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.

EOLIA trial

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 

 …and followed by large correspondence & authors/editorialists reply:
 
ECMO for Severe Acute Respiratory Distress Syndrome all available at  http://bit.ly/2T6OtPA
– 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):
2208-2210. http://bit.ly/2EJyK6y

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

the editorial

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

ECMO retrieval
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

Case reports
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

Hashtags #ECMO #ARDS #ECCO2r #ECLS #FOAMcc #FOAMed #FOAMecmo

A review to assess the current literature for PK data in pediatric patients receiving ECMO
support.

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

ECMO a year-in-review: part 2 cannulation
If you search the terms ECMO, ECLS & ECPR on PubMed, you are going to find respectively 1512, 120 & 50 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… a lot are free open access! p.s. no claim to be exhaustive and random order!

The second part of this year-in-review is dedicated to cannulation for ECMO, one of the major determinant of an adequate extracorporeal support!

Cannulation technique
Draining blood from the RA and SVC via a multistage cannula inserted in the right IJV as an ideal alternative for extracorporeal respiratory and respiratory/circulatory support: according to the authors, this strategy enables an efficient drainage, preventing differential hypoxemia in veno-arterial ECMO and minimizing recirculation in veno-venous ECMO, avoiding the need for repositioning in case of switch between different configurations.

Frenckner B, Broman M, Broomé M. Position of draining venous cannula in extracorporeal membrane oxygenation for respiratory and respiratory/circulatory support in adult patients. Crit Care. 2018 Jun 15;22(1):163. open access http://bit.ly/2BAXRUr

A review article about the role of echocardiography both to guide initial placement and troubleshooting of dual-lumen bicaval cannula for veno-venous ECMO support, with indications and patients selection, detailed description of the catheter (and all the available sizes with lengths/diameters/connectors), ultrasound guidance of wire placement with transesophageal echocardiography, image guidance of cannula placement considering goals of proper location & orientation.

Griffee MJ, Tonna JE, McKellar SH, Zimmerman JM. Echocardiographic Guidance and Troubleshooting for Venovenous Extracorporeal Membrane Oxygenation Using the Dual-Lumen Bicaval Cannula. J Cardiothorac Vasc Anesth. 2018 Feb;32(1):370-378. http://bit.ly/2AeJwx5

A step-by-step description enriched by supplemental open access video/pictures of the insertion technique of a dual-lumen cannula for VV-ECMO support, with a close monitoring by combined transthoracic and transesophageal echocardiography to ensure a safe procedure and prompt detection of eventual complications.

Cianchi G, Lazzeri C, Bonizzoli M, Batacchi S, Peris A. Echo-Guided Insertion of a Dual-Lumen Cannula for Venovenous Extracorporeal Membrane Oxygenation. ASAIO J. 2018 Jul 12. open access http://bit.ly/2SclcCO

Again dual-lumen bicaval cannula: here, different techniques of insertion and tips for troubleshooting.

Ngai CW, Ng PY, Sin WC. Bicaval dual lumen cannula in adult veno-venous extracorporeal membrane oxygenation-clinical pearls for safe cannulation. J Thorac Dis. 2018 Mar;10(Suppl 5):S624-S628. open access. http://bit.ly/2ELxbUK

A discussion about a cannulation strategy for veno-venous extracorporeal support including:
ultrasound guided percutaneous cannulation using the Seldinger technique; femoro-femoral ECMO configuration with a later option of high flow; a no skin cut serial dilation; non-suturing securing and a non-surgical manual pressure at removal.

Burrell AJC, Ihle JF Pellegrino VA, Sheldrake J, Nixon PT. Cannulation technique: femoro-femoral. J Thorac Dis. 2018 Mar;10(Suppl 5):S616-S623. open access http://bit.ly/2EFMpK9

After positioning, you need to fix your cannula! here, an in vitro study testing the the ability of
cyanoacrylate tissue adhesive to inhibit bacterial growth at the ECMO cannulation site against standard transparent dressing with ECMO cannula, and the effectiveness of TA and sutureless devices in securing ECMO cannulas and tubing. No bacterial growth occurred under TA- covered cannulas compared with transparent dressing. TA increased the pull-out force required for cannula dislodgement from the insertion point. SSDs significantly increased the force required to remove the tubing from the fixation points.

Bull T, Corley A, Smyth DJ, McMillan DJ, Dunster KR, Fraser JF. Extracorporeal membrane oxygenation line-associated complications: in vitro testing of cyanoacrylate tissue adhesive and securement devices to prevent infection and dislodgement. Intensive Care Med Exp. 2018 Mar 12;6(1):6. open access http://bit.ly/2Q0rRxY

Review of an optimal technique to secure dual-lumen bicaval cannula to facilitate early mobility, ambulation, rehabilitation and prevent ECMO cannula dislodgement.

Tignanelli CJ, Weinberg A, Napolitano LM. Optimal Methods to Secure Extracorporeal Membrane Oxygenation Bicaval Dual-Lumen Cannulae: What Works? ASAIO J. 2018 Jul 12. open access http://bit.ly/2Ndskfo

Cannulation technique in pediatrics
Femoral cannulation in children requiring veno-arterial ECMO support? when utilized in appropriate patients with distal perfusion optimization and prudent monitoring, is an effective technique avoiding the morbidities & risks associated with central and carotid cannulation; here a review of the literature about techniques for cannula placement, distal perfusion, decannulation, and arterial repair to minimize and ameliorate related complications.

Fraser CD3rd, Kovler ML, Guzman W Jr, Rhee DS, Lum YW, Alaish SM, Garcia AV. Pediatric Femoral Arterial Cannulations in Extracorporeal Membrane Oxygenation: A Review and Strategies for Optimization. ASAIO J. 2018 Sep 19. http://bit.ly/2EMGljW

Retrospective study based on the Extracorporeal Life Support Organization’s registry data
evaluating trend in method of vascular access for pediatric ECMO and its effects on morbidity and mortality; the proportion of pediatric patients undergoing percutaneous cannulation is increasing. Higher rates of mechanical cannula failure and renal/cardiovascular complications with open access and higher rates of limb complications with percutaneous access have been reported.

Cairo SB, Arbuthnot M, Boomer L, Dingeldein MW, Feliz A, Gadepalli S, Newton CR, Puligandla P, Ricca R Jr, Rycus P, Vogel AM, Yu G, Chen Z, Rothstein DH; American Pediatric Surgical Association Critical Care Committee. Comparing Percutaneous to Open Access for Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure. Pediatr Crit Care Med. 2018 Oct;19(10):981-991. http://bit.ly/2ELt4rd

A discussion on cannulation technique for extracorporeal cardiac support focusing on pediatric and neonatal patients: pre-cannulation considerations, peripheral/central cannulation, difficult cannulation, complications, distal limb perfusion and venting.

Harvey C. Cannulation for Neonatal and Pediatric Extracorporeal Membrane Oxygenation for Cardiac Support. Front Pediatr. 2018 Mar 19;6:17. open access http://bit.ly/2V6R11Q

Development of a clinical strategy for proper selection and placement of bicaval dual-lumen cannula for VV-ECMO in critically ill children weighing less than 20 kg in order to reduce the risk of migration and malposition. Imaging studies are recommended by the authors to measure the distances from the SVC/RAJ to the mid tricuspid valve and the mid tricuspid valve to the most proximal hepatic vein take-off prior to catheter selection. Larger cannulas than would be required based on body weight alone appears sometimes necessary to ensure proper positioning of distal tip.

