Extracorporeal membrane oxygenation in adult patients with hematologic malignancies and severe acute respiratory failure

Abstract

IntroductionAcute respiratory failure (ARF) is the main reason for intensive care unit (ICU) admissions in patients with hematologic malignancies (HMs). We report the first series of adult patients with ARF and HMs treated with extracorporeal membrane oxygenation (ECMO).MethodsThis is a retrospective cohort study of 14 patients with HMs (aggressive non-Hodgkin lymphoma (NHL) n = 5; highly aggressive NHL, that is acute lymphoblastic leukemia or Burkitt lymphoma, n = 5; Hodgkin lymphoma, n = 2; acute myeloid leukemia, n = 1; multiple myeloma, n = 1) receiving ECMO support because of ARF (all data as medians and interquartile ranges; age, 32 years (22 to 51 years); simplified acute physiology score II (SAPS II): 51 (42 to 65)). Etiology of ARF was pneumonia (n = 10), thoracic manifestation of NHL (n = 2), sepsis of nonpulmonary origin (n = 1), and transfusion-related acute lung injury (n = 1). Diagnosis of HM was established during ECMO in four patients, and five first received (immuno-) chemotherapy on ECMO.ResultsBefore ECMO, the PaO2/FiO2 ratio was 60 (53 to 65), (3.3 to 3.7). Three patients received venoarterial ECMO because of acute circulatory failure in addition to ARF; all other patients received venovenous ECMO. All patients needed vasopressors, and five needed hemofiltration. Thrombocytopenia occurred in all patients (lowest platelet count was 20 (11 to 21) G/L). Five major bleeding events were noted. ECMO duration was 8.5 (4 to 16) days. ICU and hospital survival was 50%. All survivors were alive at follow-up (36 (10 to 58) months); five patients were in complete remission, one in partial remission, and one had relapsed.ConclusionsECMO therapy is feasible in selected patients with HMs and ARF and can be associated with long-term disease-free survival.

Focus on immunocompromised patients

“…Benefits of extracorporeal membrane oxygenation in immunocompromised patients remain uncertain, although an increasing body of evidence suggests feasibility in selected cases. Following a case series suggesting feasibility and some long-term survival in adult patients with haematological malignancies [11], Smith et al reported similar results in nine paediatric critically ill neutropenic patients, the majority of whom had high-grade haematological malignancies [12]. In this setting, hospital mortality was found to be as high as 44% with long-term survival of 22% [12].…”

Extracorporeal membrane oxygenation as a rescue therapy for acute respiratory failure during chemotherapy in a patient with acute myeloid leukemia

“…With improvements in ECMO technology and expertise lowering morbidity and mortality, the criteria for the use of ECMO may be extended to ARDS patients with hematological malignancies such as acute leukemia and lymphoma (7,12). Wohlfarth et al (7) reported a remarkable 50% survival rate, despite the presence of numerous factors known to be associated with an adverse outcome in patients with hematological malignancies undergoing ECMO.…”

“…Wohlfarth et al (7) reported a remarkable 50% survival rate, despite the presence of numerous factors known to be associated with an adverse outcome in patients with hematological malignancies undergoing ECMO.…”

“…There are some reports on weaning adult patients with hematological malignancies such as acute lymphoid leukemia, lymphoma, and multiple myeloma from ECMO (7,12). However, there are few reports of performing this during induction chemotherapy in an adult with AML (8).…”

“…Compared to standard indications for ECMO, cytopenia further increases the risks of infection and bleeding. There are some data on the use of ECMO in patients with hematological malignancies (6)(7)(8), but few reports on its use in adults with AML through chemotherapy. Here, we report a patient with pneumonia and ARDS treated with ECMO during induction chemotherapy for AML.…”