Extracorporeal Membrane Oxygenation (ECMO) and the Critical Cardiac Patient

Baran, David A.

doi:10.1007/s40472-017-0158-5

Cited by 44 publications

(30 citation statements)

References 65 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…In patients with profound haemodynamic instability or cardiac arrest (discussed below) venoarterial‐extracorporeal membrane oxygenation (VA‐ECMO) may be a temporary or bridging measure to restore tissue perfusion. VA‐ECMO is also indicated for patients who fail to reperfuse after thrombolysis, have contraindications to immediate treatment or where diagnosis is uncertain . ECMO is only available in certain centres, and due to a significant risk profile (including infection, vascular complications and haemorrhage), it should be reserved for life‐threatening cases of aPE as a rescue therapy.…”

Section: Management Of Apementioning

confidence: 99%

“…VA-ECMO is also indicated for patients who fail to reperfuse after thrombolysis, have contraindications to immediate treatment or where diagnosis is uncertain. 79,80 ECMO is only available in certain centres, and due to a significant risk profile (including infection, vascular complications and haemorrhage), it should be reserved for life-threatening cases of aPE as a rescue therapy.…”

Section: Mechanical Supportmentioning

confidence: 99%

See 1 more Smart Citation

Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

View full text Add to dashboard Cite

An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation‐perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50–75 per 100 000 in Australia and New Zealand, with 30‐day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision‐making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation‐perfusion scans) is still necessary for objective diagnosis. Anti‐coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti‐coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti‐coagulation and review. However, treatment should be case dependent with full consideration of the patient’s clinical state. Direct oral anti‐coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti‐coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6–12 months.

show abstract

Section: Management Of Apementioning

confidence: 99%

Section: Mechanical Supportmentioning

confidence: 99%

Acute pulmonary embolism: a concise review of diagnosis and management

Hepburn-Brown

Darvall

Hammerschlag

2019

Internal Medicine Journal

View full text Add to dashboard Cite

show abstract

“…Appropriate patient selection for VA‐ECMO is an important and often difficult clinical question 1‐3 . A number of prognostic tools have been developed to aid in identifying which patients will achieve meaningful recovery after VA‐ECMO support, 4 but there remains room for improvement.…”

Section: Resultsmentioning

confidence: 99%

MELD‐XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation

et al. 2020

View full text Add to dashboard Cite

Background Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is a life‐saving method of supporting critically ill patients. However, it is expensive and associated with high morbidity and mortality, making early predictive outcome modeling extremely valuable. The model for end‐stage liver disease‐excluding international normalized ratio (MELD‐XI) scoring system has been shown to have prognostic value in other critically ill patient populations. Materials and Methods A single‐center retrospective review was performed for all adult patients managed on VA‐ECMO from May 2011 to January 2018 (n = 247). Patients were included in the study if MELD‐XI scores could be calculated during the first 48 hours on ECMO (n = 187). Receiver operating characteristic curve analysis was performed for MELD‐XI in regard to in‐hospital mortality. Results Of the 187 patients, 74 (40%) patients had MELD‐XI less than 14 (low‐risk) and 113 (60%) had a MELD‐XI of 14 or greater (high‐risk). The cohorts did not differ significantly in terms of patient characteristics or indication for ECMO. The high‐risk MELD‐XI group had significantly greater mortality during index hospitalization compared to the low‐risk group (74% vs 39%; P < .0001). Quartile stratification demonstrated progressively worse prognosis associated with higher MELD‐XI scores; the fourth quartile showed a ninefold increased risk of mortality compared to the first quartile (P < .001). The AUC for predicting index hospitalization mortality was 0.69 (95% CI, 0.62‐0.77) with a Youden index (J) of 0.36 and optimized cutoff of 12.98. Conclusions These findings suggest that the MELD‐XI scoring system can be applied to the VA‐ECMO patient population early in their course of ECMO as a prognostic tool to aid in complex clinical decision making.

show abstract

“…First, decreased cardiac preload caused by increased venous drainage reduces the venous return of blood flow to the right atrium. At the same time, cardiac afterload and vascular resistance could increase as a result of increased VA-ECMO arterial blood flow [19,20]. The decreased preload and increased afterload may reduce the patient's own cardiac output and sublingual microcirculation.…”

Section: Discussionmentioning

confidence: 99%

Contradictory responses of the microcirculation to changes in extracorporeal membrane oxygenation pump flow in patients on venoarterial extracorporeal membrane oxygenation: a prospective observational study

Wei¹,

Wang²,

Chan³

et al. 2020

Preprint

View full text Add to dashboard Cite

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) pump flow is crucial for maintaining tissue and organ perfusion in patients with cardiogenic shock. Determining the optimal VA-ECMO pump flow rate to maintain adequate tissue perfusion remains a clinical challenge. Poor microcirculation is associated with higher mortality in patients using VA-ECMO. Change in VA-ECMO pump flow is expected to result in a coherent change in microcirculatory blood flow, but this has not been investigated. This study investigated the effect of altering VA-ECMO pump flow rate on sublingual microcirculation. Methods: Sublingual microcirculation images were recorded using an incident dark-field hand held vital microscope at two time points, within 24 h (T1) and at 24-48 h (T2) after VA-ECMO placement. Microcirculation was measured before and 5 minutes after the changes in VA-ECMO pump flow rate at each time point. Events of changing VA-ECMO pump flow rate at T1 and T2 were divided into four groups according to changes in perfused vessel density (PVD): Group A, increased pump flow rate and increased or sustained PVD; Group B, increased pump flow rate and decreased PVD; Group C, decreased pump flow rate and increased or sustained PVD; and Group D, decreased pump flow rate and decreased PVD. The microcirculatory parameters, clinical parameters, and prognosis of each subgroup were recorded. Clinical parameters on 14-day and 28-day survivors and non-survivors were also compared. Results: A total of 25 patients were enrolled, and 38 events with good-quality images at T1 and T2 were categorized. Opposing response of microcirculation was observed in 43.5% of events when VA-ECMO pump flow rate was increased. Microcirculation was decreased in 33.4% of events when VA-ECMO pump flow rate was reduced. No predictive values in microcirculatory or macrocirculatory parameters before changing VA-ECMO pump flow rate were identified. Conclusions: Changes in VA-ECMO pump flow rate may have opposing effects on sublingual microcirculatory functional capillary density. We suggest that tandem measurements of microcirculation before and after altering the VA-ECMO pump flow may help to ensure optimal tissue perfusion.

show abstract

Extracorporeal Membrane Oxygenation (ECMO) and the Critical Cardiac Patient

Cited by 44 publications

References 65 publications

Acute pulmonary embolism: a concise review of diagnosis and management

Acute pulmonary embolism: a concise review of diagnosis and management

MELD‐XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation

Contradictory responses of the microcirculation to changes in extracorporeal membrane oxygenation pump flow in patients on venoarterial extracorporeal membrane oxygenation: a prospective observational study

Contact Info

Product

Resources

About