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This article discusses the value of serial assessments and the challenges of observational research in the context of extracorporeal cardiopulmonary resuscitation (ECPR) for patients with out-of-hospital cardiac arrest (OHCA). It highlights three large randomized controlled trials that evaluated the effect of ECPR on survival, each with different findings. The article then introduces a new study that examines the added value of serial lactate measurements for outcome prediction among adult patients undergoing ECPR after OHCA. The study finds that increased lactate clearance is associated with higher survival rates and more favorable neurological outcomes. However, the study has limitations, such as not incorporating arterial oxygen tension (Pao2) into the analysis, which may have influenced the results. Overall, the study emphasizes the importance of serial assessments and post-resuscitation care in improving outcomes for ECPR patients. [Extracted from the article]

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to improve neurologically favorable survival in patients with refractory out-of-hospital cardiac arrest (OHCA) caused by shockable rhythms. Further refinement of patient selection is needed to focus this resource-intensive therapy on those patients likely to benefit. This study sought to create a selection model using machine learning (ML) tools for refractory cardiac arrest patients undergoing ECPR. DESIGN: Retrospective cohort study. SETTING: Cardiac ICU in a Quaternary Care Center. PATIENTS: Adults 18-75 years old with refractory OHCA caused by a shockable rhythm. METHODS: Three hundred seventy-six consecutive patients with refractory OHCA and a shockable presenting rhythm were analyzed, of which 301 underwent ECPR and cannulation for venoarterial extracorporeal membrane oxygenation. Clinical variables that were widely available at the time of cannulation were analyzed and ranked on their ability to predict neurologically favorable survival. INTERVENTIONS: ML was used to train supervised models and predict favorable neurologic outcomes of ECPR. The best-performing models were internally validated using a holdout test set. MEASUREMENTS AND MAIN RESULTS: Neurologically favorable survival occurred in 119 of 301 patients (40%) receiving ECPR. Rhythm at the time of cannulation, intermittent or sustained return of spontaneous circulation, arrest to extracorporeal membrane oxygenation perfusion time, and lactic acid levels were the most predictive of the 11 variables analyzed. All variables were integrated into a training model that yielded an in-sample area under the receiver-operating characteristic curve (AUC) of 0.89 and a misclassification rate of 0.19. Out-of-sample validation of the model yielded an AUC of 0.80 and a misclassification rate of 0.23, demonstrating acceptable prediction ability. CONCLUSIONS: ML can develop a tiered risk model to guide ECPR patient selection with tailored arrest profiles. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to investigate the current use and impact of pulmonary artery catheters (PACs) in patients with cardiogenic shock (CS) who underwent Impella support. DESIGN: This was a prospective multicenter observational study between January 2020 and December 2021 that registered all patients with drugrefractory acute heart failure and in whom the placement of an Impella 2.5, CP, or 5.0 pump was attempted or successful in Japan. SETTING: Cardiac ICUs in Japan. PATIENTS: Between January 2020 and December 2021, a total of 3112 patients treated with an Impella were prospectively enrolled in the Japan registry for percutaneous ventricular assist device (J-PVAD). Among them, 2063 patients with CS were divided into two groups according to the PAC use. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the 30-day mortality, and the secondary endpoints were hemolysis, acute kidney injury, sepsis, major bleeding unrelated to the Impella, and ventricular arrhythmias within 30 days. PACs were used in 1358 patients (65.8%) who underwent an Impella implantation. The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) was significantly higher in the patients with PACs than in those without. Factors associated with PAC use were the prevalence of hypertension, out-of-hospital cardiac arrest, New York Heart Association classification IV, the lesser prevalence of a heart rate less than 50, and the use of any catecholamine. The primary and secondary endpoints did not significantly differ according to the PAC use. Focusing on the patients with VA-ECMO use, the 30-day mortality and hemolysis were univariately lower in the patients with PACs. CONCLUSIONS: The J-PVAD findings indicated that PAC use did not have a significant impact on the short-term outcomes in CS patients undergoing Impella support. Further prospective studies are required to explore the clinical implications of PAC-guided intensive treatment strategies in these patients. [ABSTRACT FROM AUTHOR]

The article discusses the use of extracorporeal cardiopulmonary resuscitation (ECPR) for adult patients in cardiac arrest. It emphasizes the importance of patient selection for ECPR and discusses controversies surrounding its implementation. The text also highlights the need for rapid cannulation and the potential benefits of automated mechanical compressions before ECPR. The document provides a comprehensive list of references and citations related to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, as well as a list of references specifically related to ECPR for out-of-hospital cardiac arrest. These resources can be valuable for library patrons conducting research on these topics. [Extracted from the article]

OBJECTIVES: To examine trends in utilization and outcomes among patients with the acute respiratory distress syndrome (ARDS) requiring prolonged venovenous extracorporeal membrane oxygenation (VV ECMO) support. DESIGN: Retrospective observational cohort study. SETTING: Adult patients in the Extracorporeal Life Support Organization registry. PATIENTS: Thirteen thousand six hundred eighty-one patients that required ECMO for the support of ARDS between January 2012 and December 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mortality while supported with VV ECMO and survival to hospital discharge based on ECMO duration were examined utilizing multivariable logistic regression. Among the 13,681 patients supported with VV ECMO, 4,040 (29.5%) were supported for greater than or equal to 21 days and 975 (7.1%) for greater than or equal to 50 days. Patients supported with prolonged VV ECMO were less likely to be discharged alive from the hospital compared with those with short duration of support (46.5% vs. 59.7%; p < 0.001). However, among patients supported with VV ECMO greater than or equal to 21 days, duration of extracorporeal life support was not significantly associated with mortality (odds ratio [OR], 0.99; 95% CI, 0.98-1.01; p = 0.87 and adjusted OR, 0.99; 95% CI, 0.97-1.02; p = 0.48). Even in those supported with VV ECMO for at least 120 days (n = 113), 52 (46.0%) of these patients were ultimately discharged alive from the hospital. CONCLUSIONS: Prolonged VV ECMO support of ARDS has increased and accounts for a substantial portion of cases. Among patients that survive for greater than or equal to 21 days while receiving VV ECMO support, duration is not predictive of survival to hospital discharge and clinical recovery may occur even after very prolonged VV ECMO support. [ABSTRACT FROM AUTHOR]