Ellis W1, Schafer M, Barrett CS, Butler K, Sprowell A, Twite M, Buckvold S, Jone PN, Ing RJ. Vascular anatomical considerations and clinical decision making during insertion of the Avalon® Elite Dual Lumen single-site veno-venous ECMO cannula in children weighing less than 20 kg. Perfusion. 2018 Dec 11:267659118815104. http://bit.ly/2A8JUgv

Limb ischemia & other cannula-related complications
Comparison of complication rates and overall survival in VA-ECMO patients receiving surgical or percutaneous peripheral cannulation. Percutaneous cannulation associated with fewer local infections, similar rates of ischemia and sensory-motor complications and improved 30-day survival in this large series; the higher rate of vascular complications following decannulation suggests that improvements in cannula removal techniques are needed to further improve outcomes after percutaneous approach.

Danial P, Hajage D, Nguyen LS, Mastroianni C1, Demondion P, Schmidt M, Bouglé A, Amour J, Leprince P, Combes A, Lebreton G. Percutaneous versus surgical femoro-femoral veno-arterial ECMO: a propensity score matched study. Intensive Care Med. 2018 Dec;44(12):2153-2161. http://bit.ly/2V8wSbF


A retrospective cohort study performed using the Extracorporeal Life Support Organization registry, suggesting that large dual-lumen bicaval cannula (31Fr vs 27Fr) are associated with more intracranial hemorrhage (as may increase brain venous pressure), thus, smaller cannulas may be preferable when feasible. No differences in hemolysis, cannula complications, or mortality have been reported between the 2 groups.

Mazzeffi M, Kon Z, Menaker J, Johnson DM, Parise O, Gelsomino S, Lorusso R, Herr D. Large Dual- Lumen Extracorporeal Membrane Oxygenation Cannulas Are Associated with More Intracranial Hemorrhage. ASAIO J. 2018 Nov 5. http://bit.ly/2PIIsun

Small cannula seems better also in this study, comparing clinical outcomes & procedural-related complications between patient with small arterial cannula (14–15Fr) vs large cannula (16–21Fr). The two strategies showed no significant difference in the survival to discharge, weaning success rate, initial ECMO flow/body surface area), but significantly shorter ECLS run and decreased incidence of lower limb ischemia reported for the small cannula group.

Kim J, Cho YH, Sung K, Park TK, Lee GY, Lee JM, Song YB, Hahn JY, Choi JH, Choi SH, Gwon HC, Yang JH. Impact of Cannula Size on Clinical Outcomes in Peripheral Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2018 Jul 25. http://bit.ly/2OaOM9s

Development of ipsilateral limb ischemia on veno-arterial ECMO with femoral cannulation: in this single center experience, younger age, history of peripheral arterial disease, pulmonary disease, and diabetes are predisposing factors. Because limb ischemia may occur even when a prophylactic distal perfusion catheter is present, all patients should be closely monitored for signs of arterial compromise.

Yau P, Xia Y, Shariff S, Jakobleff WA, Forest S, Lipsitz EC, Scher LA, Garg K. Factors Associated with Ipsilateral Limb Ischemia in Patients Undergoing Femoral Cannulation Extracorporeal Membrane Oxygenation. Ann Vasc Surg. 2019 Jan;54:60-65. open access http://bit.ly/2T6Q6fX

Incidence, risk factors, prognosis, and microbiological characteristic of cannula-related infection in ECMO patients. CRI were frequent in this single center experience, as concomitant bacteremia, and associated with a longer ICU and hospital stay (but no higher mortality); longer ECMO duration and higher SAPS2 identified as risk factors. The main isolated microorganisms Enterobacteriaceae, Staphylococcus spp and Pseudomonas aeruginosa.

Allou N, Lo Pinto H, Persichini R, Bouchet B, Braunberger E, Lugagne N, Belmonte O, Martinet O, Delmas B, Dangers L, Allyn J. Cannula-Related Infection in Patients Supported by Peripheral ECMO: Clinical and Microbiological Characteristics. ASAIO J. 2018 Mar 5. http://bit.ly/2AgCrfv

Case reports & more
To conclude, some interesting case reports, series and experiences related to extracorporeal support cannulation.
Unusual approach to arterial return: proximal retrograde ECMO flow using a long multi-stage cannula inserted in the femoral artery and the tip placed at the proximal descending thoracic aorta, in order to promote a proximal displacement of the arterial mixing zone, with the aim of improving brain, heart and right upper extremity perfusion.

Rodriguez ML, Maharajh G. Long venous cannula on the arterial position for VA-ECMO. Perfusion. 2018 Sep;33(6):423-425. http://bit.ly/2CvXfBe

Experience with an alternative insertion method of the dual-lumen bicaval cannula: The off-label use of a percutaneous dilatational tracheostomy kit, appearing to be safe, to allow the placement of this catheter in a country lacking the conventional access kit with the 30Fr dilator.

Cavayas YA, Sampson C, Yusuff H, Porter R, Dashey S, Harvey C. Use of a tracheal dilator for percutaneous insertion of 27F and 31F Avalon© dual-lumen cannulae for veno-venous extracorporeal membrane oxygenation in adults. Perfusion. 2018 Oct;33(7):509-511. http://bit.ly/2s0P1uR

Insertion a J-tipped guidewire into the distal perfusion catheter and visualization of the wire using ultrasound to confirm the right position of the DPC in a patient with no measurable flow in the popliteal artery.

Bunge JJH, Mahtab EAF, Caliskan K, Reis Miranda D. Fast confirmation of correct position of distal perfusion cannula during venoarterial extracorporeal membrane oxygenation. Intensive Care Med. 2018 May;44(5):658-660. open access http://bit.ly/2AaUOlS

Bicaval view on transthoracic echocardiography to allow visualization of both the ECMO cannula on VV configuration, confirming proper positioning, and color flow doppler to assess eventual recirculation.

Viau-Lapointe J, Douflé G. Transthoracic View of Extracorporeal Membrane Oxygenation Cannulae. Am J Respir Crit Care Med. 2018 Dec 20. http://bit.ly/2AgLop4

Is visualization of the guide wire in the IVC sufficient to ensure appropriate venous cannula positioning? Maybe not, according to the next 2 case reports.
Venous drainage cannula folded over inside the IVC with good blood flow, detected accidentally by fluoroscopic imaging.

Charlesworth M, Barker JM, Greenhalgh D, Garcia M, Szentgyorgyi L, Ashworth AD. Intravascular Folding of a Peripheral Venous VA-ECMO Cannula for Extracorporeal Cardiopulmonary Resuscitation. Artif Organs. 2018 Jan;42(1):104-105. open access http://bit.ly/2GBQ5iN

And a case of malposition of the drainage cannula (tip in the hepatic vein) with no disturbance in extracorporeal venous return detected during an ECMO run. Authors suggest that at the time of VA-ECMO implantation, the venous cannula has to be positioned in the right atrium using real time echo monitoring.

Winiszewski H, Perrotti A, Chocron S2 Capellier G, Piton G. Malposition of the Extracorporeal Membrane Oxygenation Venous Cannula in an Accessory Hepatic Vein. J Extra Corpor Technol. 2018 Sep;50(3): 167-169.  http://bit.ly/2RmDPqJ

Description of misplacement of the drainage cannula which cannot be identified by fluoroscopy or chest X-ray, but suggested by clinical parameters and detected by transesophageal cardiac ultrasound. This case highlights the fundamental and the specific role of echocardiography (TEE in particular) as guidance during ECLS cannulation procedure and for the evaluation of proper placement.

Giraud R, Banfi C, Bendjelid K. Echocardiography should be mandatory in ECMO venous cannula placement. Eur Heart J Cardiovasc Imaging. 2018 Dec 1;19(12):1429-1430. http://bit.ly/2CsLSK0

Modification of an ECMO cannula by embedding piezoelectric crystals acting as color Doppler markers, into each port to improve accuracy of catheter identification by ultrasound scans: testing on an animal model.

