement and main results Of 25, 22 had venoarterial extracorporeal membrane Oxygenation (88%) (nine cardiac arrest; 13 cardiogenic shock) and three had venovenous extracorporeal membrane Oxygenation cannulation (12%). The median extracorporeal membrane Oxygenation support time was 96 hours (interquartile range, 26-181 hr). The most common acute brain injury was hypoxic-ischemic brain injury (44%), followed by intracranial hemorrhage (24%), and ischemic infarct (16%). Subarachnoid hemorrhage (20%) was the most common type of intracranial hemorrhage, followed by intracerebral hemorrhage (8%), and subdural hemorrhage (4%). Only eight patients (32%) were without acute brain injury after extracorporeal membrane Oxygenation. The most common involved location for hypoxic-ischemic brain injury was cerebral cortices (82%) and cerebellum (55%). The pattern of ischemic infarct was territorial in cerebral cortices. The risk factors for acute brain injury included hypertension history (11 vs 1; p = 0.01), preextracorporeal membrane Oxygenation antiplatelet use (7 vs 0; p = 0.03), and a higher day 1 lactate level (10.0 vs 5.1; p = 0.02). Patients with hypoxic-ischemic brain injury had more hypertension (8 vs 4; p = 0.047), a higher day 1 lactate level (12.6 vs 5.8; p = 0.02), and a lower pH level (7.09 vs 7.24; p = 0.027). Extracorporeal membrane Oxygenation duration, cannulation methods, hemoglobin level, coma, renal impairment, and hepatic impairment were not associated with acute brain injury. Conclusions In the population who underwent postmortem neuropathologic evaluation, 68% of extracorporeal membrane Oxygenation nonsurvivors developed acute brain injury. Hypoxic-ischemic brain injury was the most common type of injury suggesting that patients sustained acute brain injury as a consequence of cardiogenic shock and cardiac arrest. Further research with a systematic neurologic monitoring is necessary to define the timing of acute brain injury in patients with extracorporeal membrane Oxygenation.
Ravi R. Thiagarajan - One of the best experts on this subject based on the ideXlab platform.
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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, Ravi R. Thiagarajan, Vamsi V Yarlagadda, Ryan P Barbaro, Viviane G Nasr, Peter Rycus, 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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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.
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prolonged extracorporeal membrane Oxygenation for children with respiratory failure
Pediatric Critical Care Medicine, 2012Co-Authors: Thomas V Brogan, Ravi R. Thiagarajan, Peter T. Rycus, Luke Zabrocki, Susan L BrattonAbstract:Objective: Extracorporeal membrane Oxygenation is used to support children with respiratory failure. When extracorporeal membrane Oxygenation duration is prolonged, decisions regarding ongoing support are difficult as a result of limited prognostic data. Design: Retrospective case series. Setting: Multi-institutional data reported to the Extracorporeal Life Support Organization Registry. Patients: Patients aged 1 month to 18 yrs supported with extracorporeal membrane Oxygenation for respiratory failure from 1993 to 2007 who received support for ≥21 days. Interventions: None. Measurements and Main Results: Of the 3213 children supported with extracorporeal membrane Oxygenation during the study period, 389 (12%) were supported ≥21 days. Median patient age was 9.1 months (interquartile range, 2.5–41.7 months). Median weight was 6.7 kg (interquartile range, 3.5–15.8 kg). Survival for this group was 38%, significantly lower than survival reported for children supported ≤14 days (61%, p < .001). Among children supported with extracorporeal membrane Oxygenation for ≥21 days, no differences were found between survivors and nonsurvivors with regard to acute pulmonary diagnosis, pre-extracorporeal membrane Oxygenation comorbidities, pre-extracorporeal membrane Oxygenation adjunctive therapies, or pre-extracorporeal membrane Oxygenation blood gas parameters. Only peak inspiratory pressure was significantly different in survivors. Complications occurring on extracorporeal membrane Oxygenation were more common among nonsurvivors. The use of inotropic infusion (odds ratio 1.64; 95% confidence interval 1.07–2.52), acidosis (pH <7.2) during extracorporeal membrane Oxygenation (odds ratio 2.62; 95% confidence interval 1.51–4.55), and male gender (odds ratio 1.95; 95% confidence interval 1.21–3.15) were independently as sociated with increased odds of death. Conclusion: Survival declines with duration of extracorporeal membrane Oxygenation. Male gender and inadequate cardiorespiratory status during extracorporeal membrane Oxygenation increased the risk of death. Prolonged support with extracorporeal membrane Oxygenation appears reasonable unless multiorgan failure develops. (Pediatr Crit Care Med 2012; 13:e249–e254)