The article discusses the impact of the COVID-19 pandemic on critical care and the relationship between surge conditions and mortality. A study conducted in the Netherlands found that as COVID-19 hospitalizations increased, the number of patients in the ICU with non-COVID conditions decreased. There was also a small but clear relationship between surge conditions and mortality, indicating the strain on healthcare resources and its impact on patient safety. The study highlights the need to consider the risks of deferred surgeries and the quality of care provided during high caseloads. ICUs worldwide are facing strain due to capacity and staffing issues, which has highlighted the risk of mortality. However, there is limited understanding of the factors that impact patient outcomes. There is a need for better data and research definitions to define ICU care beyond just location. Using markers of patient acuity and interventions such as pressors and mechanical ventilation can help assess the risk. It is important to capture changes in staffing and training levels. Data lakes with patient data could be used to identify safety risks, but they are often not coupled with temporal data or hospital information. Healthcare should follow the aviation industry's example and agree to submit essential information to a third party to shape our understanding of the relationship between strain and safety. At the bedside, proactive evaluation of risk mitigation can be done through tests of change, such as new staffing models and smart technology. A surge index could be developed to predict and compare strain across hospitals. ICU care should focus on preventing adverse outcomes associated with infections and pressure [Extracted from the article]

OBJECTIVES: This review aims to: 1) identify the key circuit and patient factors affecting systemic oxygenation, 2) summarize the literature reporting the association between hyperoxia and patient outcomes, and 3) provide a pragmatic approach to oxygen titration, in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (ECMO). DATA SOURCES: Searches were performed using PubMed, SCOPUS, Medline, and Google Scholar. STUDY SELECTION: All observational and interventional studies investigating the association between hyperoxia, and clinical outcomes were included, as well as guidelines from the Extracorporeal Life Support Organization. DATA EXTRACTION: Data from relevant literature was extracted, summarized, and integrated into a concise narrative review. For ease of reference a summary of relevant studies was also produced. DATA SYNTHESIS: The extracorporeal circuit and the native cardiorespiratory circuit both contribute to systemic oxygenation during venoarterial ECMO. The ECMO circuit's contribution to systemic oxygenation is, in practice, largely determined by the ECMO blood flow, whereas the native component of systemic oxygenation derives from native cardiac output and residual respiratory function. Interactions between ECMO outflow and native cardiac output (as in differential hypoxia), the presence of respiratory support, and physiologic parameters affecting blood oxygen carriage also modulate overall oxygen exposure during venoarterial ECMO. Physiologically those requiring venoarterial ECMO are prone to hyperoxia. Hyperoxia has a variety of definitions, most commonly Pa o2 greater than 150 mm Hg. Severe hypoxia (Pa o2 > 300 mm Hg) is common, seen in 20%. Early severe hyperoxia, as well as cumulative hyperoxia exposure was associated with in-hospital mortality, even after adjustment for disease severity in both venoarterial ECMO and extracorporeal cardiopulmonary resuscitation. A pragmatic approach to oxygenation during peripheral venoarterial ECMO involves targeting a right radial oxygen saturation target of 94-98%, and in selected patients, titration of the fraction of oxygen in the mixture via the air-oxygen blender to target postoxygenator Pa o2 of 150-300 mm Hg. CONCLUSIONS: Hyperoxia results from a range of ECMO circuit and patient-related factors. It is common during peripheral venoarterial ECMO, and its presence is associated with poor outcome. A pragmatic approach that avoids hyperoxia, while also preventing hypoxia has been described for patients receiving peripheral venoarterial ECMO. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The objective of this study was to determine the association of the use of extracorporeal cardiopulmonary resuscitation (ECPR) with survival to hospital discharge in pediatric patients with a noncardiac illness category. A secondary objective was to report on trends in ECPR usage in this population for 20 years. DESIGN: Retrospective multicenter cohort study. SETTING: Hospitals contributing data to the American Heart Association's Get With The Guidelines-Resuscitation registry between 2000 and 2021. PATIENTS: Children (<18 yr) with noncardiac illness category who received greater than or equal to 30 minutes of cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity score weighting balanced ECPR and conventional CPR (CCPR) groups on hospital and patient characteristics. Multivariable logistic regression incorporating these scores tested the association of ECPR with survival to discharge. A Bayesian logistic regression model estimated the probability of a positive effect from ECPR. A secondary analysis explored temporal trends in ECPR utilization. Of 875 patients, 159 received ECPR and 716 received CCPR. The median age was 1.0 [interquartile range: 0.2-7.0] year. Most patients (597/875; 68%) had a primary diagnosis of respiratory insufficiency. Median CPR duration was 45 [35-63] minutes. ECPR use increased over time (p < 0.001). We did not identify differences in survival to discharge between the ECPR group (21.4%) and the CCPR group (16.2%) in univariable analysis (p = 0.13) or propensity-weighted multivariable logistic regression (adjusted odds ratio 1.42 [95% CI, 0.84-2.40; p = 0.19]). The Bayesian model estimated an 85.1% posterior probability of a positive effect of ECPR on survival to discharge. CONCLUSIONS: ECPR usage increased substantially for the last 20 years. We failed to identify a significant association between ECPR and survival to hospital discharge, although a post hoc Bayesian analysis suggested a survival benefit (85% posterior probability). [ABSTRACT FROM AUTHOR]

