ECMO - A year in review: 2018
ADULT ECMO FOR RESPIRATORY FAILURE AND SEPTIC SHOCK
If you search terms in ECMO, ECLS & ECPR on PubMED, you are going to find respectively 1512, 120 & 57 results for papers published in 2018…
Do not have the time to run through all of them? Don’t worry, we have tried to make a selection … and most of them are free open access!
P.S.: no claim to be exhaustive and random order! The first part ist dedicated to ECMO support for respiratory failure.
What better way to start than with the EOLIA trial?? The 2018 has been the year of the publication of the results of the “ECMO to rescue Lung Injury in severe ARDS” trial, comparing ECMO support with conventional lung-protective ventilation with the option for rescue extracorporeal membrane oxygenation among patients with very severe acute respiratory distress syndrome, on a widely expected and broadly debated NEJM paper
Combes A, Hajage D, Capellier G, Demoule A, Lavoué S, Guervilly C, Da Silva D, Zafrani L, Tirot P, Veber B, Maury E, Levy B, Cohen Y, Richard C, Kalfon P, Bouadma L, Mehdaoui H, Beduneau G, Lebreton G, Brochard L, Ferguson ND, Fan E, Slutsky AS, Brodie D, Mercat A; EOLIA Trial Group, REVA, and ECMONet. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018 May 24;378(21):1965-1975. open access http://bit.ly/2IFvOtf
published together with two accompanying editorials …
Hardin CC, Hibbert K. ECMO for Severe ARDS. N Engl J Med. 2018 May 24;378(21):2032-2034. open access http://bit.ly/2LrQ92P
Harrington D, Drazen JM. Learning from a Trial Stopped by a Data and Safety Monitoring Board. N Engl J Med. 2018 May 24;378(21):2031-2032. open access http://bit.ly/2LqvU5z
– Shanholtz C, Reed RM, Brower RG. N Engl J Med. 2018 Sep 13;379(11):1090.
– Patel BV, Barrett NA, Vuylsteke A; NHS England–commissioned ECMO service for adults with
respiratory failure. N Engl J Med. 2018 Sep 13;379(11):1090-1.
– Muñoz J, Keough EA, Visedo LC. N Engl J Med. 2018 Sep 13;379(11):1091.
– Combes A, Slutsky AS, Brodie D. N Engl J Med. 2018 Sep 13;379(11):1091-2.
– Hardin CC, Hibbert K. N Engl J Med. 2018 Sep 13;379(11):1092-3
EOLIA trial results underwent a post hoc Bayesian reanalysis providing information about the posterior probability of mortality benefit under a broad set of assumptions, in the attempt to help interpretation of the study findings. Here, the paper:
Goligher EC, Tomlinson G, Hajage D, Wijeysundera DN, Fan E, Jüni P, Brodie D, Slutsky AS, Combes A. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome and Posterior Probability of Mortality Benefit in a Post Hoc Bayesian Analysis of a Randomized Clinical Trial.
JAMA. 2018 Dec 4;320(21):2251-2259. bit.ly/2RcMMPh
and its related editorial, stating that clinician and researchers should no longer ask “Does ECMO work?” because that question appears to be answered. Instead, the key question that should now be asked is “By how much does ECMO work, in whom, and at what cost?”
Lewis RJ, Angus DC. Time for Clinicians to Embrace Their Inner Bayesian?: Reanalysis of Results of a Clinical Trial of Extracorporeal Membrane Oxygenation. JAMA. 2018 Dec 4;320(21):
Debate about EOLIA trial and its results is still ongoing, and many comments, editorials and expert opinions have been published in the last months; in the following paper, closer considerations about results & rationale, feasibility, utility of veno-venous extracorporeal support trials, by Luciano Gattinoni.
Gattinoni L, Vasques F, Quintel M. Use of ECMO in ARDS: does the EOLIA trial really help? Crit Care. 2018 Jul 5;22(1):171. open access http://bit.ly/2KO1lcF
History of extracorporeal respiratory support
Some words to remember the impact of the work of Dr. Theodor Kolobow, who passed away this year on March 24th, aged 87, on extracorporeal oxygenation & CO2 removal:
Gattinoni L, Pesenti A, Berra L, Bartlett R. Ted Kolobow. Intensive Care Med. 2018 May;44(5):551-552. open access http://bit.ly/2AbxMvf
and about the evolution of ECMO support for respiratory failure in adults
Brodie D. The Evolution of Extracorporeal Membrane Oxygenation for Adult Respiratory Failure. Ann Am Thorac Soc. 2018 Feb;15(Supplement_1):S57-S60. open access http://bit.ly/2T56ptw
Mechanical ventilation on veno-venous extracorporeal support
Any doubt about how to manage ventilation of native lung in patients on ECMO support? Read the followings… to start this editorial, looking back at the management of mechanical ventilation on ECMO through the years, with a nice summarizing table about recent studies reporting association between MV parameters and outcomes.
