Is Extracorporeal Membrane Oxygenation Withdrawal a Safe Option After Double-Lung Transplantation?

The Impact of New Treatments on Short- and MID-Term Outcomes in Bilateral Lung Transplant: A Propensity Score Study

“…Fessler and colleagues investigated a large cohort of LT patients, distinguishing between ‘off-pump’, ‘unplanned’-ECMO and ‘planned’-ECMO, as carried out in our investigation. Based on their findings, 72-h PGD, the incidence of re-intubation or tracheostomy and septic shock were comparable between ‘off-pump’ and ‘planned’-ECMO, while their data about the perioperative need of blood products were unclear [ 6 ]. In contrast, Ius and colleagues found a more complicated perioperative and early po course in recipients supported by VA ECMO versus ‘off-pump’, with no difference in PGD rates [ 33 ].…”

“…Patients were divided into three groups based on io support: (i) ‘off-pump’, if no extracorporeal support was adopted during surgery; (ii) io ‘prophylactic’ VA ECMO, if VA ECMO was applied from the beginning of the surgical procedure; and (iii) ‘rescue’ VA ECMO, if extracorporeal support was instituted emergently during LT for acute life-threatening conditions, not manageable with standard care [ 6 ].…”

“…The following variables were collected from electronic health records: (i) demographic data (age, gender, body mass index (BMI)); (ii) therapies at home (i.e., corticosteroids or O 2 -therapy); (iii) diabetes or chronic kidney injury; (iv) Oto score [ 22 ]; (v) lung-allocation score (LAS) [ 23 ]; (vi) underlying diseases leading to LT (see full description in Table 1 ); (vii) pre-existing recipient-related Gram-negative (GN) colonization; (viii) provenience (hospital, home); (ix) surgical characteristics (time of LT, time of graft ischemia, io fluid support and peri/po surgical revisions, bleeding needing surgery and thromboembolic/ischemic events); (x) io use of ‘prophylactic’, ‘rescue’ or ‘prolonged’ ECMO [ 1 , 5 , 6 , 20 ]; (xi) immunosuppressive therapy; (xii) length of invasive mechanical ventilation; (xiii) Clavien-Dindo score [ 24 , 25 ]; and (xiv) short- and mid-term outcomes of interest (72-h PGD), perioperative blood units (transfused within 72–96 h after LT), ICU length of stay (LOS), re-tracheal intubation and/or tracheostomy, AKI (only stage 2 or 3, according to the KDIGO guidelines) and/or renal replacement therapy, multi-drug resistant (MDR)/extended-beta lactamases (ESBL) gram-negative bacteria, acute cellular rejection within 30 days after LT (according to the International Society for Heart and Lung Transplantation criteria), and hospital (H) LOS and mortality [ 14 , 15 , 24 , 25 , 26 , 27 ].…”

“…In particular, many efforts have been made to clarify the applicability and benefits of intraoperative (io) veno-arterial extracorporeal membrane oxygenation (VA ECMO), using it not only as a ‘rescue’ device helpful for managing acute life-threatening complications (i.e., pulmonary hypertension with right ventricular failure) but also as an io extracorporeal support routinely applicable ‘in advance’ for every patient [ 3 , 4 , 5 , 6 ].…”

Practical considerations for developing a lung transplantation anesthesiology program

“…Intraoperative anesthetic variables influencing PGD and technical complications (used with permission from Martin, A.K. et al, 2020)[4] ECMO, extracorporeal membrane oxygenation; F I O 2 , fraction of inspired oxygen; PGD, primary graft dysfunction; TIVA, total intravenous anesthesia understanding the intricacies in the different management issues between ECMO and CPB, identifying the implications of anesthetic management as it relates to ECMO and CPB, utilizing ECMO in both planned and unplanned circumstances, and recognizing patients that will benefit from prolonged ECMO[7,13,14]. Recent studies have shown that the use of intraoperative ECMO, compared to CPB, for lung transplant reduces patient hospital length of stay (LOS), intensive care LOS, mechanical ventilation requirement, blood transfusion requirement, and 90-day mortality[13,14], further emphasizing the need for the anesthesiologists' comprehensive understanding of ECMO management.…”