OBJECTIVES: Extracorporeal membrane oxygenation to support cardiopulmonary resuscitation (CPR) is increasingly used in children suffering cardiac arrest after cardiac surgery. However, its efficacy in promoting survival has not been evaluated. We compared survival of pediatric cardiac surgery patients suffering in-hospital cardiac arrest who were resuscitated with extracorporeal CPR (E-CPR) to those resuscitated with conventional CPR (C-CPR) using propensity matching. DESIGN: Retrospective study using multicenter data from the American Heart Association Get With The Guidelines-Resuscitation registry (2008-2020). SETTING: Multicenter cardiac arrest database containing cardiac arrest and CPR data from U.S. hospitals. PATIENTS: Cardiac surgical patients younger than 18 years old who suffered in-hospital cardiac arrest and received greater than or equal to 10 minutes of CPR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 1223 patients, 741 (60.6%) received C-CPR and 482 (39.4%) received E-CPR. E-CPR utilization increased over the study period (p < 0.001). Duration of CPR was longer in E-CPR compared with C-CPR recipients (42 vs. 26 min; p < 0.001). In a propensity score matched cohort (382 E-CPR recipients, 382 C-CPR recipients), E-CPR recipients had survival to discharge (odds ratio [OR], 2.22; 95% CI, 1.7-2.9; p < 0.001). E-CPR survival was only higher when CPR duration was greater than 18 minutes. Propensity matched analysis using patients from institutions contributing at least one E-CPR case (n = 35 centers; 353 E-CPR recipients, 353 C-CPR recipients) similarly demonstrated improved survival in E-CPR recipients compared with those who received C-CPR alone (OR, 2.08; 95% CI, 1.6-2.8; p < 0.001). CONCLUSIONS: E-CPR compared with C-CPR improved survival in children suffering cardiac arrest after cardiac surgery requiring CPR greater than or equal to 10 minutes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Signs of life (SOLs) during cardiac arrest (gasping, pupillary light reaction, or any form of body movement) are suggested to be associated with favorable neurologic outcomes in out-of-hospital cardiac arrest (OHCA). While data has demonstrated that extracorporeal cardiopulmonary resuscitation (ECPR) can improve outcomes in cases of refractory cardiac arrest, it is expected that other contributing factors lead to positive outcomes. This study aimed to investigate whether SOL on arrival is associated with neurologic outcomes in patients with OHCA who have undergone ECPR. DESIGN: Retrospective multicenter registry study. SETTING: Thirty-six facilities participating in the Study of Advanced life support for Ventricular fibrillation with Extracorporeal circulation in Japan II (SAVE-J II). PATIENTS: Consecutive patients older than 18 years old who were admitted to the Emergency Department with OHCA between January 1, 2013, and December 31, 2018, and received ECPR. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were classified into two groups according to the presence or absence of SOL on arrival. The primary outcome was a favorable neurologic outcome (Cerebral Performance Category 1 or 2) at discharge. Of the 2157 patients registered in the SAVE-J II database, 1395 met the inclusion criteria, and 250 (17.9%) had SOL upon arrival. Patients with SOL had more favorable neurologic outcomes than those without SOL (38.0% vs. 8.1%; p < 0.001). Multivariate analysis showed that SOL on arrival was independently associated with favorable neurologic outcomes (odds ratio, 5.65 [95% CI, 3.97-8.03]; p < 0.001). CONCLUSIONS: SOL on arrival was associated with favorable neurologic outcomes in patients with OHCA undergoing ECPR. In patients considered for ECPR, the presence of SOL on arrival can assist the decision to perform ECPR. [ABSTRACT FROM AUTHOR]

The article explores the use of left ventricular (LV) unloading devices in combination with extracorporeal cardiopulmonary resuscitation (ECPR) for patients with cardiac arrest. The authors present a meta-analysis of observational studies and find that using an LV unloading device may reduce mortality but also increase complications. However, more scientific evidence is needed to establish guidelines for the use of LV unloading devices in cardiac arrest. The article also discusses the challenges of conducting randomized clinical trials in this context and emphasizes the importance of well-trained teams and timely interventions. Ethical considerations and the impact on quality of life are also addressed. Further research is needed to determine which patients would benefit from LV unloading in ECPR and to understand the ethical implications of mechanical cardiac support devices. [Extracted from the article]