Belohlavek M, Katayama M, Vaitkus VV, Kumar V, Fatemi M, Grabham J, Sandweiss B. A Real-time Color Doppler Marker for Echocardiographic Guidance of an Acoustically Active Extracorporeal Membrane Oxygenation Cannula. J Ultrasound Med. 2018 Nov 12. http://bit.ly/2Q1cZiM

Ambulating patients supported with VA-ECMO, despite femoral arterial cannulation? in this experience appears safe and feasible in carefully selected patients: no related major bleeding events, vascular complications, or decannulation events have been observed.

Pasrija C, Mackowick KM, Raithel M, Tran D, Boulos FM, Deatrick KB, Mazzeffi MA, Rector R, Pham SM, Griffith BP, Kon ZN. Ambulation with Femoral Arterial Cannulation Can be Safely Performed on Veno- Arterial Extracorporeal Membrane Oxygenation. Ann Thorac Surg. 2018 Nov 30. http://bit.ly/2Cyq6of

ECMO a year-in-review: part 3 – The circuit
If you search the terms ECMO, ECLS & ECPR on PubMed, you are going to find respectively 1512, 120 & 50 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… a lot are free open access! p.s. no claim to be exhaustive and random order!

The third part of this year-in-review is dedicated to the extracorporeal circuit… To make it clear, let’s start with a consensus paper of multispecialty international representatives of the ELSO – Extracorporeal Life Support Organization, including the North American, Latin American, European, South and West Asian, and Asian-Pacific chapters, providing a consistent, unambiguous nomenclature and abbreviations for the description of the practice of ECLS and associated devices and techniques.

Conrad SA, Broman LM, Taccone FS, Lorusso R, Malfertheiner MV, Pappalardo F, Di Nardo M, Belliato M, Grazioli L, Barbaro RP, McMullan DM, Pellegrino V, Brodie D, Bembea MM, Fan E, Mendonca M, Diaz R, Bartlett RH. The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization. Am J Respir Crit Care Med. 2018 Aug 15;198(4):447-451. http://bit.ly/2q6K9n7

Whole Circuit
Do you keep preassembled, primed ECMO circuits for emergencies? are them expected to be sterile? In this study, 4 extracorporeal circuits (2 neonatal/pediatric, 2 adolescent/adult) have been assembled and primed under sterile conditions, maintained at room temperature and tested. All cultures obtained from the priming solution produced no bacterial or fungal growth for the study period, suggesting that systems may maintain sterility for a period up to 65 days, consistently longer than periods previously reported.

Tan VE, Evangelista AT, Carella DM, Marino D, Moore WS, Gilliam N, Chopra A, Cies JJ. Sterility Duration of Preprimed Extracorporeal Membrane Oxygenation Circuits. J Pediatr Pharmacol Ther. 2018 Jul-Aug; 23(4):311-314. open access http://bit.ly/2Rf6cH7

Ex-vivo study to evaluate the migration of plasticizers from the ECMO circuit and the potential toxic risk for the patient: trioctyltrimellitate (TOTM), main plasticizer in the system, is weakly released during ECLS, concentrations are not cytotoxic and exposure well below acceptable daily doses. In contrast, diethylhexylphthalate (DEHP) doses are higher than the derived no effect leve,l despite a lower presence of in the circuit. DEHP appears coming from the priming bag: Replacing this with a multilayer one could avoids the exposure.

Fernandez-Canal C, Pinta PG, Eljezi T, Larbre V, Kauffmann S, Camilleri L, Cosserant B, Bernard L, Pereira B, Constantin JM, Grimandi G, Sautou V; for Armed Study Group. Patients’ exposure to PVC plasticizers from ECMO circuits. Expert Rev Med Devices. 2018 May;15(5):377-383. http://bit.ly/2QOFSUS

Reviewing both present & future of novel surfaces modification in ECMO circuits to obviate the need for systemic anticoagulation: Biomimetic surfaces (heparin, nitric oxide, direct thrombin inhibitors), biopassive surfaces (phosphorylcholine, albumin, Poly-2-MethoxyEthylAcrylate, fluid- Repellent omniphobic surfaces), endothelialization of blood contacting surface (in vitro & in vivo induced). Balance between systemic anticoagulation & clotting is challenging on ECLS as blood is continuously in contact with a foreign extracorporeal circuit predisposing a prothrombotic state: to improve hemocompatibility replication of anti-thrombotic/anti-inflammatory properties of the endothelium would be ideal.

Ontaneda A, Annich GM. Novel Surfaces in Extracorporeal Membrane Oxygenation Circuits. Front Med (Lausanne). 2018 Nov 20;5:321. open access http://bit.ly/2UTHN97

In the following review, regulatory issues related to the introduction of new medical products in the European market, with regards to ECMO devices, and a summary of currently available pumps and membrane lungs, with their technical features as released by the manufacturers.

Di Nardo M, Vercaemst L, Swol J, Barret N, Taccone FS, Malfertheiner MV, Broman LM, Pappalardo F, Belohlavek J, Mueller T, Lorusso R, Lonero M, Belliato M; *on behalf of EuroELSO Workgroup “Innovation on ECMO and ECLS”. A narrative review of the technical standards for extracorporeal life support devices (pumps and oxygenators) in Europe. Perfusion. 2018 Oct;33(7):553-561. http://bit.ly/2RkttY9

A review of the individual components that make up the modern neonatal ECMO circuits, exploring specific features with relations to the peculiarities of infant physiology, as size-based limitations and demands.

Connelly J, Blinman T. Special equipment considerations for neonatal ECMO. Semin Perinatol. 2018 Mar; 42(2):89-95. http://bit.ly/2AjBbbd


Membrane Lung
Really interesting free open access paper focusing on the membrane lung and its relationship with the patient: physiology & pathology, oxygen transfer, carbon dioxide removal, interactions between ML/native lung, gas exchange partitioning & monitoring.

Epis F, Belliato M. Oxygenator performance and artificial-native lung interaction. J Thorac Dis. 2018 Mar; 10(Suppl 5):S596-S605. open access http://bit.ly/2LA6m6F

Development of a surface modification acting as barrier to protein adsorption, improving hemocompatibility of polymethylpentene membranes and preventing activation of the coagulation cascade. The antifouling layers (nonionic and zwitterionic polymer brushes directly grafted) markedly increases recalcification time and decreases platelet and leukocyte adhesion, both central in coagulation and thrombus formation.

Obstals F, Vorobii M, Riedel T, de Los Santos Pereira A, Bruns M, Singh S, Rodriguez-Emmenegger C Improving Hemocompatibility of Membranes for Extracorporeal Membrane Oxygenators by Grafting Nonthrombogenic Polymer Brushes. Macromol Biosci. 2018 Mar;18(3). http://bit.ly/2Aql1gz

Development and validation of an ultrasound dilution technology to quantitatively assess clotting of the membrane lung, using measurements of the oxygenator blood volume, decreasing over time due to thrombosis.

Krivitski N, Galyanov G, Cooper D, Said MM, Rivera O, Mikesell GT, Rais-Bahrami K. In vitro and in vivo assessment of oxygenator blood volume for the prediction of clot formation in an ECMO circuit (theory and validation). Perfusion. 2018 May;33(1_suppl):51-56. http://bit.ly/2TfXmX7

Administration of nitric oxide into the gas phase of the membrane lung during ECMO run in children in order to mitigate ischaemia reperfusion injury and end-organ dysfunction? reported as
safe and not causing adverse effects, as potential gas to blood leak and gas embolism, in this pilot study (not designed to evaluate clinical benefit).

Chiletti R, Horton S, Bednarz A, Bartlett R, Butt W. Safety of nitric oxide added to the ECMO circuit: a pilot study in children.Perfusion. 2018 Jan;33(1):74-76. http://bit.ly/2QPxfJy

However, results from this ex-vivo model of ECMO suggest potential harm associated with the intravascular administration of mesenchymal stem cells during extracorporeal support. MSCs could adversely impact the function of the membrane lung, resulting in reduced blood flow through the circuit and increased pressure drop in comparison to controls; immunohistochemistry analysis demonstrates quantities of MSCs highly adherent to oxygenator fibers.