Fan E. “There is Nothing New Except What Has Been Forgotten”: The Story of Mechanical Ventilation During Extracorporeal Support. Am J Respir Crit Care Med. 2018 Oct 3. http://bit.ly/2QNIa6A
Let’s continue with an open access review summarizing the rationale, the available evidence, and
provide recommendations about respiratory monitoring and ventilator strategy to adopt in patients with ARDS undergoing veno-venous ECMO support.
Patroniti N, Bonatti G, Senussi T, Robba C. Mechanical ventilation and respiratory monitoring during extracorporeal membrane oxygenation for respiratory support. Ann Transl Med. 2018 Oct;6(19):386. open access http://bit.ly/2V5NlNB
On the debate about the unsettled optimal compromise between lung recruitment and lung rest, why and how ventilate patients on ECMO with the target of protecting the lung while warranting viable blood gases?
Pesenti A, Carlesso E, Langer T, Mauri T. Ventilation during extracorporeal support: Why and how. Med Klin Intensivmed Notfmed. 2018 Feb;113(Suppl 1):26-30. open access http://bit.ly/2zJLkvr
The role of ECMO in optimizing lung-protective ventilation strategy minimizing ventilator- induced lung injury in patients with Acute Respiratory Distress Syndrome.
Parekh M, Abrams D, Brodie D, Yip NH. Extracorporeal Membrane Oxygenation for ARDS: Optimization of Lung Protective Ventilation. Respir Care. 2018 Sep;63(9):1180-1188. http://bit.ly/2NcnpyO
And if the patients remains hypoxemic? is proning on extracorporeal support feasible? according to this single center study, prone positioning on ECMO is a safe and reliable technique when performed in a recognised ECMO centre with the appropriately trained staﬀ and standard procedures; no accidental dislodgement of intravascular lines, endotracheal tubes, chest tubes or a decrease in ECMO blood flow has been observed in all the observed group.
Lucchini A, De Felippis C, Pelucchi G, Grasselli G, Patroniti N, Castagna L, Foti G, Pesenti A, Fumagalli R. Application of prone position in hypoxaemic patients supported by veno-venous ECMO. Intensive Crit Care Nurs. 2018 Oct;48:61-68. http://bit.ly/2NPOuJv
What about spontaneous breathing on VV ECMO? in this review, pathophysiology, technical challenges and monitoring issues of the use of extracorporeal support in awake spontaneously breathing patients with acute respiratory failure of diﬀerent etiologies.
Crotti S, Bottino N, Spinelli E. Spontaneous breathing during veno-venous extracorporeal membrane oxygenation. J Thorac Dis. 2018 Mar;10(Suppl 5):S661-S669. open access http://bit.ly/2V7T2uq
And in pediatrics? The authors of the next paper suggest a strategy involving extracorporeal support and one-lung ventilation in VILI.
Di Nardo M, Nunziata J, Stoppa F, Lonero M, Perrotta D, Cecchetti C, Grasso S. Single lung ventilation associated to ECMO: an alternative approach to manage ventilator-induced lung injuries in infants. Minerva Anestesiol. 2018 May 15. http://bit.ly/2So83qc
Tracheostomy on extracorporeal support
Do your patient need tracheostomy? this single (high-volume) center study suggests that percutaneous tracheostomy in patients on veno-venous ECMO appears to be safe procedure even if anticoagulation is continued.
Kruit N, Valchanov K, Blaudszun G, Fowles JA, Vuylsteke A. Bleeding Complications Associated With Percutaneous Tracheostomy Insertion in Patients Supported With Venovenous Extracorporeal Membrane
Oxygen Support: A 10-Year Institutional Experience. J Cardiothorac Vasc Anesth. 2018 Jun;32(3): 1162-1166. http://bit.ly/2T4jJi8
Trester JT, Grawe ES, Hurford WE. Percutaneous Tracheostomy On Veno-Venous Extracorporeal Membrane Oxygenation: Balancing the Risk of Bleeding With Thrombosis. J Cardiothorac Vasc Anesth. 2018 Jun;32(3):1167-1168. http://bit.ly/2EEsLyf
… and a comment
Charlesworth M, Szentgyorgyi L, Ashworth AD, Feddy L. Tracheostomy Insertion During Venovenous Extracorporeal Membrane Oxygenation: Do the Benefits Outweigh the Risks? J Cardiothorac Vasc Anesth. 2018 Jun;32(3):e69-e70. open acces http://bit.ly/2SnodjC
Diﬀerent results here… percutaneous dilatational tracheostomy seems associated with a considerable complication rate in veno-venous ECMO patients according to this single-center study. Pre-procedure circuit performance as indicated by post-membrane lung PO2 is an independent predictor of major complications.