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) serves as a lifesaving intervention for patients experiencing refractory cardiac arrest. With its expanding usage, there is a burgeoning focus on improving patient outcomes through optimal management in the acute phase after cannulation. This review explores systematic post-cardiac arrest management strategies, associated complications, and prognostication in ECPR patients. DATA SOURCES: A PubMed search from inception to 2023 using search terms such as post-cardiac arrest care, ICU management, prognostication, and outcomes in adult ECPR patients was conducted. STUDY SELECTION: Selection includes original research, review articles, and guidelines. DATA EXTRACTION: Information from relevant publications was reviewed, consolidated, and formulated into a narrative review. DATA SYNTHESIS: We found limited data and no established clinical guidelines for post-cardiac arrest care after ECPR. In contrast to non-ECPR patients where systematic post-cardiac arrest care is shown to improve the outcomes, there is no high-quality data on this topic after ECPR. This review outlines a systematic approach, albeit limited, for ECPR care, focusing on airway/breathing and circulation as well as critical aspects of ICU care, including analgesia/sedation, mechanical ventilation, early oxygen/Co2, and temperature goals, nutrition, fluid, imaging, and neuromonitoring strategy. We summarize common on-extracorporeal membrane oxygenation complications and the complex nature of prognostication and withdrawal of life-sustaining therapy in ECPR. Given conflicting outcomes in ECPR randomized controlled trials focused on pre-cannulation care, a better understanding of hemodynamic, neurologic, and metabolic abnormalities and early management goals may be necessary to improve their outcomes. CONCLUSIONS: Effective post-cardiac arrest care during the acute phase of ECPR is paramount in optimizing patient outcomes. However, a dearth of evidence to guide specific management strategies remains, indicating the necessity for future research in this field. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR. DATA SOURCES: Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). STUDY SELECTION: Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta- Analysis checklist. DATA EXTRACTION: Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model. DATA SYNTHESIS: Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses. CONCLUSIONS: ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Concise definitive review of the use of venopulmonary arterial extracorporeal membrane oxygenation (V-PA ECMO) support in patients with cardiopulmonary failure. DATA SOURCES: Original investigations identified through a PubMed search with search terms "percutaneous right ventricular assist device," "oxy-RVAD," "V-PA ECMO," and "veno-pulmonary arterial ECMO" were reviewed and evaluated for relevance. STUDY SELECTION: Studies that included more than three patients supported with V-PA ECMO were included. DATA EXTRACTION: Clinically relevant data from included studies, including patient-important outcomes, were summarized and discussed. DATA SYNTHESIS: We identified four groups of patients where V-PA ECMO has been studied: acute respiratory distress syndrome, right ventricular dysfunction after left ventricular assist device placement, bridge to lung transplantation, and pulmonary embolism. Most identified works are small, single center, and retrospective in nature, precluding definitive conclusions regarding the efficacy of V-PA ECMO. There have been no clinical trials evaluating the efficacy of V-PA ECMO for any indication. CONCLUSIONS: V-PA ECMO is a promising form of extracorporeal support for patients with right ventricular dysfunction. Future work should focus on identifying the optimal timing and populations for the use of V-PA ECMO. [ABSTRACT FROM AUTHOR]

The article discusses the use of machine learning algorithms to predict clinical outcomes in patients with cardiac arrest who are supported with venoarterial extracorporeal membrane oxygenation (VA ECMO). The study found that patients who achieved return of spontaneous circulation (ROSC) and were in refractory cardiogenic shock had better outcomes with VA ECMO. However, there are limitations to the study, including the lack of diversity in the patient population and the specific characteristics of the high-volume VA ECMO center where the study was conducted. The authors emphasize the need for further research and ethical considerations in the use of VA ECMO. [Extracted from the article]

The article discusses the process of weaning patients from venovenous extracorporeal membrane oxygenation (ECMO), a treatment used for severe acute respiratory distress syndrome (ARDS). The authors highlight the lack of standardized guidelines for weaning and the variation in practices among different ECMO centers. They present findings from a study conducted at a German ECMO center, which identified risk factors for failed weaning trials. The article also compares different weaning methods and discusses the importance of considering factors such as respiratory drive and fluid management during the weaning process. The authors emphasize the need for further research to develop optimal weaning approaches. [Extracted from the article]

OBJECTIVES: Critically ill women may receive less vital organ support than men but the mortality impact of this differential treatment remains unclear. We aimed to quantify sex differences in vital organ support provided to adult ICU patients and describe the relationship between sex, vital organ support, and mortality. DESIGN: In this retrospective observational study, we examined the provision of invasive ventilation (primary outcome), noninvasive ventilation, vasoactive medication, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), or any one of these five vital organ supports in women compared with men. We performed logistic regression investigating the association of sex with each vital organ support, adjusted for illness severity, diagnosis, preexisting treatment limitation, year, and hospital. We performed logistic regression for hospital mortality adjusted for the same variables, stratified by vital organ support (secondary outcome). SETTING AND PATIENTS: ICU admissions in the Australia and New Zealand Intensive Care Society Adult Patient Database 2018–2021. This registry records admissions from 90% of ICUs in the two nations. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We examined 699,535 ICU admissions (43.7% women) to 199 ICUs. After adjustment, women were less likely than men to receive invasive ventilation (odds ratio [OR], 0.64; 99% CI, 0.63–0.65) and each other organ support except ECMO. Women had lower adjusted hospital mortality overall (OR, 0.94; 99% CI, 0.91–0.97). Among patients who did not receive any organ support, women had significantly lower adjusted hospital mortality (OR, 0.82; 99% CI, 0.76–0.88); among patients who received any organ support women and men were equally likely to die (OR, 1.01; 99% CI, 0.97–1.04). CONCLUSIONS: Women received significantly less vital organ support than men in ICUs in Australia and New Zealand. However, our findings suggest that women may not be harmed by this conservative approach to treatment. [ABSTRACT FROM AUTHOR]

This article discusses the use of extracorporeal membrane oxygenation (ECMO) as a treatment for respiratory failure in young patients. The study examines whether there are differences in outcomes between teenagers and young adults who receive ECMO. The researchers analyzed data from the International Registry of the Extracorporeal Life Support Organization and found that young adults had a higher survival rate compared to teenagers. The study also identified differences in pre-ECMO factors and management during ECMO between the two groups. The authors highlight the need for further research to determine optimal management strategies for these patients. [Extracted from the article]