Millar JE, von Bahr V, Malfertheiner MV, Ki KK, Redd MA, Bartnikowski N, Suen JY, McAuley DF, Fraser JF. Administration of mesenchymal stem cells during ECMO results in a rapid decline in oxygenator performance. Thorax. 2018 Apr 5. http://bit.ly/2EOouJD

The pump
Thrombus formation in the ECMO circuit may occur due to direct platelet activation from shear-stress over time, or due to the stretching of native vWF multimers and hemolysis. In this paper, the results of a study on the potential thrombogenicity of different extracorporeal circuit components: Centrifugal pump, cannulae and tubing connectors; the largest risk for activation was found for the centrifugal pump-head followed by the return and drainage cannula; the lowest risk was observed for straight tubing connector. Long residence time and high shear-rate have been identified as the causes for pump thrombogenicity.

Fuchs G, Berg N, Broman LM, Prahl Wittberg L. Flow-induced platelet activation in components of the extracorporeal membrane oxygenation circuit. Sci Rep. 2018 Sep 18;8(1):13985. open access http://bit.ly/2VbixeI

Application of a novel miniaturized rotational pump with a diagonally streamed impeller for mechanical circulatory and respiratory support: data from seven pediatric centers seems demonstrate its efficacy and an encouraging complication rate.

Stiller B, Houmes RJ, Rüffer A, Kumpf M, Müller A, Kipfmüller F, Köditz H, Herber Jonat S, Schmoor C, Benk C, Tibboel D, Fleck T. Multicenter Experience With Mechanical Circulatory Support Using a New Diagonal Pump in 233 Children. Artif Organs. 2018 Apr;42(4):377-385.  http://bit.ly/2RgL3MS


Heater units
Description of the Queensland Health centralized and coordinated response to Mycobacterium chimaera contamination of heater-cooler units, to mitigate the risk detecting and preventing potential exposure. Water sampling and testing protocols have been standardized; M. chimaera was also found in ECMO HU. No further cases of M. chimaera infection have been identified in the Australian region since the introduction of this approach.

Robertson J, McLellan S, Donnan E, Sketcher-Baker K, Wakefield J, Coulter C. Responding to Mycobacterium chimaera heater-cooler unit contamination: international and national intersectoral collaboration coordinated in the state of Queensland, Australia. J Hosp Infect. 2018 Nov;100(3):e77-e84. http://bit.ly/2GIinYY


Renal Replacement Therapy on ECMO circuit
Do your patient on extracorporeal support need renal replacement therapy? As it is common for patients to require a form of RRT during the ECLS run, integrating this extracorporeal therapy directly on the ECMO circuit could provides advantages compared with additional central venous catheterization. Many alternative configurations could be chosen, each one with specificities and eventual risks. In 2018, many articles dedicated to this actual and interesting topic have been published.

A review explaining the most important aspects of continuous renal replacement therapy in a patient on extracorporeal support, including the different configurations to include the RRT system on the ECMO circuit, with pros & cons.

Poveda R, Fajardo C, Agliati R, Díaz R. Continuous renal replacement therapy in patients with extracorporeal membrane oxygenation. Rev Med Chil. 2018 Jan;146(1):78-90. open access (Article in Spanish). http://bit.ly/2EM2aPR

Proposal of a new strategy to connect the extracorporeal therapy lines directly to the ECMO circuit: inlet line connected to the membrane lung, outlet line connected either to the femoral artery antegrade perfusion cannula in veno-arterial support or to the lateral vent of the return cannula in veno-venous ECMO. In this paper, the approach is reported as a simple, effective, costless and successful in overcoming the ECMO circuit high pressures issue during RRT.

Laverdure F, Masson L, Tachon G, Guihaire J, Stephan F. Connection of a Renal Replacement Therapy or Plasmapheresis Device to the ECMO Circuit. ASAIO J. 2018 Jan/Feb;64(1):122-125. open access http://bit.ly/2QUHhJt


According to the results of this observational study, directly connecting CVVH system to the ECLS circuit vs using a dedicated dialysis catheter is well tolerated and may ensure a better, more stable, blood flow allowing for a prolonged circuit life, with lower anticoagulant doses but lower clotting rate.

de Tymowski C, Desmard M, Lortat-Jacob B, Pellenc Q, Alkhoder S, Alouache A, Fritz B, Montravers P, Augustin P. Impact of connecting continuous renal replacement therapy to the extracorporeal membrane oxygenation circuit. Anaesth Crit Care Pain Med. 2018 Dec;37(6):557-564. http://bit.ly/2PpBM3R

… and the related editorial

Schetz M, Legrand M. CRRT and ECMO: Dialysis catheter or connection to the ECMO circuit? Anaesth Crit Care Pain Med. 2018 Dec;37(6):519-520. http://bit.ly/2Rk0tfw

Evaluating an alternative neonatal extracorporeal support circuit containing a centrifugal pump or roller pump with one of seven configurations of CRRT: impact on hemodynamic performance.

Profeta E, Shank K, Wang S, O’Connor C, Kunselman AR, Woitas K, Myers JL, Ündar A. Evaluation of Hemodynamic Performance of a Combined ECLS and CRRT Circuit in Seven Positions With a Simulated Neonatal Patient. Artif Organs. 2018 Feb;42(2):155-165. http://bit.ly/2BIks1a

By the same authors, an ex-vivo evaluation of the hemodynamic performance and gaseous microemboli handling ability of a simulated neonatal ECLS circuit, using a centrifugal or roller pump, with an in-line CRRT device added at distinct locations, such that blood entered CRRT between the pump and oxygenator, recirculated through the pump, or bypassed the pump. According to this study, the last configuration appears unsafe and not advisable for clinical use.

Shank KR, Profeta E, Wang S, O’Connor C, Kunselman AR, Woitas K, Myers JL, Ündar A. Evaluation of Combined Extracorporeal Life Support and Continuous Renal Replacement Therapy on Hemodynamic Performance and Gaseous Microemboli Handling Ability in a Simulated Neonatal ECLS System. Artif Organs. 2018 Apr;42(4):365-376. http://bit.ly/2ELCqDb

Another review describing different strategies of combining RRT and ECMO, outlining their advantages and drawbacks: An integrated approach as an in-line hemofilter or directly connected CRRT device, or a parallel system with separate ECLS and RRT circuits. Currently, there is no evidence that the different methods of combining the two extracorporeal treatments impact mortality.

Ostermann M, Connor M Jr, Kashani K. Continuous renal replacement therapy during extracorporeal membrane oxygenation: why, when and how? Curr Opin Crit Care. 2018 Dec;24(6):493-503. http://bit.ly/2rTNtCP


Simulation & training
ECMO simulations are challenging, due to the complex circuit/patient interactions, but mandatory to properly train the team. How to enhance the fidelity of the scenarios? In the following 3 papers, a proposal of solution by the ECSiTeD – ECMO Simulation Team of Doha group. To start, development of an ECMO simulator prototype allowing for easier, more realistic simulations, in order to reduce the current gap there is between simulation-based education and real care of patients on extracorporeal support. The system emulates the ECMO machine interface with remotely controllable pressure parameters, bleeding, line chattering, air bubble noise and simulated blood colour change, enabling the simulation of common ECLS emergencies.

Alinier G, Hassan IF, Alsalemi A, Al Disi M, Ait Hssain A, Labib A, Alhomsi Y, Bensaali F, Amira A, Ibrahim AS. Addressing the challenges of ECMO simulation. Perfusion. 2018 Oct;33(7):568-576. http://bit.ly/2BJx8EW

Their simulator offers a comprehensive, realistic, cost-effective and user-friendly solution for ECMO simulation based training that does not rely on the use of real equipment, preventing the risk of confusing learners due to unusual circuit alterations.

