Brain injury during venovenous extracorporeal membrane oxygenation

Luyt, Charles‐Édouard; Bréchot, Nicolas; Demondion, Pierre; Jovanović, Tamara; Hékimian, Guillaume; Lebreton, Guillaume; Nieszkowska, Ania; Schmidt, Matthieu; Trouillet, Jean‐Louis; Leprince, Pascal; Chastre, Jean; Combes, Alain

doi:10.1007/s00134-016-4318-3

Cited by 209 publications

(240 citation statements)

References 31 publications

Supporting

Mentioning

215

Contrasting

Unclassified

Order By: Relevance

“…However, since the CESAR study was criticized for methodological limitations and due to the fact that results of non-randomized case series of ECMO are prone to selection biases, indications for ECMO use remain highly controversial [28][29][30].…”

Section: Resultsmentioning

confidence: 99%

Indications for extracorporeal support: why do we need the results of the EOLIA trial?

Bréchot

Schmidt

2017

Med Klin Intensivmed Notfmed

View full text Add to dashboard Cite

Section: Resultsmentioning

confidence: 99%

Indications for extracorporeal support: why do we need the results of the EOLIA trial?

Bréchot

Schmidt

2017

Med Klin Intensivmed Notfmed

View full text Add to dashboard Cite

“…Furthermore, the mechanisms underlying the high rate of cerebral hemorrhage experienced in V-V subjects might be different from the same event observed in V-A patients, who, instead, have higher rates of brain death and ischemic injury. The importance of altered blood gases, particularly of CO 2 clearance, in the genesis of neurologic adverse events has been underlined by several investigators (4,5,13).…”

mentioning

confidence: 99%

“…Besides the understanding of underlying mechanisms of CNS events during ECLS, monitoring and timely recognition of the adequacy of brain perfusion or the onset of maladaptive changes and cerebral injury, either perfusion or structurerelated, is paramount, but mostly lacking in ECLS patients. On-line information about appropriateness of anticoagulation state and presence and extent of coagulation disorder, brain perfusion and onset of cerebral tissue injury, as well as information about vascular structural and functional integrity, are all part of the complex puzzle which constitutes the ECLS/ patient interplay which is, at the moment, poorly defined and understood (12)(13)(14)(15)(16)(17)(18). As mentioned, it is likely that CNS event-related etiology is multifactorial, but we are still far from understanding why some patients develop such brain damages and some not.…”

mentioning

confidence: 99%

Extracorporeal life support and neurologic complications: still a long way to go

Lorusso

2017

J. Thorac. Dis.

View full text Add to dashboard Cite

The actual impact of neurological complications on patient outcome during extracorporeal life support (ECLS) has emerged only since a few years (1,2) despite the use of such a temporary heart/lung support for more than four decades.The recent appraisal of the rather high incidence and ominous prognosis of these adverse events in ECLS patients have now alerted attending physicians and personnel upon continuous surveillance and early recognition. Nonetheless, it is increasingly evident that the mechanisms underlying the occurrence are not simply linked to embolization, bleeding, or low-flow related brain hypoxia (3-5) which were thought to represent the sole source of injury of the brain in ECLS patients.Following a study addressing the neurologic complications in the neonatal population (6), other two studies realized by analysing the Registry of the Extracorporeal Life Support Organization (ELSO), have recently investigated and clearly shown the entity of neurologic adverse events in veno-arterial (V-A) and veno-venous (V-V) ECLS configurations in adult patient populations (7,8). Incidence rates of brain injury were 15% in V-A and 7% in V-V patients, respectively, with an in-hospital survival of 10% in the first group, and 25% in the second, underlining the ominous prognosis once a neurological event occurs in the ECLS patients (7,8). These studies analyzed also the type of brain damage, according to the ELSO reporting system (embolism, hemorrhage, seizures, brain death) but also, more importantly, the trends of the overall CNS complications and of the single typerelated rates of such adverse events during a 20-year period whose assessment provided interesting findings (7,8).The difference of neurologic complication rates between V-A and V-V is not surprising. However, the two studies, as also highlighted by the comments provided by Pappalardo, Hirose, and Perico herewith enclosed (9-11), have provided several relevant clues for further interpretation and discussion. Interestingly, the incidence of CNS events in V-A ECLS patients steadily declined in the recent years, whereas no substantial change was observed in the V-V ECLS population (7,8). It is well-known that patients undergoing V-A ECLS, by definition and as also confirmed by the ELSO Registry data, are usually more prone to experience bleeding and hemodynamic instability after ECLS implant than V-V cases, therefore at higher risk also for brain injury. This is due to either the underlying disease, settings, and clinical conditions of the ECLS candidates or to the ECLS access (arterial cannulation certainly at higher risk of bleeding than venous access). V-A ECLS, indeed, is often applied nowadays in patients suffering from cardiac arrest, condition which is directly linked to brain hypoperfusion