The article discusses the use of extracorporeal cardiopulmonary resuscitation (ECPR) in patients who have experienced cardiac arrest. The study examines the association between patient age and outcomes following cardiac arrest. The authors found that older patients had lower odds of survival compared to younger patients. However, the study has limitations, including selection bias and the lack of long-term outcome measures. The authors suggest that further research is needed to understand how age and other factors impact the effectiveness of ECPR. [Extracted from the article]

OBJECTIVES: A recent study from Germany found that survival after respiratory extracorporeal life support (ECLS) was lower among patients 10–20 years old than 20–30 years old. The objective of this study was to compare survival between teenage and young adult patients who receive respiratory ECLS. DESIGN: Retrospective cohort study. SETTING: Extracorporeal Life Support Organization registry, an international prospective quality improvement database. PATIENTS: All patients ages 16–30 years cannulated for respiratory indications from 1990 to 2020 were included. Patients were divided into two groups, teens (16–19 yr old) and young adults (20–30 yr old). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was survival to discharge. Variables were considered for the multivariate logistic regression model if there was both a statistically significant difference (p ≤ 0.05) and a clinically meaningful absolute difference between the groups. A total of 5,751 patients were included, of whom 1,653 (29%) were teens and 4,098 (71%) were young adults. Survival to discharge was higher in young adults than teens, 69% versus 63% (p < 0.001). Severity of illness was higher among teens; however, survival within each stratum defined by Pa o 2/F io 2 ratio was higher in young adults than in teens. Use of venoarterial ECLS was higher in teens than in young adults, 15% versus 7%, respectively. Teens were more likely to receive high-frequency oscillatory ventilation and this therapy was associated with a longer time from admission to ECLS initiation. After adjusting for variables that differ significantly between the groups, the odds ratio for survival in young adults compared with teens was 1.14 (95% CI, 1.004–1.3). CONCLUSIONS: In this large multicenter retrospective study, mortality was higher in teens than in young adults who received respiratory ECLS. This difference persisted after adjusting for multiple variables and the mechanism underlying these findings remains unclear. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) with femoral access is obtained through unilateral or bilateral groin cannulation. Whether one cannulation strategy is associated with a lower risk for limb ischemia remains unknown. We aim to assess if one strategy is preferable. DESIGN: A retrospective cohort study based on the Extracorporeal Life Support Organization registry. SETTING: ECMO centers worldwide included in the Extracorporeal Life Support Organization registry. PATIENTS: All adult patients (≥ 18 yr) who received peripheral venoarterial ECMO with femoral access and were included from 2014 to 2020. INTERVENTIONS: Unilateral or bilateral femoral cannulation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the occurrence of limb ischemia defined as a composite endpoint including the need for a distal perfusion cannula (DPC) after 6 hours from implantation, compartment syndrome/fasciotomy, amputation, revascularization, and thrombectomy. Secondary endpoints included bleeding at the peripheral cannulation site, need for vessel repair, vessel repair after decannulation, and in-hospital death. Propensity score matching was performed to account for confounders. Overall, 19,093 patients underwent peripheral venoarterial ECMO through unilateral (n = 11,965) or bilateral (n = 7,128) femoral cannulation. Limb ischemia requiring any intervention was not different between both groups (bilateral vs unilateral: odds ratio [OR], 0.92; 95% CI, 0.82–1.02). However, there was a lower rate of compartment syndrome/fasciotomy in the bilateral group (bilateral vs unilateral: OR, 0.80; 95% CI, 0.66–0.97). Bilateral cannulation was also associated with lower odds of cannulation site bleeding (bilateral vs unilateral: OR, 0.87; 95% CI, 0.76–0.99), vessel repair (bilateral vs unilateral: OR, 0.55; 95% CI, 0.38–0.79), and in-hospital mortality (bilateral vs unilateral: OR, 0.85; 95% CI, 0.81–0.91) compared with unilateral cannulation. These findings were unchanged after propensity matching. CONCLUSIONS: This study showed no risk reduction for overall limb ischemia-related events requiring DPC after 6 hours when comparing bilateral to unilateral femoral cannulation in peripheral venoarterial ECMO. However, bilateral cannulation was associated with a reduced risk for compartment syndrome/fasciotomy, lower rates of bleeding and vessel repair during ECMO, and lower in-hospital mortality. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Analysis of the prevalence and risk factors for weaning failure from venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with severe acute respiratory insufficiency. DESIGN: Single-center retrospective observational study. SETTING: Sixteen beds medical ICU at the University Hospital Regensburg. PATIENTS: Two hundred twenty-seven patients with severe acute respiratory insufficiency requiring VV-ECMO support between October 2011 and December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients meeting our ECMO weaning criteria (Sp o 2 ≥ 90% with F io 2 ≤ 0.4 or Pa o 2/F io 2 > 150 mm Hg, pH = 7.35–7.45, positive end-expiratory pressure ≤ 10 cm H2O, driving pressure < 15 cm H2O, respiratory rate < 30/min, tidal volume > 5 mL/kg, ECMO bloodflow ≈ 1. 5 L/min, sweep gas flow ≈ 1 L/min, heart rate < 120/min, systolic blood pressure 90–160 mm Hg, norepinephrine < 0.2 µg/[kg*min]) underwent an ECMO weaning trial (EWT) with pausing sweep gas flow. Arterial blood gas analysis, respiratory and ventilator parameters were recorded prior, during, and after EWTs. Baseline data, including demographics, vitals, respiratory, ventilator, and laboratory parameters were recorded at the time of cannulation. One hundred seventy-nine of 227 (79%) patients were successfully decannulated. Ten patients (4%) underwent prolonged weaning of at least three failed EWTs before successful decannulation. The respiratory rate (19/min vs 16/min, p = 0.002) and Pa co 2 (44 mm Hg vs 40 mm Hg, p = 0.003) were higher before failed than successful EWTs. Both parameters were risk factors for ECMO weaning failure (Pa co 2: odds ratio [OR] 1.05; 95% CI, 1.001–1.10; p = 0.045; respiratory rate: OR 1.10; 95% CI, 1.04–1.15; p < 0.001) in multivariable analysis. The rapid shallow breathing index [42 (1/L*min), vs 35 (1/L*min), p = 0.052) was higher before failed than successful EWTs. The decline of Sa o 2 and Pa o 2/F io 2 during EWTs was higher in failed than successful trials. CONCLUSIONS: Seventy-nine percent of patients were successfully decannulated with only 4% needing prolonged ECMO weaning. Before EWT only parameters of impaired ventilation (insufficient decarboxylation, higher respiratory rate) but not of oxygenation were predictive for weaning failure, whereas during EWT-impaired oxygenation was associated with weaning failure. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database. DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization registry. PATIENTS: Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020. MEASUREMENTS AND MAIN RESULTS: The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18–49, 50–64, 65–74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46–66 yr). There was a significantly lower aOR of survival for those 65–74 (0.68l 95% CI, 0.57–0.81) or those greater than 75 (0.54; 95% CI, 0.41–0.69), compared with 18–49. Patients 50–64 had a significantly higher aOR of survival compared with those 65–74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79–1.05). A sensitivity analysis using alternative age categories (18–64, 65–69, 70–74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65–69: odds ratio [OR], 0.71; 95% CI, 0.59–0.86; for age 70–74: OR, 0.84; 95% CI, 0.67–1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50–0.81). CONCLUSIONS: This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Trimethoprim-sulfamethoxazole (TMP-SMX)-associated severe acute respiratory distress syndrome (ARDS) has gone underrecognized. We propose the first disease definition and clinical evaluation for a novel adverse drug reaction (ADR) based on a series of recently identified rare cases of life-threatening ADRs. DESIGN: A retrospective study was conducted. All medical records were evaluated. Available pathology samples were sent to Massachusetts General for clinical consultation. Blood samples from surviving patients were obtained and human leukocyte antigen (HLA) analysis was performed by the Children’s Mercy Hospital Genomic Center and Vanderbilt University Medical Center. SETTING: U.S. ICUs, 1996–2021. PATIENTS: Nineteen young patients (10–37) were identified. Patients were previously healthy, with no preexisting pulmonary disease, no other cause for respiratory failure, and no chronic history of smoking/vaping. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Through our retrospective analysis, we analyzed clinical characteristics associated with TMP-SMX. Pathology samples were reviewed, and HLA analysis was performed on available samples by the study team or as standard of care at treatment hospitals in some cases. In 19 critically ill patients, we identified a pattern of severe respiratory failure requiring ICU admission, mechanical ventilation, and frequent extracorporeal membrane oxygenation use. We describe the first three-part clinical diagnosis and evaluation strategy: 1) Clinical definition: Unexplained severe respiratory failure in a patient receiving greater than or equal to 6 days of TMP-SMX at treatment dose (not prophylaxis). TMP-SMX ARDS is a diagnosis of exclusion. 2) Genetic association: One hundred percent of currently available TMP-SMX respiratory failure patient genomic data, (n = 11) have been carriers of both HLA-B*07:02 and HLA-C*07:02 alleles. HLA allele evaluation could be considered in patients with suspected TMP-SMX respiratory failure. 3) Lung pathology: A unique pulmonary pathologic pattern of lung injury termed diffuse alveolar injury with delayed epithelialization has been observed in these cases. In suspected cases, surgical lung biopsy early in the clinical course could be considered. CONCLUSIONS: TMP-SMX is a commonly prescribed antibiotic. However, we find it imperative to share this relatively rare but life-threatening condition with clinicians as the mortality rate approaches 40%. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether multisite versus single-site dual-lumen (SSDL) cannulation is associated with outcomes for COVID-19 patients requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization Registry. Propensity score matching (2:1 multisite vs SSDL) was used to control for confounders. PATIENTS: The matched cohort included 2,628 patients (1,752 multisite, 876 SSDL) from 170 centers. The mean (sd) age in the entire cohort was 48 (11) years, and 3,909 (71%) were male. Patients were supported with mechanical ventilation for a median (interquartile range) of 79 (113) hours before VV-ECMO support. INTERVENTIONS: None. MEASUREMENTS: The primary outcome was 90-day survival. Secondary outcomes included survival to hospital discharge, duration of ECMO support, days free of ECMO support at 90 days, and complication rates. MAIN RESULTS: There was no difference in 90-day survival (49.4 vs 48.9%, p = 0.66), survival to hospital discharge (49.8 vs 48.2%, p = 0.44), duration of ECMO support (17.9 vs 17.1 d, p = 0.82), or hospital length of stay after cannulation (28 vs 27.4 d, p = 0.37) between multisite and SSDL groups. More SSDL patients were extubated within 24 hours (4% vs 1.9%, p = 0.001). Multisite patients had higher ECMO flows at 24 hours (4.5 vs 4.1L/min, p < 0.001) and more ECMOfree days at 90 days (3.1 vs 2.0 d, p = 0.02). SSDL patients had higher rates of pneumothorax (13.9% vs 11%, p = 0.03). Cannula site bleeding (6.4% vs 4.7%, p = 0.03), oxygenator failure (16.7 vs 13.4%, p = 0.03), and circuit clots (5.5% vs 3.4%, p = 0.02) were more frequent in multisite patients. CONCLUSIONS: In this retrospective study of COVID-19 patients requiring VV-ECMO, 90-day survival did not differ between patients treated with a multisite versus SSDL cannulation strategy and there were only modest differences in major complication rates. These findings do not support the superiority of either cannulation strategy in this setting. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) is an advanced treatment for acute severe respiratory failure. Patients on ECMO are frequently maintained sedated and immobilized until weaning from ECMO, first, and then from mechanical ventilation. Avoidance of sedation and invasive ventilation during ECMO may have potential advantages. We performed a systematic literature review to assess efficacy and safety of awake ECMO without invasive ventilation in patients with respiratory failure. DATA SOURCES: PubMed, Web of Science, and Scopus were searched for studies reporting outcome of awake ECMO for adult patients with respiratory failure. STUDY SELECTION: We included all studies reporting outcome of awake ECMO in patients with respiratory failure. Studies on ECMO for cardiovascular failure, cardiac arrest, or perioperative support and studies on pediatric patients were excluded. Two investigators independently screened and selected studies for inclusion. DATA EXTRACTION: Two investigators abstracted data on study characteristics, rate of awake ECMO failure, and mortality. Primary outcome was rate of awake ECMO failure (need for intubation). Pooled estimates with corresponding 95% CIs were calculated. Subgroup analyses by setting were performed. DATA SYNTHESIS: A total of 57 studies (28 case reports) included data from 467 awake ECMO patients. The subgroup of patients with acute respiratory distress syndrome showed a pooled estimate for awake ECMO failure of 39.3% (95% CI, 24.0–54.7%), while in patients bridged to lung transplantation, pooled estimate was 23.4% (95% CI, 13.3–33.5%). Longest follow-up mortality was 121 of 439 (pooled estimate, 28%; 95% CI, 22.3–33.6%). Mortality in patients who failed awake ECMO strategy was 43 of 74 (pooled estimate, 57.2%; 95% CI, 40.2–74.3%). Two cases of cannula self-removal were reported. CONCLUSIONS: Awake ECMO is feasible in selected patients, although the effect on outcome remains to be demonstrated. Mortality is almost 60% in patients who failed awake ECMO strategy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: ICU resource strain leads to adverse patient outcomes. Simple, well-validated measures of ICU strain are lacking. Our objective was to assess whether the “Activity index,” an indicator developed during the COVID-19 pandemic, was a valid measure of ICU strain. DESIGN: Retrospective national registry-based cohort study. SETTING: One hundred seventy-five public and private hospitals in Australia (June 2020 through March 2022). SUBJECTS: Two hundred seventy-seven thousand seven hundred thirty-seven adult ICU patients INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from the Australian and New Zealand Intensive Care Society Adult Patient Database were matched to the Critical Health Resources Information System. The mean daily Activity index of each ICU (census total of “patients with 1:1 nursing” + “invasive ventilation” + “renal replacement” + “extracorporeal membrane oxygenation” + “active COVID19,” divided by total staffed ICU beds) during the patient’s stay in the ICU was calculated. Patients were categorized as being in the ICU during very quiet (Activity index < 0.1), quiet (0.1 to < 0.6), intermediate (0.6 to < 1.1), busy (1.1 to < 1.6), or very busy time-periods (≥ 1.6). The primary outcome was in-hospital mortality. Secondary outcomes included after-hours discharge from the ICU, readmission to the ICU, interhospital transfer to another ICU, and delay in discharge from the ICU. Median Activity index was 0.87 (interquartile range, 0.40–1.24). Nineteen thousand one hundred seventy-seven patients died (6.9%). In-hospital mortality ranged from 2.4% during very quiet to 10.9% during very busy time-periods. After adjusting for confounders, being in an ICU during time-periods with higher Activity indices, was associated with an increased risk of in-hospital mortality (odds ratio [OR], 1.49; 99% CI, 1.38–1.60), after-hours discharge (OR, 1.27; 99% CI, 1.21–1.34), readmission (OR, 1.18; 99% CI, 1.09–1.28), interhospital transfer (OR, 1.92; 99% CI, 1.72–2.15), and less delay in ICU discharge (OR, 0.58; 99% CI, 0.55–0.62): findings consistent with ICU strain. CONCLUSIONS: The Activity index is a simple and valid measure that identifies ICUs in which increasing strain leads to progressively worse patient outcomes. [ABSTRACT FROM AUTHOR]