Dimopoulos S, Joyce H, Camporota L, Glover G, Ioannou N, Langrish CJ, Retter A, Meadows CIS, Barrett NA, Tricklebank S. Safety of Percutaneous Dilatational Tracheostomy During Veno-Venous Extracorporeal Membrane Oxygenation Support in Adults With Severe Respiratory Failure. Crit Care Med. 2018 Nov 13. http://bit.ly/2zgoWM5
Extracorporeal gas removal
A mathematical model of gas exchange during VV-ECMO to understand the physiology of extracorporeal support, focusing CO2 exchange. Main determinants of PaCO2 on vv-ECMO? pulmonary shunt fraction, metabolic CO2 production, gas flow to the oxygenator and extracorporeal circuit recirculation.
Joyce C, Shekar K Cook DA. A mathematical model of CO2, O2 and N2 exchange during venovenous extracorporeal membrane oxygenation. Intensive Care Med Exp. 2018 Aug 9;6(1):25. open access http://bit.ly/2V5b6pi
Evaluating carbon dioxide removal capacity of diﬀerent membrane lungs with under standardized conditions.
Sun L, Kaesler A, Fernando P, Thompson AJ, Toomasian JM, Bartlett RH. CO2 clearance by membrane lungs. Perfusion. 2018 May;33(4):249-253. open access http://bit.ly/2EDB51e
In this review the consensus opinion of an international group of clinicians in managing acute respiratory failure with ECCO2r techniques, with recommendations for clinical practice and future research.
Boyle AJ, Sklar MC, McNamee JJ, Brodie D, Slutsky AS, Brochard L, McAuley DF; International ECMO Network (ECMONet). Extracorporeal carbon dioxide removal for lowering the risk of mechanical ventilation: research questions and clinical potential for the future. Lancet Respir Med. 2018 Nov;6(11): 874-884. http://bit.ly/2QIzY7L
Again about extracorporeal carbon dioxide removal
Di Nardo M, Taccone FS, Swol J, Vercaemst L, Belliato M; EuroELSO Working Group “Innovation on ECMO and ECLS”. ECCO2R: are we ready for the prime time? Minerva Anestesiol. 2018 May;84(5): 644-645. open access http://bit.ly/2Sg8X8r
But not only CO2. Rationale, current evidence, indication and eﬀects of extracorporeal mid to high flow and low flow gas exchange.
Moerer O, Vasques F, Duscio E, Cipulli F, Romitti F, Gattinoni L, Quintel M. Extracorporeal Gas Exchange. Crit Care Clin. 2018 Jul;34(3):413-422. http://bit.ly/2PUNEXW
Determining the frequency of hyperoxia and hypocapnia on pediatric ECMO and their impact on outcome, a prospective data collection by the Collaborative Pediatric Critical Care Research Network. Hyperoxia reported as common and associated with mortality, while hypocapnia appears to occur less often and, although associated with complications, an association with mortality has not been observed.
Cashen K, Reeder R, Dalton HJ, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Dean JM, Tamburro R, Meert KL; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN). Hyperoxia and Hypocapnia During Pediatric Extracorporeal Membrane Oxygenation: Associations With Complications, Mortality, and Functional Status Among Survivors. Pediatr Crit Care Med. 2018 Mar;19(3): 245-253. open access http://bit.ly/2GCixkA
here the related editorial
MacLaren G. How Much Extracorporeal Membrane Oxygenation Is Enough? Oxidative Stress and the
Goldilocks Principle. Pediatr Crit Care Med. 2018 Mar;19(3):270-271. http://bit.ly/2QNmWpi
Physiology of extracorporeal support
Etiology of right ventricular failure in ARDS and beneficial impact of veno-venous extracorporeal support through oxygenation, decarboxylation, normalization of pH and decreased airway pressures; here, a review with recommendations about proper configuration and management of RV function failure on ECMO.
Bunge JJH, Caliskan K, Gommers D, Reis Miranda D. Right ventricular dysfunction during acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation. J Thorac Dis. 2018 Mar;10(Suppl 5):S674-S682. open access http://bit.ly/2RbVz81
An editorial on the potential role of echocardiography during VV ECMO support.