Al Disi M, Alsalemi A, Alhomsi Y, Bensaali F, Amira A, Alinier G. Extracorporeal membrane oxygenation simulation-based training: methods, drawbacks and a novel solution. Perfusion. 2018 Oct 19:267659118802749. http://bit.ly/2Vdk6IN

Here, details about a central component of this simulator, capable of visually reproducing blood oxygenation color change (or the lack of) using thermochromism; the manipulation of heat creates a temperature difference between the fluid in the drainage line and the fluid in the return line of the circuit and, hence, a color difference.

Al Disi M, Alsalemi A, Alhomsi Y, Bensaali F, Amira A, Alinier G. Using thermochromism to simulate blood oxygenation in extracorporeal membrane oxygenation. Perfusion. 2018 Sep 7:267659118798140. http://bit.ly/2rkjIuv

We move to Italy for an experience evaluating the impact a simulations based ECMO curriculum among the personnel of a PICU. Since the introduction of the high-fidelity simulation program, a decrease in time needed to effectively manage bedside the most common ECLS emergencies (pump failure, oxygenator change and air embolism) and improvement of the behavioural skills, have been observed.

Di Nardo M, David P, Stoppa F, Lorusso R, Raponi M, Amodeo A, Cecchetti C, Guner Y, Taccone FS. The introduction of a high-fidelity simulation program for training pediatric critical care personnel reduces the times to manage extracorporeal membrane oxygenation emergencies and improves teamwork. J Thorac Dis. 2018 Jun;10(6):3409-3417. open access http://bit.ly/2Rm8lAI


Case reports & more
A case of thrombus in the pump-head on ECMO, with suggestions to detect/visualize thrombosis and an interesting slowmotion video.

Diehl A, Gantner D. Pump head thrombosis in extracorporeal membrane oxygenation (ECMO). Intensive Care Med. 2018 Mar;44(3):376-377. http://bit.ly/2PkZ5bd

An unusual & potentially life-threatening embolic complication during CVC insertion on ECMO support: sucking of the guidewire into the drainage line due to negative pressure… be cautious!

Aizawa M, Ishihara S, Yokoyama T. ECMO circuit embolism: A potentially hazardous complication during ECMO therapy. J Clin Anesth. 2018 Dec 12;54:162-163. http://bit.ly/2PFdm2E

Report of a case of repeated, rapid-onset plasma leakage from the membrane lung during an ECMO run in an hyperbilirubinemic infant; disassembly of the oxygenator revealed congestion from bilirubin in the membrane fibers.

Kida Y, Ohshimo S, Kyo M, Tanabe Y, Suzuki K, Hosokawa K, Shime N. Rapid-onset plasma leakage of extracorporeal oxygenation membranes possibly due to hyperbilirubinemia. J Artif Organs. 2018 Dec; 21(4):475-478. http://bit.ly/2BKvwec

Noninvasive monitoring of gaseous microemboli using two Doppler probes in adults on veno-arterial ECMO support, with correlation to clinical events during routine patient care. Intravenous injections accounted for an estimated 68% of GME and 88% of GME volume, whereas care involving movement accounted for an estimated 6% of GME and 3% of volume. According to the results of this observational study, the overall estimated embolic rates of 24,000 GME, totaling 4 μl/hr, rivals rates reported during cardiopulmonary bypass, raising concerns for effects on microcirculation and organ dysfunction.

Jiao Y, Gipson KE, Bonde P, Mangi A, Hagberg R, Rosinski DJ, Gross JB, Schonberger RB. Quantification of Postmembrane Gaseous Microembolization During Venoarterial Extracorporeal Membrane Oxygenation. ASAIO J. 2018 Jan/Feb;64(1):31-37. http://bit.ly/2Ri0jsG

Coagulation/fibrinolysis indicated by soluble fibrin levels as marker for predicting ECMO circuit exchange because of circuit clots on extracorporeal support.

Hoshino K, Muranishi K, Kawano Y, Hatomoto H, Yamasaki S, Nakamura Y, Ishikura H. Soluble fibrin is a useful marker for predicting extracorporeal membrane oxygenation circuit exchange because of circuit clots. J Artif Organs. 2018 Jun;21(2):196-200. http://bit.ly/2EcyZWm

 

ECMO a year-in-review: part 4 – ECPR Extracorporeal Cardio-Pulmonary Resuscitation
If you search the terms ECMO, ECLS & ECPR on PubMed, you are going to find nearly 2000 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 are free open access! p.s. no claim to be exhaustive and random order!
The fourth part of this year-in-review is dedicated to Extracorporeal Cardio-Pulmonary Resuscitation in cardiac arrest and life threatening emergencies.

To start…
Waiting for the results of the ongoing RCTs on ECPR, a second line treatment for refractory cardiac arrest, in this paper, a multi-centre perspective on challenges and pillars of an ECPR program: implementation location and technique/device, ECMO team, peri-ECPR resuscitation. Extracorporeal CPR may offer salvage therapy for temporary management of refractory cardiac arrest, to be implemented within 60 minutes of collapse. Providing patients with access to ECPR in a timely manner requires a system-wide approach and engagement, whether implemented in-hospital or in the out-of-hospital setting.

Hutin A, Abu-Habsa M, Burns B, Bernard S, Bellezzo J, Shinar Z, Torres EC6, Gueugniaud PY, Carli P, Lamhaut L. Early ECPR for out-of-hospital cardiac arrest: Best practice in 2018. Resuscitation. 2018 Sep;130:44-48. http://bit.ly/2P7iWhS

Refractory VF/VT in out-of-hospital cardiac arrest: How to get a 48% functionally intact 3- month survival? immediate 24/7 availability of a spectrum of surgical and medical specialty expertise in a sophisticated medical/trauma center is required to provide emergent life-saving interventions. Results from 100 consecutive adults supported with ECPR implemented in the cath-lab form the group of Demetris Yannopoulos. Multi-system organ failure occurred in all patients but improved with adequate hemodynamic support; CPR caused traumatic injury requiring procedural/surgical intervention in 27% of patients (all considered eligible for necessary intervention/surgery until declaration of death). Neurologic recovery was prolonged requiring delayed prognostication; poor neurologic outcomes associated with anoxic injury or cerebral edema on admission head CT, decline in cerebral oximetry over the first 48 h, and elevated NSE on CICU admission.

Bartos JA, Carlson K, Carlson C, Raveendran G, John R, Aufderheide TP, Yannopoulos D. Surviving refractory out-of-hospital ventricular fibrillation cardiac arrest: Critical care and extracorporeal membrane oxygenation management. Resuscitation. 2018 Nov;132:47-55. open access http://bit.ly/2CGBX3X

In this analysis of refractory OHCA treated with ECMO assisted cardiopulmonary resuscitation implanted by a prehospital mobile intensive care unit, high rate of coronary artery disease (majority double or triple vessel disease and proximal lesions), especially in patients with shockable rhythm. The severity and extension of CAD may explain the refractory nature of the cardiac arrest. Immediate coronary angiography eventually followed by percutaneous coronary interventions, seems warranted in refractory cardiac arrest after implantation of ECPR.

Lamhaut L, Tea V, Raphalen JH, An K, Dagron C, Jouffroy R, Jouven X, Cariou A, Baud F, Spaulding C, Hagege A, Danchin N, Carli P, Hutin A, Puymirat E. Coronary lesions in refractory out of hospital cardiac arrest (OHCA) treated by extra corporeal pulmonary resuscitation (ECPR). Resuscitation. 2018 May; 126:154-159. http://bit.ly/2T1pBZo

Single-center study investigating the outcome patients with different initial rhythm at the time of decision for ECPR for in-hospital cardiac arrest: Reported survival to discharge in PEA 23.8%, 40% if shockable rhythm; all survivors to discharge had a good neurological outcome (CPC 1or 2). No patients with asystole as initial rhythm survived discharge. Authors suggest carefully considering for ECMO assisted CPR patients with PEA.

