Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation

Schmidt, Matthieu; Bailey, Michael; Kelly, Joshua; Hodgson, Carol; Cooper, Jamie; Scheinkestel, Carlos; Pellegrino, Vincent; Bellomo, Rinaldo; Pilcher, David

doi:10.1007/s00134-014-3360-2

Cited by 151 publications

(160 citation statements)

References 52 publications

(68 reference statements)

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“…The physiological rationale for limiting fluid volume in ARDS has been detailed in numerous reviews and is supported by clinical evidence. [19][20][21] Our recommendation is based on the results from the ARDS network trial (FACTT study) 19 that compared a fluid-restrictive vs. fluid-liberal approach in adults with mild to severe ARDS (i.e. targeting either a neutral fluid balance or central venous pressure and pulmonary-arteryocclusion pressure at 10-14 mmHg and 14-18 mmHg, respectively).…”

Section: A General Note On Recommendations For Unlicensed Drug Usementioning

confidence: 99%

Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome

Claesson

Freundlich

Gunnarsson

et al. 2016

Acta Anaesthesiol Scand

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Background The objective of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force on fluid and drug therapy in adults with acute respiratory distress syndrome (ARDS) was to provide clinically relevant, evidence‐based treatment recommendations according to standards for trustworthy guidelines. Methods The guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations. Results A total of seven ARDS interventions were assessed. We suggest fluid restriction in patients with ARDS (weak recommendation, moderate quality evidence). Also, we suggest early use of neuromuscular blocking agents (NMBAs) in patients with severe ARDS (weak recommendation, moderate quality evidence). We recommend against the routine use of other drugs, including corticosteroids, beta2 agonists, statins, and inhaled nitric oxide (iNO) or prostanoids in adults with ARDS (strong recommendations: low‐ to high‐quality evidence). These recommendations do not preclude the use of any drug or combination of drugs targeting underlying or co‐existing disorders. Conclusion This guideline emphasizes the paucity of evidence of benefit – and potential for harm – of common interventions in adults with ARDS and highlights the need for prudence when considering use of non‐licensed interventions in this patient population.

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Section: A General Note On Recommendations For Unlicensed Drug Usementioning

confidence: 99%

Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome

Claesson

Freundlich

Gunnarsson

et al. 2016

Acta Anaesthesiol Scand

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“…The addition of CRRT (with bicarbonate-based solutions) efficiently manages severe lactic acidosis avoiding fluid overload and hypocalcemia in hemodynamically unstable patients. Hence combining ECMO with CRRT might result in rapid reversal of the metabolic sequelae of lactic acidosis [4][5][6].…”

Section: Indications and Benefits Of Combined Ecmo-crrt Treatmentmentioning

confidence: 99%

“…It can correct azotemia, electrolyte imbalance and decrease levels of inflammatory cytokines as well as systemic inflammatory response syndrome induced by ECMO. The latter might be beneficial in terms of decreasing ECMO-induced renal injury [4][5][6].…”

Section: Indications and Benefits Of Combined Ecmo-crrt Treatmentmentioning

confidence: 99%

“…Hence, early initiation of CRRT before the onset of fluid overload should be considered in patients on ECMO. Blijdorp et al observed that initiating preemptive CRRT during ECMO in neonatal patients improved outcomes by decreasing time on ECMO due to improved fluid management [6,7]. It has also been shown that odds ratio for death was higher when CRRT was started later and longer it was performed.…”

