Cause of In-Hospital Death After Weaning from Venoarterial-Extracorporeal Membrane Oxygenation

Abstract

Purpose A survival gap between weaning from venoarterial-extracorporeal membrane oxygenation (VA-ECMO) and the hospital discharge has been consistently reported. The aim of this study is to investigate the clinical features of patients who underwent successful VA-ECMO decannulation at our institution and to identify the major contributors responsible for adverse outcomes. Methods We retrospectively reviewed all patients supported with VA-ECMO in our institution between January 2013 and June 2020. Only patients that survived VA-ECMO and underwent successful decannulation were included and dichotomized based on survival to hospital discharge: non-survivors versus survivors. The primary study outcome was the cause of death after successful VA-ECMO decannulation. Results Of the 262 adult patients who underwent VA-ECMO decannulation, 72 (27.5%) patients did not survive to hospital discharge. Non-survivors were older (62 vs. 54 years, p < 0.001) and suffering from many pre-existing comorbidities. Pneumonia and sepsis were the most frequent infectious complication and almost twice as likely in non-survivors. Major causes of death were: cardiovascular (31.9%), infections (25.0%) and neurological (20.8%). The survival curve demonstrated that 51.4% of our patients died within 8 days after decannulation. Multivariate analysis identified older age, central venous cannulation, pulmonary bleeding and infection, dialysis after VA-ECMO, sepsis, and ischemic stroke (OR = 7.86, 95% CI: 2.76-2.43, p < 0.001) as factors significantly predisposing to patients’ death. Conclusion In our study, one-third of patients decannulated off VA-ECMO did not survive to hospital discharge due to end-stage heart failure, infections or neurological injury. The first 8 post-decannulation days were recognized as a critical period where thorough strategies to prevent acquired infections and cautious support of end-organ function should be warranted. Future large-scale trials are needed to confirm our results.

Extracorporeal membrane oxygenation in patients with acute coronary syndrome during high-risk percutaneous coronary intervention

“…The ECMO-related infection is a common complication, the rate of ECMO-related infections is associate with many factors, such as auxiliary time of VA-ECMO (22) and patients' quality of care (23). The infection rate seems higher in our study than ELSO interim guidelines (24), whereas, no patient was found by culture proven infection.…”

Metagenomic Next-generation Sequencing for Pathogen Identification in Bronchoalveolar Lavage Fluid From Neonates Receiving Extracorporeal Membrane Oxygenation

“…This is consistent with previously reported infectious agents. 19 Therefore, when performing VA-ECMO surgery, catheter care, and strict aseptic procedures, especially cleaning and maintenance of the airway and central venous access, may be important measures to prevent VA-ECMOrelated hospital infections. 9,21,30 Neonates on ECMO have a higher incidence of mixed infections due to their immunocompromised status and the placement of multiple invasive catheters.…”

“…However, ECMO may increase the risk of ECMO-associated nosocomial infections because it can induce abnormal immune function in patients through pan-endothelial damage, leukocyte activation, and pro-inflammatory responses, as well as pharmacokinetic and pharmacodynamic changes in antimicrobial drugs. 19 Infection is one of the most common complications in ECMO patients, leading to increased morbidity and mortality. 20 The rate of hospital-acquired infections in ECMO neonates has been reported to be significantly higher than in non-ECMO neonates (13.8 vs. 8.8/1000 ICU admission days) and has serious consequences, leading to prolonged ECMO support time, duration of mechanical ventilation, duration of central venous catheterization and ICU stay.…”