Pabst D, Brehm CE. Is pulseless electrical activity a reason to refuse cardiopulmonary resuscitation with ECMO support? Am J Emerg Med. 2018 Apr;36(4):637-640. http://bit.ly/2LDMAHu

An experimental animal model of refractory ECPR assessing the effect on macrocirculatory, metabolic and microcirculatory parameters of two extracorporeal Blood-Flow strategies, low (30-35 ml/kg/min) versus standard (65-70 ml/kg/min), with the same MAP target of 65 mmHg adjusted with norepinephrine, in the first six hours of ECMO initiation. Application of a low BF target is not associated with a better haemodynamic status nor with a decrease in inflammatory burst; moreover, is associated with a slower lactate clearance and a decreased cerebral perfusion when compared to a normal BF. According to these results, during the first six hours of ECPR, a normal pump blood flow should be used in order to improve end-organ perfusion as well as preserve brain perfusion.

Luo Y, Fritz C, Hammache N, Grandmougin D, Kimmoun A, Orlowski S, Tran N, Albuisson E, Levy B. Low versus standard-blood-flow reperfusion strategy in a pig model of refractory cardiac arrest resuscitated with Extra Corporeal Membrane Oxygenation. Resuscitation. 2018 Dec;133:12-17. http://bit.ly/2P0FU6U

Observational single-center comparison of survival and delay times between recognition and ECPR in refractory OHCA patients treated with extracorporeal support before and after the implementation of an innovative strategy named OSCAR-ECLS (Out of hoSpital Cardiac ARrest– ExtraCorporeal Life Support), aimed at enhancing patient selection and reducing prehospital delays to significantly shorten low-flow time. The use of a this paradigm dramatically reduce time spent on site by more than 20 min; most patients had an elapsed time from collapse to arrival in the catheterization laboratory of less than 1 h. Survival improved from 7% to 25%.

Chouihed T, Kimmoun A, Lauvray A, Laithier FX, Jaeger D, Lemoine S, Maureira JP, Nace L, Duarte K, Albizzati S, Girerd N, Levy B. Improving Patient Selection for Refractory Out of Hospital Cardiac Arrest Treated with Extracorporeal Life Support. Shock. 2018 Jan;49(1):24-28. open access link http://bit.ly/2TpmJWu

Health-related quality of life outcomes of patients treated with ECPR after refractory out-of and in-hospital cardiac arrest of presumed cardiac etiology: in properly selected patients, scores approximating HRQoL of subjects chronic renal failure.

Spangenberg T, Schewel J, Dreher A, Meincke F, Bahlmann E, van der Schalk H, Kreidel F, Frerker C, Stoeck M, Bein B, Kuck KH, Ghanem A. Health related quality of life after extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest. Resuscitation. 2018 Jun;127:73-78. http://bit.ly/2F2rYs1

Predicting weaning & survival
A retrospective single-center study to determine outcome in nonhighly selected patients treated with ECPR for in-hospital cardiac arrest, investigating possible predictors of survival: ECMO could be successful even in this population, as survival to discharge of patients with shockable rhythm was 40.7%. Serum lactate ≥ 8, pulseless electrical activity or asystole and male gender associated with poor outcome, while age, body mass index, renal replacement– dependent kidney injury had no significant influence on survival outcome.

Pabst D, El-Banayosy A, Soleimani B, Brehm CE. Predictors of Survival for Nonhighly Selected Patients Undergoing Resuscitation With Extracorporeal Membrane Oxygenation After Cardiac Arrest. ASAIO J. 2018 May/Jun;64(3):368-374. http://bit.ly/2F0Gn7W

In this retrospective analysis, the factors most strongly associated with mortality following ECPR are ongoing CPR at time of ECMO initiation and arrest to cannulation time; interventions aimed at reducing time to initiation of extracorporeal support may improve outcomes.

Zakhary B, Nanjayya VB, Sheldrake J, Collins K, Ihle JF, Pellegrino V. Predictors of mortality after extracorporeal cardiopulmonary resuscitation. Crit Care Resusc. 2018 Sep;20(3):223-230. open access  http://bit.ly/2AesBe5

Lactate clearance determined through arterial blood gas 6 hours after extracorporeal CPR significantly predict survival to discharge in patients treated with ECMO after cardiac arrest, and might support decision whether continuing ECPR is adequate or not, a monocentric experience.


Mizutani T, Umemoto N, Taniguchi T, Ishii H, Hiramatsu Y, Arata K, Takuya H, Inoue S, Sugiura T, Asai T, Yamada M, Murohara T, Shimizu K. The lactate clearance calculated using serum lactate level 6 h after is an important prognostic predictor after extracorporeal cardiopulmonary resuscitation: a single-center retrospective observational study. J Intensive Care. 2018 Jun 1;6:33. open access http://bit.ly/2sA0LF1

The significant associations of high serum lactate level with poor survival and poor neurological outcome in CA patients supported with ECMO is highlighted from the results of this systematic review and meta-analysis; moreover, a slight significant association of high creatinine with poor survival has been found, too.

Zhang Y, Li CS, Yuan XL, Ling JY, Zhang Q, Liang Y, Liu B, Zhao LX. Association of serum biomarkers with outcomes of cardiac arrest patients undergoing ECMO. Am J Emerg Med. 2018 Nov;36(11):2020-2028. http://bit.ly/2F1j4uG

A retrospective study including 135 patients to investigate the prognostic factors in ECPR for witnessed OHCA: low-flow time significantly associated with a favorable neurological outcome; suggested cut-off value to perform ECLS: within 58min of low-flow time.

Otani T, Sawano H, Natsukawa T, Nakashima T, Oku H, Gon C, Takahagi M, Hayashi Y. Low-flow time is associated with a favorable neurological outcome in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation. J Crit Care. 2018 Dec;48:15-20. http://bit.ly/2RnUfyX

Interplay between age and low-flow time on neuro-outcomes of ECMO assisted CPR: for elderly patients with low-flow < 60′, neurologic outcomes reported in this single-center experience not as poor as previously thought, underlying cause of cardiac collapse affects hospital survival more than age. ECPR suitable for either elderly patients with short cardiac arrest durations or young patients with long CA, while extracorporeal CPR not recommended in elderly patients with prolonged CA owing to relatively poor associated outcomes.

Yu HY, Wang CH, Chi NH, Huang SC, Chou HW, Chou NK, Chen YS. Effect of interplay between age and low-flow duration on neurologic outcomes of extracorporeal cardiopulmonary resuscitation. Intensive Care Med. 2018 Dec 13. open access http://bit.ly/2PFRjZF

A single‐center retrospective, observational study to compare survival between in-and out-of- hospital cardiac arrest patients supported with ECMO; despite greater low-flow and no-flow time, survival and neurological outcome was comparable between the two groups. Initial lactate level and baseline blood creatinine have been identified as factors independently associated with mortality. In the authors’ opinion, strict eligibility criteria, early alert of the ECMO team and optimization of organ perfusion during resuscitation and transport through a mechanical chest compression device can lead to good results in OHCA treated with ECLS.

Ellouze O, Vuillet M, Perrot J, Grosjean S, Missaoui A, Aho S, Malapert G, Bouhemad B, Bouchot O, Girard C. Comparable Outcome of Out-of-Hospital Cardiac Arrest and In-Hospital Cardiac Arrest Treated With Extracorporeal Life Support. Artif Organs. 2018 Jan;42(1):15-21. open access http://bit.ly/2QdWb8t

Modificatied Alberta Stroke Program Early Computed Tomography Score – mASPECTS feasible and reliable for predicting neurological outcomes in patients after ECPR: A retrospective, multicenter, observational study.