Zochios V, Roscoe A. Echocardiography as an Adjunct in Venovenous Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth. 2018 Feb;32(1):379-380. http://bit.ly/2PZSseR
and its comment…
Lazzeri C, Peris A. Echocardiography as a Clinical Stratification Tool in Venovenous Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth. 2018 Aug;32(4):e75-e76. http://bit.ly/2GAgb5J
Positive impact of early fluid removal in patients on VV-ECMO and concomitant CRRT In summary, an observational study suggests that this strategy is associated with improvement in
native pulmonary compliance and with a trend toward improved survival.
McCanny P, Smith MW, O’Brien SG, Buscher H, Carton EG. Fluid Balance and Recovery of Native Lung Function in Adult Patients Supported by Venovenous Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy. ASAIO J. 2018 Aug 14. http://bit.ly/2JuxJhk
Evaluating referrals to an ECMO centre and identifying factors associated with the decision- making process outcome: declined transfer due to perceived futility; accepted in principle but remain at the referring centre with ongoing surveillance; retrieved using conventional ventilation. The approach is imperfect and more robust, objective system is desirable and the use of a predictive model appealing.
Gillon SA, Rowland K, Shankar-Hari M, Camporota L, Glover GW, Wyncoll DLA, Barrett NA, Ioannou N, Meadows CIS. Acceptance and transfer to a regional severe respiratory failure and veno-venous extracorporeal membrane oxygenation (ECMO) service: predictors and outcomes. Anaesthesia. 2018 Feb; 73(2):177-186. open access http://bit.ly/2PZpHie
Routine CT imaging of the head, chest, abdomen and pelvis on admission for all patients
retrieved on veno-venous extracorporeal support: in this single center experience, the practice can be clinically justified as could impact on patient’s management and is not associated with adverse events, transfer is safe, but resource intensive.
Richmond KM, Warburton KG, Finney SJ, Shah S, Reddi BAJ. Routine CT scanning of patients retrieved to a tertiary centre on veno-venous extracorporeal membrane oxygenation: a retrospective risk benefit analysis. Perfusion. 2018 Sep;33(6):438-444. http://bit.ly/2T3Z2mc
We retrospectively reviewed our institutional database of all ECMO transports for neonatal and pediatric respiratory failure from February 2013 to February 2018. The Institutional Review Board approved this database for research studies. .
And what about neonatal & pediatric ECLS retrieval? can be safely performed with a dedicated team, maintaining strict adherence to well-designed management protocols: here the 5 years data from an Italian experience. Over the years, revision of ECMO transport protocols; standardization of equipment and MV, improvements in the transitions of care between the referring hospital and the referral PICU, have increased the team’s self-confidence, inducing an extension of the ECMO inclusion criteria for the higher risk patients and for those from remote areas.
Di Nardo M, Lonero M, Pasotti E, Cancani F, Perrotta D, Cecchetti C, Stoppa F, Pirozzi N, La Salvia O, Nicolini A, Amodeo A, Patroniti N Pesenti A. The first five years of neonatal and pediatric transports on extracorporeal membrane oxygenation in the center and south of Italy: The pediatric branch of the Italian “Rete Respira” network. Perfusion. 2018 May;33(1_suppl):24-30. http://bit.ly/2Ag6ML3
To conclude, some interesting case reports, series and experiences with selected populations supporting new indications of extracorporeal respiratory support:
Three cases of patients with acute respiratory distress syndrome on prolonged ECMO support with normal baseline right ventricular function upon cannulation, who developed Acute Cor Pulmonale later in the course than is usually described for non-ECMO ARDS patients; Potentially modifiable causes include thromboembolic burden to the pulmonary vasculature, maybe a phenomenon more common than recognized to be understood as to allow for modifiable interventions.
Dong ER, Ng DG, Ramzy D, Chung JS, Friedman O, Combes A1, Arabia FA, Nurok M. Acute Cor Pulmonale in Veno-Venous Extracorporeal Membrane Oxygenation: Three Case Reports. ASAIO J. 2018 Nov/Dec;64(6):e187-e190. http://bit.ly/2EKjWnk
And a related experience of cor pulmonale in children with acute respiratory failure on veno- venous extracorporeal membrane oxygenation.
McConnell PI, Hayes D Jr. Cor Pulmonale in Children With Acute Respiratory Failure on Venovenous Extracorporeal Membrane Oxygenation. ASAIO J. 2018 Mar 26. open access http://bit.ly/2EBDsBL
A pilot study evaluating lung ultrasound as a tool for daily monitoring of ARDS patients on ECMO, providing significant information about severity of loss of aeration before cannulation, disease course and eventual lung recovery.
