Serum Total Bilirubin With Hospital Survival in Adults During Extracorporeal Membrane Oxygenation

Abstract

BackgroundExtracorporeal membrane oxygenation (ECMO) is widely used for refractory cardiopulmonary failure treatment. The disadvantage of ECMO is its higher risk profile and clinical resource consumption. This observation examines the role of serum total bilirubin (TBIL) as a predictor of adult patient outcomes on ECMO support.MethodsThis retrospective observation reports a single-center experience with adults on ECMO support between 2018 and 2021. Data were collected regarding demographics, ECMO details, laboratory parameters, and outcomes. We examined the elevation of TBIL to predict survival and variables associated with hyperbilirubinemia.ResultsThe patients who died within 28 days had a twofold higher peak level of TBIL than those who survived [73.10 (38.60, 98.64) vs. 34.50 (24.03, 54.85); P = 0.003]. Univariate logistic regression analyses demonstrated that high TBIL was remarkably associated with an elevated risk of 28-day mortality (OR: 7.25; 95% CI: 2.31–25.49; P = 0.001) and total mortality (OR: 5.71; 95% CI: 1.82–20.66; P = 0.001). The TBIL value was 65 μmol/L as the best cut-off value, and the observation group was divided into a high TBIL subgroup (n = 21) or a low TBIL subgroup (n = 39). The demographic and clinical features did not show a difference, whereas Sequential Organ Failure Assessment (SOFA) and APACHE II scores and ALT, AST, and LAC before ECMO initiation correlated with high or low TBIL (P < 0.05). For coagulation function at the time of TBIL peak, the levels of prothrombin time (PT), activated partial thromboplastin time (APTT), prothrombin time activity (PTA), and fibrinogen (FIB) were different between the two subgroups (P < 0.05). The SOFA score was potentially associated with hyperbilirubinemia after ECMO initiation, and the prediction accuracy was 0.800.ConclusionSerum total bilirubin elevation appears after ECMO initiation and correlates with survival, while other markers of liver injury do not. Serum total bilirubin is an easy-to-measure biomarker to be a predictor of survival after ECMO initiation.

Commentary: Serum total bilirubin with hospital survival in adults during extracorporeal membrane oxygenation

“…However, increased bilirubin values before ECMO initiation was not associated with increased in-ICU mortality ( 6 ). ECMO-associated DHB was also associated with high mortality in children receiving ECMO support ( 8 ), as reported by Huang et al ( 9 ). Round-the-clock monitoring of serum bilirubin would therefore be beneficial for the precision management of patients receiving ECMO.…”

“…Advanced strategies for the management of liver failure, including artificial liver support systems, plasma exchange, and bilirubin adsorption, are gradually seeing increased usage in critically ill patients. Huang et al ( 9 ) showed that the SOFA score was potentially associated with hyperbilirubinemia occurrence after ECMO initiation, with a prediction accuracy of 0.800.…”

“…Huang et al ( 9 ) reported on the important role of serum TBIL in predicting survival in adults on ECMO support. Their work produced several key findings: First, the patients who died within 28 days had twice the peak level of TBIL as those who survived.…”

“…Moreover, complications such as acute kidney injury, pneumonia, sepsis, and bleeding are common during ECMO support ( 4 ). Recently, ECMO-associated liver injury or direct hyperbilirubinemia (DHB) has been receiving more attention in both adult and pediatric populations due to its association with high mortality ( 5 – 9 ). It is noteworthy that the incidence of DHB (defined as >3 mg/dL of serum bilirubin) was as much as 73% in patients undergoing venoarterial ECMO (VA-ECMO) ( 7 ).…”

ECMO Retrieval Program: What Have We Learned So Far

“…In addition, Kohs et al found that severe thrombocytopenia was associated with adverse outcomes in patients on ECMO [ 31 ]. Further authors have shown that serum bilirubin elevation was associated with an increased risk of in-hospital mortality after ECMO [ 32 ]. Likewise, Joo et al mentioned that total bilirubin ( p = 0.017), acute kidney injury ( p = 0.005) and dialysis ( p = 0.001) were predictors for adverse outcomes and were associated with higher mortality in patients on ECMO [ 33 ].…”