Ryu JA, Lee YH, Chung CR, Cho YH, Sung K, Jeon K, Suh GY, Park TK, Lee JM, Chae MK, Hong JH, Lee SH, Kim HS, Yang JH. Prognostic value of computed tomography score in patients after extracorporeal cardiopulmonary resuscitation. Crit Care. 2018 Nov 22;22(1):323. open access http://bit.ly/2BEFqiP

Successful weaning from veno-arterial ECMO support as rescue strategy to stabilize haemodynamics in AMI complicated by cardiac arrest, a multi-center retrospective study: early predictors post-PCI TIMI flow grade, MAP at 4 hours, and serum lactate at 24 hours; in patients who failed to wean from ECMO, LV systolic function did not recover within 48 hours.

Sugiura A, Abe R, Nakayama T, Hattori N, Fujimoto Y, Himi T, Sano K, Oda S, Kobayashi Y. Predictors of Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation After Coronary Revascularization for Acute Myocardial Infarction Complicated by Cardiac Arrest: A Retrospective Multicenter Study. Shock. 2018 Aug 3. http://bit.ly/2F50bqO

Reviews
Emergent ECLS in the ED: description, indications/contraindications, cannulation and circuit management, anticoagulation, complications, transport on ECMO, general logistics and organization of the dedicated team, outcomes. Extracorporeal support plays an increasing role in the emergency department in selected life-threatening conditions in which the alternative is a poor outcome or certain death, providing a bridge to recovery, definitive therapy, intervention or surgery. Close cooperation between all the involved services/units is essential for success, as an appropriately organized and trained staff, equipment resources and logistical planning.

Swol J, Belohlávek J, Brodie D, Bellezzo J, Weingart SD, Shinar Z, Schober A, Bachetta M, Haft JW, Ichiba S, Sakamoto T, Peek GJ, Lorusso R, Conrad SA. Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation. 2018 Dec;133:108-117. http://bit.ly/2SBVYhC

A review summarizing the recent knowledge on videomicroscopic imaging to perform bedside tissue microcirculatory peripheral perfusion assessment and therapy monitoring in cardiac arrest setting and discussing the impact of extracorporeal reperfusion on microcirculation.

Krupičková P, Mormanová Z, Bouček T, Belza T, Šmalcová J, Bělohlávek J. Microvascular perfusion in cardiac arrest: a review of microcirculatory imaging studies. Perfusion. 2018 Jan;33(1):8-15. http:// bit.ly/2T5r2G5

Background & rationale for pre-hospital delivery of ECPR to shortening the interval between collapse and restoration of circulation improving outcomes after OHCA; in this paper a review of the published evidence considering candidate selection, logistics, complications. The clinical benefits of rapid response and shorter low-flow time need to be balanced with the costs of over-triage and resource utilization.

Singer B, Reynolds JC, Lockey DJ, O’Brien B. Pre-hospital extra-corporeal cardiopulmonary resuscitation. Scand J Trauma Resusc Emerg Med. 2018 Mar 27;26(1):21. open access http://bit.ly/2Tptd7R

ECPR in pediatric population
Resuscitation in children with heart disease: AHA statement with recommendations for ECLS and ECPR: duration of conventional CPR before extracorporeal support, ECPR deployment location, cannulation, circuit, management, complications & outcomes, team, training issues.

Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC; American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation. 2018 May 29;137(22):e691-e782. http://bit.ly/2VkKReI

Exploring variations in resuscitative practices during cardiac arrest escalating to ECPR by surveying clinicians who care for pediatric patients with congenital and/or acquired heart disease. According to the authors, the observed variability supports a call for consensus building and standardization across centers, highlighting opportunities to investigate ECPR’s best practices and to develop quality improvement efforts.

Lasa JJ, Jain P, Raymond TT, Minard CG, Topjian A, Nadkarni V, Gaies M, Bembea M, Checchia PA, Shekerdemian LS, Thiagarajan R. Extracorporeal Cardiopulmonary Resuscitation in the Pediatric Cardiac Population: In Search of a Standard of Care. Pediatr Crit Care Med. 2018 Feb;19(2):125-130. open access http://bit.ly/2QYAMWa


ECPR in accidental hypothermia
Retrospective study aiming to build a prediction score including age, sex, core temperature at admission, serum potassium level, mechanism of cooling, and CPR duration, to determine the probability of survival following rewarming of hypothermic patients in cardiac arrest with extracorporeal life support, to improving the decision-making process when considering ECLS in this population. In the authors’ opinion, this multivariable model seems superior to dichotomous triage based only on serum potassium level.

Pasquier M, Hugli O, Paal P, Darocha T, Blancher M, Husby P, Silfvast T, Carron PN, Rousson V. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: The HOPE score. Resuscitation. 2018 May;126:58-64. http://bit.ly/2RudF52

ECLS in severe accidental hypothermia: According to the findings of this meta-analysis, ECMO support in hypothermic cardiac arrest provides a favourable chance of survival; rewarming rate, gender, history of presumed asphyxiation, and serum potassium level are independent variables associated with survival with a good neurologic outcome, and can assist clinicians in the prognostication of patients.

Saczkowski RS, Brown DJA, Abu-Laban RB, Fradet G, Schulze CJ, Kuzak ND. Prediction and risk stratification of survival in accidental hypothermia requiring extracorporeal life support: An individual patient data meta-analysis. Resuscitation. 2018 Jun;127:51-57. http://bit.ly/2GAXyNY

A study aiming to assess the costs of veno-arterial ECMO support and rewarming in severely hypothermic (Swiss Stage III-IV) patients in cardiac arrest or acute cardiac failure. Reported mean cost equalled 35% of all ICU expenditures, substantially lower than previuosly reported; one year after discharge, 45% of patients are still alive.

Kosiński S, Darocha T, Czerw A, Paal P, Pasquier M, Krawczyk P, Drwiła R, Gałązkowski R. Cost-utility of extracorporeal membrane oxygenation rewarming in accidentally hypothermic patients-A single-centre retrospective study. Acta Anaesthesiol Scand. 2018 Apr 23. http://bit.ly/2R51hsX

A case highlights the potential for favourable outcomes of hypothermia-related cardiac arrest: unwitnessed OHCA patient found with head immersed in water at of 23°C, with unclear history and poor prognostic indicators (asystole, pH 6.8, potassium 8.3 mmol/L, lactate 16.0 mmol/L); ECMO support was initiated after 95 minutes of CPR and the patient survived with a good neurological outcome.

Graeff I, Schacher S, Lenkeit S, Widmann CN, Schewe JC. Beyond the limits – ECPR in putative fatal circumstances. CJEM. 2018 Oct;20(S2):S70-S73. open access http://bit.ly/2J9n3UP

Survival with complete neurologic recovery for this 14-year-old healthy boy drowned and trapped two meters under a river water at 15°C for 43min, rescued with extracorporeal support and rewarming following about 60′ of conventional CPR.

Scandroglio AM, Bove T, Calabrò MG, Votta CD, Pappalardo F, Giacomello R, Landoni G, Zangrillo A Extracorporeal membrane oxygenation to resuscitate a 14-year-old boy after 43min drowning. Med Intensiva. 2018 Nov;42(8):509-510. http://bit.ly/2QZ3eat

Extracorporeal CPR to achieve hemodynamic stabilization and rapid & safe rewarming in a case of severe hypothermia after prolonged exposure to an urban night environment as a result of alcohol and drugs abuse.