Section: Timing Of Initiation Of Crrt In Ecmo Patientsmentioning

confidence: 99%

See 1 more Smart Citation

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

Thajudeen¹,

Daheshpour²,

Bijin³

2016

Extracorporeal Membrane Oxygenation: Advances in Therapy

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Extracorporeal membrane oxygenation (ECMO) is a supportive therapy, which provides cardiopulmonary and end-organ support in critically ill patients when other measures fail. These patients receive large amounts of fluid for volume resuscitation, blood products and caloric intake, which results in fluid overload and which in turn is associated with impairment of oxygen transport and increased incidence of multiple organ failure especially heart, lungs and brain. It is common to see a decrease in urine output during ECMO that may be associated with acute renal failure. The acute renal failure is a manifestation of multiple organ system failure due to acute decompensated heart failure, sepsis, hemolysis, use of vasopressors/inotropes, nephrotoxic medications, and activation of complement system during ECMO support. It is associated with poor prognosis and higher mortality in ECMO patients. Continuous renal replacement therapy (CRRT) in patients on ECMO provides an efficient and potentially beneficial method of fluid overload and acute kidney injury management. In addition, recent data suggest that the use of CRRT may remove inflammatory cytokine released as a result of circulation of blood across synthetic surfaces during ECMO. The two most common methods to provide CRRT are through the use of an inline hemofilter or through a traditional CRRT device connected to the extracorporeal circuit. The primary objective of this chapter is to discuss current state and role of renal replacement therapy in patients on ECMO and address the controversies and challenges about its application.

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“…Fluid balance is also associated with oxygenation alterations. It was recently shown [15] that a positive fluid balance on ECMO day 3 was associated with a higher hospital mortality, while there was no difference among survivors and patients who died during the first 2 days. This result strongly confirms that it is difficult to minimize fluid administration during the very early phase of ARDS.…”

mentioning

confidence: 97%

Focus on veno-venous ECMO in adults with severe ARDS

Papazian

Herridge

2016

Intensive Care Med

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Veno-venous extracorporeal membrane oxygenation (vvECMO) improves oxygenation and promotes carbon dioxide (CO 2 ) removal [1,2]. In the most severe form of ARDS, ECMO rapidly facilitates the correction of severe derangement in gas exchange and saves time, which allows one to treat the cause of lung injury. Recent advances in ECMO technology have improved safety and promoted its use [3][4][5].Knowledge of the gas exchange performance of membrane oxygenators is important to help choose the optimal system for patients suffering from acute respiratory failure. In an in vivo study of 317 vvECMO patients supported with four different ECMO systems, Lehle et al. [6] showed that CO 2 transfer was dependent on sweep gas flow and blood flow, while O 2 transfer was only dependent on blood flow when it was above 3 L/min.The association between ECMO use and the development of thrombocytopenia secondary to circuit-induced platelet activation and aggregation has been suggested, although never carefully evaluated. In a retrospective cohort study of 100 adults who received vvECMO for acute respiratory failure, Abrams et al. [7] demonstrated that the severity of critical illness and platelet count at the time of cannulation were independently associated with the development of severe thrombocytopenia, while the duration of ECMO support was not.A position paper [8] from an international group of experts described the optimal approach to organizing programs and delivering safe and proficient ECMO for acute respiratory failure. They encouraged restraint in the widespread use of ECMO until a better appreciation of both the potential clinical applications and the optimal techniques for performing ECMO are available. They also underlined the need for further randomized controlled trials assessing this technique.Using hospital ECMO volumes from 290 international centers, a retrospective study of more than 55,000 ECMO patients [9] found an association between higher adult ECMO hospital volume and lower ECMO mortality rates. Patients receiving ECMO at hospitals with more than 30 adult annual ECMO cases had significantly lower odds of mortality (adjusted odds ratio, 0.61; 95 % confidence interval 0.46-0.80) compared with those receiving ECMO at hospitals with fewer than six cases annually.In a review paper, Levy et al.[10] proposed a multistep therapeutic approach with optimization of ECMO blood flow, red blood cell transfusion, moderate hypothermia, and short-action beta-blockers for the management of persistent severe hypoxemia under vvECMO. Important technical considerations for the care of ECMO patients by nurses [11] and physicians were also detailed in a review.The optimal ventilatory strategy for ARDS patients under ECMO remains unclear. Controlled mechanical ventilation is recommended in the first few days [12]. While the ventilator settings should be as low as possible to reduce ventilator-induced lung injury (VILI), there is an increased risk of derecruitment. In a recent international study [13] it was suggested that higher PEEP ...

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Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation

Abstract: Positive FB at ECMO day 3 is an independent predictor of 90-day mortality. Further interventional studies aimed at testing the value of strategy of tight control of FB during the early ECMO period are now warranted.

Cited by 151 publications

References 52 publications

Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome

Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

Focus on veno-venous ECMO in adults with severe ARDS

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