Standardized liberation trials in patients with COVID-19 ARDS treated with venovenous extracorporeal membrane oxygenation: when ready, let them breathe!

Teijeiro-Paradis, Ricardo; Tiwari, Pradip Kumar; Spriel, A.; Sorbo, Lorenzo Del; Fan, Eddy

doi:10.1007/s00134-021-06523-x

Cited by 11 publications

(7 citation statements)

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“…Further, no universal definition of successful decannulation exists (49). Recent data have described standardized approaches to liberation (50, 51), showing promising reductions in ECMO duration (52) and potentially reducing complications and costs. Deciding when to liberate patients from V-V ECMO is complex, and while more evidence is generated, a standardized approach is needed.…”

Section: Weaning and Decannulationmentioning

confidence: 99%

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Complications Associated With Venovenous Extracorporeal Membrane Oxygenation—What Can Go Wrong?

Teijeiro-Paradis

Gannon

Fan

2022

Critical Care Medicine

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Despite increasing use and promising outcomes, venovenous extracorporeal membrane oxygenation (V-V ECMO) introduces the risk of a number of complications across the spectrum of ECMO care. This narrative review describes the variety of short-and long-term complications that can occur during treatment with ECMO and how patient selection and management decisions may influence the risk of these complications.DATA SOURCES: English language articles were identified in PubMed using phrases related to V-V ECMO, acute respiratory distress syndrome, severe respiratory failure, and complications. STUDY SELECTION:Original research, review articles, commentaries, and published guidelines from the Extracorporeal Life support Organization were considered.DATA EXTRACTION: Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS:Selecting patients for V-V ECMO exposes the patient to a number of complications. Adequate knowledge of these risks is needed to weigh them against the anticipated benefit of treatment. Timing of ECMO initiation and transfer to centers capable of providing ECMO affect patient outcomes. Choosing a configuration that insufficiently addresses the patient's physiologic deficit leads to consequences of inadequate physiologic support. Suboptimal mechanical ventilator management during ECMO may lead to worsening lung injury, delayed lung recovery, or ventilator-associated pneumonia. Premature decannulation from ECMO as lungs recover can lead to clinical worsening, and delayed decannulation can prolong exposure to complications unnecessarily. Short-term complications include bleeding, thrombosis, and hemolysis, renal and neurologic injury, concomitant infections, and technical and mechanical problems. Long-term complications reflect the physical, functional, and neurologic sequelae of critical illness. ECMO can introduce ethical and emotional challenges, particularly when bridging strategies fail. CONCLUSIONS:V-V ECMO is associated with a number of complications. ECMO selection, timing of initiation, and management decisions impact the presence and severity of these potential harms.

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Section: Weaning and Decannulationmentioning

confidence: 99%

Section: Weaning and Decannulationmentioning

confidence: 99%

Complications Associated With Venovenous Extracorporeal Membrane Oxygenation—What Can Go Wrong?

Teijeiro-Paradis

Gannon

Fan

2022

Critical Care Medicine

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“…Readiness for liberation can be tested by performing standardized liberation trials (SLTs), emulating spontaneous breathing trials in ventilated patients (Table 2) [62 ▪ ,63 ▪▪ ]. Monitoring during these trials include hemodynamic and respiratory parameters, and markers of adequate gas exchange.…”

Section: Respiratory Monitoringmentioning

confidence: 99%

Monitoring during extracorporeal membrane oxygenation

Castro

Morris

Teijeiro-Paradis

et al. 2022

Current Opinion in Critical Care

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Purpose of reviewExtracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support. Recent findingsSurrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients. SummaryNovel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.

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“…In contrast to the Regensburg method of weaning comprising proactive ECMO blood flow reductions (to nadir ~ 1.5 L/min) leading up to EWT, Teijeiro-Paradis et al (4) reported weaning attempts in patients receiving higher ECMO levels of support (ECBF ≤ 5 L/min and SGF ≤ 4 L/min), in whom just 31% of the 61 trials led to decannulation. Failure was for hypoxemia (40%) and increased work of breathing (36%) at a median of 0.25 hours, although successful sweep gas off trials (SGOTs) was conducted for approximately 24 hours; two patients failed, of whom one survived a further ECMO run (4). Impaired respiratory mechanics before and during SGOTs predicted failure, whereas higher Pao 2 /Fio 2 ratio and lower ventilatory ratio were associated with success.…”

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confidence: 99%

Weaning From Venovenous Extracorporeal Membrane Oxygenation—The Regensburg Way?*

Worku,

Brodie,

Shekar

2023

Critical Care Medicine

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Standardized liberation trials in patients with COVID-19 ARDS treated with venovenous extracorporeal membrane oxygenation: when ready, let them breathe!

Cited by 11 publications

References 5 publications

Complications Associated With Venovenous Extracorporeal Membrane Oxygenation—What Can Go Wrong?

Complications Associated With Venovenous Extracorporeal Membrane Oxygenation—What Can Go Wrong?

Monitoring during extracorporeal membrane oxygenation

Weaning From Venovenous Extracorporeal Membrane Oxygenation—The Regensburg Way?*

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