show abstract

“…Intracranial haemorrhage occurs in around 5% of patients undergoing vv-ECMO [7]. Haemorrhage appears to also be a common issue in patients undergoing ECCO 2 -R, with around one-third of them developing bleeding [8].…”

mentioning

confidence: 99%

Focus on ECMO and ECCO2R in ARDS patients

Bein

Aubron²,

Papazian

2017

Intensive Care Med

View full text Add to dashboard Cite

The technical aspects of veno-venous extracorporeal membrane oxygenation (vv-ECMO) are still improving, permitting the treatment of ARDS patients with very severe hypoxaemia. A recent German survey showed that the incidence of vv-ECMO in the population increased from 1.0:100,000 inhabitants/year in 2007 to a maximum of 3.0:100,000 in 2012, and then stabilised at 2.4:100,000 in 2014 [1]. The in-hospital mortality slightly decreased over time but remained high, at 58.1% in 2014. This real-life mortality rates in an unselected population of patients undergoing ECMO for ARDS is even higher than previously reported. The extracorporeal CO 2 -removal (ECCO 2 -R) is a modification of ECMO characterised by a reduction in extracorporeal blood and sweep gas flow. The aims of ECCO 2 -R are: (1) the management of acute 'isolated' hypercapnic respiratory failure, (2) the reduction of tidal volume (3-4 ml/kg) and the control of hypercapnia, and (3) the avoidance of intubation in exacerbated chronic obstructive lung disease. While in the latter situation a number of small observational studies or case reports exerted promising results, the scientific evidence for the use and benefit of ECCO 2 -R in ARDS patients is limited [2].The prospective observational study by Hermann et al. [3], investigating the efficacy and safety of a novel pumpdriven ECCO2-R-system demonstrated a significant, but 'intensity'-dependent, amount of CO 2 removal between 40 and 70 ml/min. The CO 2 transfer was dependent on the amount of blood flow (0.5-2.0 l/min) and sweep gas flow. A rapid normalisation of hypercapnia secondary to higher blood flows (>1.0 l/min) and a moderate increase in oxygenation were found. However, very high sweep gas flows (higher than 10 l/min) were associated with a deterioration in O 2 and CO 2 transfer. Based on these study results, it is recommended to use ECCO 2 -R settings that combine moderate blood flow (1-1.5 l/min) and sweep gas flow (2-8 l/min) to achieve the best clinical effect and to avoid adverse effects. The combination of ECCO 2 -R and renal replacement therapy was investigated in 11 patients with ARDS and acute renal failure [4]. A membrane oxygenator was inserted in a continuous RRT system, resulting in an average CO 2 removal rate of 80 ml/ min (corresponds to a reduction of ≈20% of the arterial PaCO 2 level). Consequently, the tidal volume was lowered from 6 to 4 ml/kg and the plateau pressure could be reduced from 25 to 21 cm H 2 O (p < 0.01); no adverse events were reported. It is concluded that the combination of ECCO 2 -R with renal replacement therapy allows a safe and adequate blood 'purification' of renal-and pulmonary-associated substances together while enhancing lung protective ventilation in critically ill patients. The trend towards a 'personalised medicine' has reached intensive care medicine and the management of ARDS patients should be revisited accordingly [5]. ECCO 2 -R could become an important part of such a project in a 'balanced' portfolio of extracorporeal lung support. Although vv-ECMO r...

show abstract

Brain injury during venovenous extracorporeal membrane oxygenation

Cited by 209 publications

References 31 publications

Indications for extracorporeal support: why do we need the results of the EOLIA trial?

Indications for extracorporeal support: why do we need the results of the EOLIA trial?

Extracorporeal life support and neurologic complications: still a long way to go

Focus on ECMO and ECCO2R in ARDS patients

Contact Info

Product

Resources

About