Extracorporeal membrane oxygenation support for refractory septic shock in liver transplantation recipients

Abstract

PurposeThis study was designed to assess the outcome of the extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) recipients with refractory septic shock and predict the prognosis of those cases.MethodsFrom February 2005 to October 2012, ECMO was used in 8 cases of refractory septic shock. Laboratory values including lactate and total bilirubin level just before starting ECMO were obtained and sepsis-related organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACH) II score and simplified acute physiology score (SAPS) 3 were calculated. Subsequent peak serum lactate and total bilirubin level, and SOFA score after 24 hours of starting ECMO were measured.ResultsComparisons were made between survivors and nonsurvivors. ECMO was weaned off successfully in 3 patients (37.5%) and 2 patients (25%) survived to hospital discharge. Clinical scores including SOFA, APACH II, and SAPS3 and laboratory results including lactate, total bilirubin and CRP were not significantly different between survivor and nonsurvivor groups. Lactate level and SOFA score tended to decrease after ECMO support in survivor group and total bilirubin and CRP level tended to increase in nonsurvivor group.ConclusionOur findings suggest that the implantation of ECMO might be considered in highly selected LT recipients with refractory septic shock.

Abdominal Surgery Needs Extracorporeal Life Support as a Final Back-up

“…A similar survival rate was reported when ECMO support was used as an acute resuscitation tool for in-hospital cardiac arrest [10,11]. On the other hand, Lee et al [1] reported that the survival rate of patients with refractory hypotension after liver transplantation who received ECMO was 25%. Enhanced survival after ECMO support was reported among patients who suffered from heart failure due to fulminant myocarditis and those who underwent VV-ECMO for H1N1-related ARDS.…”

“…The benefits of the use of ECMO in various critical contexts, including cardiogenic shock, refractory septic shock, in-hospital cardiac arrest, ARDS or transplantation, have been reported in other series [1]. Among patients with cardiogenic shock or postcardiotomy syndrome who were receiving ECMO, the reported rate of survival to hospital discharge was between 24% and 45% [3,12,14].…”

“…During post-operative care after major abdominal surgery, rapid patient deterioration leading to critical conditions, such as refractory hypotension or ARDS, may develop and are associated with high mortality rates despite intensive resuscitation [1,2]. Although ECMO may be used to rescue patients, general surgeons or critical care physicians often fear that ECMO-related complications may result in 3 even more catastrophic consequences, such as massive surgical site bleeding haemorrhage or major thromboembolic events [3].…”

Use of ECMO in Sepsis and Septic Shock

“…Several publications [24][25][26][27] report on the use of ECMO in immunocompromised patients, mainly kidney and liver transplanted patients. Infections are the leading cause of critical illness and mortality in liver transplant patients.…”

“…Mortality is higher in recipients with bacteremia due to 'ESKAPE' pathogens, which stands for Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species [28]. Over a 7-year period, a South Korean university center [24] used ECMO in 8 (of in total 854) liver transplanted patients with refractory septic shock. Primary liver disease in these patients was hepatocellular carcinoma (n = 3), liver cirrhosis due to hepatitis B infection (n = 3), alcoholic liver cirrhosis (n = 1) and toxic hepatitis (n = 1).…”