The article explores the use of extracorporeal cardiopulmonary resuscitation (ECPR) in children with primary noncardiac diagnoses. A study comparing outcomes of pediatric patients who received ECPR versus conventional CPR found no significant difference in survival to discharge. However, more research is needed to fully understand the potential benefits of ECPR in this population. The document also references other studies and articles that discuss the effects of intra-arrest transport, immediate invasive assessment and treatment, and early ECPR on functional neurologic outcome in refractory cases of out-of-hospital cardiac arrest. These sources emphasize the need for further evidence and research in the field of ECPR for out-of-hospital cardiac arrest. [Extracted from the article]

The article discusses the potential benefits of Extracorporeal Cardiopulmonary Resuscitation (E-CPR) in pediatric cardiac critical care. It highlights the high rates of in-hospital cardiac arrest in children recovering from cardiac surgery and the significant long-term neurodevelopmental disabilities and resource utilization associated with it. The study compares survival rates between pediatric cardiac surgery patients who received E-CPR and those who received conventional CPR (C-CPR) using multicenter data from the American Heart Association. The study found that E-CPR was associated with higher survival rates and favorable neurologic outcomes compared to C-CPR. However, the study's retrospective and observational nature limits the establishment of causality, and further research is needed to validate and explore the benefits and risks of E-CPR. The article emphasizes the need for broader implementation of E-CPR in pediatric cardiac critical care and the importance of ongoing research in refining resuscitation strategies. [Extracted from the article]