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Extracorporeal membrane Oxygenation support after the Fontan operation
The Journal of Thoracic and Cardiovascular Surgery, 2011Co-Authors: Kelly L. Rood, Sarah A. Teele, Cindy S. Barrett, Joshua W. Salvin, Peter T. Rycus, Francis Fynn-thompson, Peter C. Laussen, Ravi R. ThiagarajanAbstract:Objective Extracorporeal membrane Oxygenation has been used to support children with cardiac failure after the Fontan operation. Mortality is high, and causes of mortality remain unclear. We evaluated the in-hospital mortality and factors associated with mortality in these patients. Methods Extracorporeal Life Support Organization registry data on patients requiring extracorporeal membrane Oxygenation after the Fontan operation from 1987 to 2009 were retrospectively analyzed. Demographics and extracorporeal membrane Oxygenation data were compared for survivors and nonsurvivors. A multivariable logistic regression model was used to identify factors associated with mortality. Results Of 230 patients, 81 (35%) survived to hospital discharge. Cardiopulmonary resuscitation was more frequent (34% vs 17%, P = .04), and median fraction of inspired oxygen concentration was higher (1 [confidence interval, 0.9–1.0] vs 0.9 [confidence interval, 0.8–1.0], P = .03) before extracorporeal membrane Oxygenation in nonsurvivors compared with survivors. Extracorporeal membrane Oxygenation duration and incidence of complications, including surgical bleeding, neurologic injury, renal failure, inotrope use on extracorporeal membrane Oxygenation, and bloodstream infection, were higher in nonsurvivors compared with survivors ( P Conclusions Cardiac failure requiring extracorporeal membrane Oxygenation after the Fontan operation is associated with high mortality. Complications during extracorporeal membrane Oxygenation support increase mortality odds. Prompt correction of surgical bleeding when possible may improve survival.
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indication for initiation of mechanical circulatory support impacts survival of infants with shunted single ventricle circulation supported with extracorporeal membrane Oxygenation
The Journal of Thoracic and Cardiovascular Surgery, 2007Co-Authors: Catherine K Allan, Ravi R. Thiagarajan, Melvin C Almodovar, Pedro J Del Nido, Stephen J Roth, Peter C. LaussenAbstract:Objectives The use of extracorporeal membrane Oxygenation to support patients with shunted single-ventricle physiology has been controversial. Variable survivals are reported in a number of small case series. We sought to evaluate outcomes and identify predictors of survival for patients with shunted single-ventricle physiology who require extracorporeal membrane Oxygenation support. Methods We retrospectively reviewed the medical records of all patients aged less than 1 year with shunted single-ventricle physiology who were supported with extracorporeal membrane Oxygenation at Children's Hospital Boston between 1996 and 2005. Survivors and nonsurvivors were compared with respect to demographics, diagnosis, operative variables, indication for extracorporeal membrane Oxygenation, and extracorporeal membrane Oxygenation variables. Results Forty-four infants with shunted single-ventricle physiology were supported with extracorporeal membrane Oxygenation. Diagnoses included hypoplastic left heart syndrome (24), other single-ventricle lesions (12), and pulmonary atresia/intact ventricular septum or a variant (8). Overall survival to discharge was 48%. Indication for extracorporeal membrane Oxygenation was the strongest predictor of survival to discharge, with 81% of patients cannulated for hypoxemia but only 29% of those cannulated for hypotension surviving to discharge. Specifically, patients cannulated for shunt obstruction had the highest survival (83%). Conclusions Overall survival to discharge for patients with shunted single-ventricle physiology is similar to survival reported in the Extracorporeal Life Support Organization registry for all infants supported with cardiac extracorporeal membrane Oxygenation. Thus, shunted single-ventricle physiology should not be considered a contraindication to extracorporeal membrane Oxygenation. Patients cannulated for hypoxemia, particularly shunt thrombosis, had markedly improved survival compared with those supported primarily for hypotension/cardiovascular collapse. Survival did not differ depending on anatomic diagnosis.