Grapatsas K, Leivaditis V, Panagiotopoulos I, Spiliotopoulos K, Koletsis E, Dahm M, Kosmidis C, Laskou S, Zarogoulidis P, Katsaounis A, Pavlidis E, Giannakidis D, Koulouris C, Mantalovas S, Konstantinou F, Amaniti A, Munteanu A, Surlin V, Sapalidis K, Kesisoglou I. Deep accidental hypothermia accompanied with cardiac arrest after alcohol and drug poisoning treated with extracorporeal life support. Respir Med Case Rep. 2018 Jun 19;25:66-67. open access http://bit.ly/2VqzMZF

Extracorporeal support to provide temporary organ perfusion and effective rewarming in severe accidental hypothermia (≤25.4°C) and prolonged refractory ventricular fibrillation oxygenation: the patient survived without neurologic deficit.

Fister M, Knafelj R, Radsel P, Zlicar M, Goslar T, Noc M. Cardiopulmonary Resuscitation with Extracorporeal Membrane Oxygenation in a Patient with Profound Accidental Hypothermia and Refractory Ventricular Fibrillation. Ther Hypothermia Temp Manag. 2018 Aug 10.  http://bit.ly/2LGbAh5


Case reports & more
To conclude, some interesting case reports, series and experiences with selected populations supporting new indications of extracorporeal cardio-pulmonary resuscitation: In this case report, a novel technique to rapidly establish hemodynamic monitoring on ECPR by modifying the circuit introducing a 5 F pigtail catheter connected with a pressure transducer through an Y connector implemented in the arterial cannula and equipped with a hemostatic valve at its blind end; this approach allows for an easy and safe measurement of central blood pressure without need for a potentially hazardous additional arterial line.

Lunz D, Philipp A, Birner C. A novel technique to establish hemodynamic monitoring in patients supported with extracorporeal life support systems (ECLS) for cardiopulmonary resuscitation (ECPR). J Crit Care. 2018 Oct;47:219-221. http://bit.ly/2EZNTPI

Fluctuating or low ECMO blood flow as early sign of intra-abdominal bleeding due to traumatic injury after prolonged CPR: Considered these lesions earlier in diagnostic algorithms & promptly assess!

Ranney D, Hatch S, Bonadonna D, Daneshmand M. ECMO Flow as a Sign of Intraabdominal Hemorrhage After Prolonged CPR. ASAIO J. 2018 Nov 28.open access http://bit.ly/2PfNjin

Here, a case of profound refractory cardiac arrest associated associated with significant local anesthetic systemic toxicity after oropharyngeal topical anesthesia with lidocaine prior to TEE, successfully rescued with ECLS.

Bacon B, Silverton N, Katz M, Heath E, Bull DA, Harig J, Tonna JE. Local Anesthetic Systemic Toxicity Induced Cardiac Arrest After Topicalization for Transesophageal Echocardiography and Subsequent Treatment With Extracorporeal Cardiopulmonary Resuscitation. J Cardiothorac Vasc Anesth. 2018 Jan 31. open access http://bit.ly/2HtdO0b

Survival with favorable neurological outcome despite a CPR time of 73 minutes and VF continuing for 8 hours, in a 40-year-old female who suffered from refractory OHCA. In selected cases, implementing ECPR into routine care for refractory OHCA seems reasonable, and all efforts should be undertaken to adjust prehospital and early hospital logistics to provide emergency ECPR.

Lálová I, Filipovská L, Skalická H, Šmíd O1, Linhart A, Kollárová H, Bělohlávek J. Refractory Ventricle Arrhythmias Alternating with Pulseless Electrical Activity in a Young Woman Rescued by Extracorporeal Cardiopulmonary Resuscitation. Case Rep Med. 2018 Jan 14;2018:5686790. open access http://bit.ly/2pNZ8Bk

Veno-arterial ECMO support in life-threatening refractory electrical storm to restore systemic circulation and provide organ perfusion, ensuring oxygenation, preventing pro-arrhythmogenic conditions & facilitating electrophysiology study/procedures with hemodynamic stability, without interfering with ablation catheters. Here a couple of experiences

Uribarri A, Bravo L, Jimenez-Candil J, Martin-Moreiras J, Villacorta E, Sanchez PL. Percutaneous extracorporeal membrane oxygenation in electrical storm: five case reports addressing efficacy, transferring allowance or radiofrequency ablation support. Eur Heart J Acute Cardiovasc Care. 2018 Aug; 7(5):484-489. http://bit.ly/2TrLUb1

García Carreño J, Sousa-Casasnovas I, Vicent Alaminos ML, Atienza Fernández F, Martínez Sellés M, Fernández Avilés F. Extracorporeal Membrane Oxygenation in Patients With Electrical Storm: A Single- center Experience. Rev Esp Cardiol (Engl Ed). 2018 Jul 23.http://bit.ly/2LC9rq9

ECMO support in conjunction with systemic thrombolysis, catheter-directed therapy or as a bridge to surgical embolectomy to reduce morbidity and mortality in patients with massive pulmonary embolism who suffer a cardiac arrest: presentation, management and outcomes from a PERT – pulmonary embolism response team registry.

Al-Bawardy R, Rosenfield K, Borges J, Young MN, Albaghdadi M, Rosovsky R, Kabrhel C. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a case series and review of the literature. Perfusion. 2018 Jul 1:267659118786830. http://bit.ly/2F3bEGH

Complete recovery of a 3-year-old child with accidental home exposure to aluminium phosphide resulting in cardiac arrest and persistent acidosis related to AP induced mitochondrial dysfunction managed with ECPR: A case report highlighting the importance of multidisciplinary teamwork in these settings.

Lehoux J, Hena Z, McCabe M, Peek G. Aluminium phosphide poisoning resulting in cardiac arrest, successful treatment with Extracorporeal Cardiopulmonary resuscitation (ECPR): a case report. Perfusion. 2018 Oct;33(7):597-598. http://bit.ly/2EXFRXs

Central ECLS to effectively rescue a iatrogenic pulmonary artery rupture during elective balloon valvuloplasty for pulmonary valve stenosis in a 10-month-old infant who presented bradycardia and hypotension due to hemorrhage and tamponade.

Soynov I, Kornilov I, Zubritskiy A, Nichay N, Kulyabin Y, Gorbatykh A, Omelchenko A, Bogachev- Prokophiev A. Extracorporeal cardiopulmonary resuscitation after pulmonary artery rupture. Perfusion. 2018 Dec 22:267659118815311. http://bit.ly/2s3DB9C

ECPR in a case of refractory ventricular fibrillation with cardiac arrest in the ED caused by occlusion of the left main coronary artery and subsequent successful life-saving percutaneous coronary intervention on ECMO support to restore coronary perfusion.

Ni TY, Siao FY, Chiu CW, Yen HH. Successful resuscitation with extracorporeal membrane oxygenation support for refractory ventricular fibrillation caused by left main coronary artery occlusion. Am J Emerg Med. 2018 Nov 16. http://bit.ly/2LFwAoq

Successful ECPR in a sudden cardiac arrest due to catastrophic amniotic-fluid embolism during labor, a rare but fatal obstetric emergency.

Seong GM, Kim SW, Kang HS, Kang HW. Successful extracorporeal cardiopulmonary resuscitation in a postpartum patient with amniotic fluid embolism. J Thorac Dis. 2018 Mar;10(3):E189-E193. open access http://bit.ly/2BMBThp

ECMO support to rescue with positive outcome a patient with severe acute hypervolemic hyponatremia and catastrophic circulatory arrest secondary to excessive glycine absorption during elective hysteroscopic resection of uterine fibroids.

Charlesworth M, Barker JM, Greenhalgh D, Ashworth AD. Perioperative Extracorporeal Cardiopulmonary Resuscitation: The Defibrillator of the 21st Century?: A Case Report. A A Pract. 2018 Aug 15;11(4):87-89. http://bit.ly/2RqKoIB