Mongodi S, Pozzi M, Orlando A, Bouhemad B, Stella A, Tavazzi G, Via G, Iotti GA, Mojoli F. Lung ultrasound for daily monitoring of ARDS patients on extracorporeal membrane oxygenation: preliminary experience. Intensive Care Med. 2018 Jan;44(1):123-124. open access http://bit.ly/2ByzSVL
403 days long ECMO run while waiting for a LTx in an awake patient with acute exacerbation of idiopathic pulmonary fibrosis.
Umei N, Ichiba S, Sakamoto A. Idiopathic pulmonary fibrosis patient supported with extracorporeal membrane oxygenation for 403 days while waiting for a lung transplant: A case report. Respir Med Case Rep. 2018 Apr 26;24:86-88. open access http://bit.ly/2PXgVkD
Report of the successful use of venovenous ECMO in conjunction with tracheal stent to treat
and heal multiple tracheal-neo-oesophageal fistulae following oesophagectomy.
Jeng EI, Piovesana G, Taylor J, Machuca TN. Extracorporeal membrane oxygenation to facilitate tracheal healing after oesophagogastric catastrophe. Eur J Cardiothorac Surg. 2018 Jan 1;53(1):288-289. http://bit.ly/2V13K6h
A case of ECMO support as a safe and eﬀective way to manage patients with iatrogenic tracheobronchial injury when surgical repair with minimally invasive ventilation is needed
Antonacci F, De Tisi C, Donadoni I, Maurelli M, Iotti G, Taccone FS, Orlandoni G, Pellegrini C, Belliato M. Veno-venous ECMO during surgical repair of tracheal perforation: A case report. Int J Surg Case Rep. 2018;42:64-66. open access http://bit.ly/2QOAotl
Massive life-threatening pulmonary haemorrhage successfully managed with extracorporeal membrane oxygenation support and clamping the endotracheal tube for 15h as tamponade therapy to control blood loss from the lungs.
Lee CF, Huang CT, Ruan SY. Endotracheal tube clamping and extracorporeal membrane oxygenation to resuscitate massive pulmonary haemorrhage. Respirol Case Rep. 2018 Apr 6;6(5):e00321. open access http://bit.ly/2EFGoNK
A series of diﬃcult airway cases preemptively managed with ECMO assistance.
Yunoki K, Miyawaki I, Yamazaki K, Mima H. Extracorporeal Membrane Oxygenation-Assisted Airway Management for Diﬃcult Airways. J Cardiothorac Vasc Anesth. 2018 Dec;32(6):2721-2725. http://bit.ly/2EH8WGn
A patient with severe bilateral pulmonary contusions with traumatic bronchial injury and alveolar hemorrhage with intractable hypoxemia and hypercapnia successfully managed with veno-venous ECMO maintained without anticoagulation.
Ryu KM, Chang SW. Heparin-free extracorporeal membrane oxygenation in a patient with severe pulmonary contusions and bronchial disruption. Clin Exp Emerg Med. 2018 Sep;5(3):204-207. open access http://bit.ly/2GDfNTW
Extracorporeal support in patients with burn injury, toxic epidermal necrolysis, or inhalation injury and severe ARDS: according to this low mortality rate series, ECMO is a viable rescue strategy in this population when conventional interventions are unsuccessful.
Ainsworth CR, Dellavolpe J, Chung KK, Cancio LC, Mason P. Revisiting extracorporeal membrane oxygenation for ARDS in burns: A case series and review of the literature. Burns. 2018 Sep;44(6): 1433-1438. http://bit.ly/2AdE918
The largest case series to date of HIV-positive patients with severe respiratory failure, most with concomitant PJP infection, supported with ECLS with optimal outcomes (survival to hospital discharge 68%).
Capatos G, Burke CR, Ogino MT, Lorusso RR, Brogan TV, McMullan DM, Dalton HJ. Venovenous extracorporeal life support in patients with HIV infection and Pneumocystis jirovecii pneumonia.
Perfusion. 2018 Sep;33(6):433-437. http://bit.ly/2rQkrDT
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A review to assess the current literature for PK data in pediatric patients receiving ECMO
Di Nardo M, Wildschut ED. Drugs pharmacokinetics during veno-venous extracorporeal membrane oxygenation in pediatrics. J Thorac Dis. 2018 Mar;10(Suppl 5):S642-S652. open access http://bit.ly/ 2QMyvgH