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, Peter T. Rycus, Ryan P Barbaro, 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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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.
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prolonged extracorporeal membrane Oxygenation for children with respiratory failure
Pediatric Critical Care Medicine, 2012Co-Authors: Thomas V Brogan, Ravi R. Thiagarajan, Peter T. Rycus, Luke Zabrocki, Susan L BrattonAbstract:Objective: Extracorporeal membrane Oxygenation is used to support children with respiratory failure. When extracorporeal membrane Oxygenation duration is prolonged, decisions regarding ongoing support are difficult as a result of limited prognostic data. Design: Retrospective case series. Setting: Multi-institutional data reported to the Extracorporeal Life Support Organization Registry. Patients: Patients aged 1 month to 18 yrs supported with extracorporeal membrane Oxygenation for respiratory failure from 1993 to 2007 who received support for ≥21 days. Interventions: None. Measurements and Main Results: Of the 3213 children supported with extracorporeal membrane Oxygenation during the study period, 389 (12%) were supported ≥21 days. Median patient age was 9.1 months (interquartile range, 2.5–41.7 months). Median weight was 6.7 kg (interquartile range, 3.5–15.8 kg). Survival for this group was 38%, significantly lower than survival reported for children supported ≤14 days (61%, p < .001). Among children supported with extracorporeal membrane Oxygenation for ≥21 days, no differences were found between survivors and nonsurvivors with regard to acute pulmonary diagnosis, pre-extracorporeal membrane Oxygenation comorbidities, pre-extracorporeal membrane Oxygenation adjunctive therapies, or pre-extracorporeal membrane Oxygenation blood gas parameters. Only peak inspiratory pressure was significantly different in survivors. Complications occurring on extracorporeal membrane Oxygenation were more common among nonsurvivors. The use of inotropic infusion (odds ratio 1.64; 95% confidence interval 1.07–2.52), acidosis (pH <7.2) during extracorporeal membrane Oxygenation (odds ratio 2.62; 95% confidence interval 1.51–4.55), and male gender (odds ratio 1.95; 95% confidence interval 1.21–3.15) were independently as sociated with increased odds of death. Conclusion: Survival declines with duration of extracorporeal membrane Oxygenation. Male gender and inadequate cardiorespiratory status during extracorporeal membrane Oxygenation increased the risk of death. Prolonged support with extracorporeal membrane Oxygenation appears reasonable unless multiorgan failure develops. (Pediatr Crit Care Med 2012; 13:e249–e254)
Graeme Maclaren - One of the best experts on this subject based on the ideXlab platform.
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venoarterial extracorporeal membrane Oxygenation for postcardiotomy shock analysis of the extracorporeal life support organization registry
Critical Care Medicine, 2021Co-Authors: Mariusz Kowalewski, Daniel Brodie, Graeme Maclaren, Kamil Zielinski, Glenn J R Whitman, Giuseppe Maria Raffa, U Boeken, Kiran Shekar, Yihsharng Chen, Christian BermudezAbstract:Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane Oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane Oxygenation for postcardiotomy cardiogenic shock. Analysis of extracorporeal life support organization registry from January 2010 to December 2018. Multicenter worldwide registry. Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane Oxygenation for postcardiotomy cardiogenic shock. Venoarterial extracorporeal membrane Oxygenation. Hospital death, weaning from extracorporeal membrane Oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane Oxygenation. A significant trend toward more extracorporeal membrane Oxygenation use in recent years (coefficient, 0.009; p The analysis confirmed increased use of venoarterial extracorporeal membrane Oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.
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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.
Chris L Wells - One of the best experts on this subject based on the ideXlab platform.
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safety and feasibility of early physical therapy for patients on extracorporeal membrane oxygenator university of maryland medical center experience
Critical Care Medicine, 2018Co-Authors: Ali Tabatabai, Chris L Wells, Jenny Forrester, Joshua Vogel, Raymond Rector, Daniel HerrAbstract:OBJECTIVES: To examine the feasibility and safety of mobilizing patients while on extracorporeal membranous Oxygenation support. DESIGN: Retrospective cohort study. SETTING: Medical and Surgical ICUs in a large tertiary care hospital in the United States. PATIENTS: Adults supported on extracorporeal membranous Oxygenation from January 2014 to December 2015. MEASUREMENTS AND MAIN RESULTS: We reviewed the medical records from physical therapy, perfusion, and intensivists to obtain the number and type of physical therapy interventions and discharge status; extracorporeal membranous Oxygenation type and description of support, cannulation sites; and risk management details of adverse effects, if any. Of 254 patients supported on extracorporeal membranous Oxygenation, 167 patients (66.7%) received a total of 607 physical therapy sessions while on extracorporeal membranous Oxygenation support. In this cohort, 134 patients (80.2%) had at least one femoral cannula during physical therapy intervention. Sixty-six of the 167 patients (39.5%) were supported on extracorporeal membranous Oxygenation with bifemoral cannulas, and 44 (26.3%) were on veno-arterial extracorporeal membranous Oxygenation. A dual lumen catheter was only used in five cases. Twenty-five patients (15%) (13 bifemoral cases) participated in standing or ambulation activities. Seventy-five patients (68.8%) who were successfully weaned from extracorporeal membranous Oxygenation were discharged to a rehabilitation facility; 26 patients (23.8%) went home. Three minor events (< 0.5%) involving two episodes of arrhythmias and a hypotension event interrupted the therapy sessions, but mobility activities and exercises resumed that day. No major events were reported. CONCLUSIONS: With a highly trained multidisciplinary team and a focus on restoring function, it is feasible and safe to deliver early rehabilitation including standing and ambulation to patients on extracorporeal membranous Oxygenation support even those with femoral cannulation sites with veno-arterial extracorporeal membranous Oxygenation and veno-venous extracorporeal membranous Oxygenation.
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safety and feasibility of early physical therapy for patients on extracorporeal membrane oxygenator university of maryland medical center experience
Critical Care Medicine, 2018Co-Authors: Ali Tabatabai, Chris L Wells, Jenny Forrester, Joshua Vogel, Raymond Rector, Daniel L HerrAbstract:OBJECTIVES To examine the feasibility and safety of mobilizing patients while on extracorporeal membranous Oxygenation support. DESIGN Retrospective cohort study. SETTING Medical and Surgical ICUs in a large tertiary care hospital in the United States. PATIENTS Adults supported on extracorporeal membranous Oxygenation from January 2014 to December 2015. MEASUREMENTS AND MAIN RESULTS We reviewed the medical records from physical therapy, perfusion, and intensivists to obtain the number and type of physical therapy interventions and discharge status; extracorporeal membranous Oxygenation type and description of support, cannulation sites; and risk management details of adverse effects, if any. Of 254 patients supported on extracorporeal membranous Oxygenation, 167 patients (66.7%) received a total of 607 physical therapy sessions while on extracorporeal membranous Oxygenation support. In this cohort, 134 patients (80.2%) had at least one femoral cannula during physical therapy intervention. Sixty-six of the 167 patients (39.5%) were supported on extracorporeal membranous Oxygenation with bifemoral cannulas, and 44 (26.3%) were on veno-arterial extracorporeal membranous Oxygenation. A dual lumen catheter was only used in five cases. Twenty-five patients (15%) (13 bifemoral cases) participated in standing or ambulation activities. Seventy-five patients (68.8%) who were successfully weaned from extracorporeal membranous Oxygenation were discharged to a rehabilitation facility; 26 patients (23.8%) went home. Three minor events (< 0.5%) involving two episodes of arrhythmias and a hypotension event interrupted the therapy sessions, but mobility activities and exercises resumed that day. No major events were reported. CONCLUSIONS With a highly trained multidisciplinary team and a focus on restoring function, it is feasible and safe to deliver early rehabilitation including standing and ambulation to patients on extracorporeal membranous Oxygenation support even those with femoral cannulation sites with veno-arterial extracorporeal membranous Oxygenation and veno-venous extracorporeal membranous Oxygenation.