The article discusses the use of single-site versus multisite cannulation for venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome (ARDS) caused by COVID-19. The authors acknowledge the limitations of the existing evidence and emphasize the need for high-quality randomized controlled trials (RCTs) to assess patient-centered outcomes and mortality associated with blood purification techniques. They also highlight the lack of available information in the dataset used for their study, which limits the analysis of certain variables. The authors agree with the commenters that additional variables should be studied in future iterations of the dataset or other large, multicenter datasets. [Extracted from the article]

OBJECTIVE: We summarize the existing data on the occurrence of physical, emotional, and cognitive dysfunction associated with postintensive care syndrome (PICS) in adult survivors of venoarterial extracorporeal membrane oxygenation (VA-ECMO). DATA SOURCES: MEDLINE, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched. STUDY SELECTION: Peer-reviewed studies of adults receiving VA-ECMO for any reason with at least one measure of health-related quality of life outcomes or PICS at long-term follow-up of at least 6 months were included. DATA EXTRACTION: The participant demographics and baseline characteristics, in-hospital outcomes, long-term health outcomes, quality of life outcome measures, and prevalence of PICS were extracted. DATA SYNTHESIS: Twenty-seven studies met inclusion criteria encompassing 3,271 patients who were treated with VA-ECMO. The studies were limited to single- or two-center studies. Outcomes variables and follow-up time points evaluated were widely heterogeneous which limits comprehensive analysis of PICS after VA-ECMO. In general, the longer-term PICS-related outcomes of survivors of VA-ECMO were worse than the general population, and approaching that of patients with chronic disease. Available studies identified high rates of abnormal 6-minute walk distance, depression, anxiety, and posttraumatic stress disorder that persisted for years. Half or fewer survivors return to work years after discharge. Only 2 of 27 studies examined cognitive outcomes and no studies evaluated cognitive dysfunction within the first year of recovery. No studies evaluated the impact of targeted interventions on these outcomes. CONCLUSIONS: Survivors of VA-ECMO represent a population of critically ill patients at high risk for deficits in physical, emotional, and cognitive function related to PICS. This systematic review highlights the alarming reality that PICS and in particular, neurocognitive outcomes, in survivors of VA-ECMO are understudied, underrecognized, and thus likely undertreated. These results underscore the imperative that we look beyond survival to focus on understanding the burden of survivorship with the goal of optimizing recovery and outcomes after these life-saving interventions. Future prospective, multicenter, longitudinal studies in recovery after VA-ECMO are justified. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To investigate temporal trends and outcomes associated with early antibiotic prescribing in patients hospitalized with COVID-19. DESIGN: Retrospective propensity-matched cohort study using the National COVID Cohort Collaborative (N3C) database. SETTING: Sixty-six health systems throughout the United States that were contributing to the N3C database. Centers that had fewer than 500 admissions in their dataset were excluded. PATIENTS: Patients hospitalized with COVID-19 were included. Patients were defined to have early antibiotic use if they received at least 3 calendar days of intravenous antibiotics within the first 5 days of admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 322,867 qualifying first hospitalizations, 43,089 patients received early empiric antibiotics. Antibiotic use declined across all centers in the data collection period, from March 2020 (23%) to June 2022 (9.6%). Average rates of early empiric antibiotic use (EEAU) also varied significantly between centers (deviance explained 7.33% vs 20.0%, p < 0.001). Antibiotic use decreased slightly by day 2 of hospitalization and was significantly reduced by day 5. Mechanical ventilation before day 2 (odds ratio [OR] 3.57; 95% CI, 3.42-3.72), extracorporeal membrane oxygenation before day 2 (OR 2.14; 95% CI, 1.75-2.61), and early vasopressor use (OR 1.85; 95% CI, 1.78-1.93) but not region of residence was associated with EEAU. After propensity matching, EEAU was associated with an increased risk for in-hospital mortality (OR 1.27; 95% CI, 1.23-1.33), prolonged mechanical ventilation (OR 1.65; 95% CI, 1.50-1.82), late broad-spectrum antibiotic exposure (OR 3.24; 95% CI, 2.99-3.52), and late Clostridium difficile infection (OR 1.60; 95% CI, 1.37-1.87). CONCLUSIONS: Although treatment of COVID-19 patients with empiric antibiotics has declined during the pandemic, the frequency of use remains high. There is significant inter-center variation in antibiotic prescribing practices and evidence of potential harm. Our findings are hypothesis-generating and future work should prospectively compare outcomes and adverse events. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Although COVID-19 vaccines can reduce the need for intensive care unit admission in COVID-19, their effect on outcomes in critical illness remains unclear. We evaluated outcomes in vaccinated patients admitted to the ICU with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and the association between vaccination and booster status on clinical outcomes. DESIGN: Retrospective cohort. SETTING AND PATIENTS: All patients were admitted to an ICU between January 2021 (after vaccination was available) and July 2022 with a diagnosis of COVID-19 based on a SARS-CoV-2 polymerase chain reaction test in Alberta, Canada. INTERVENTIONS: None. MEASUREMENT: The propensity-matched primary outcome of all-cause in-hos-pital mortality was compared between vaccinated and unvaccinated patients, and vaccinated patients were stratified by booster dosing. Secondary outcomes were mechanical ventilation (MV) duration ICU length of stay (LOS). MAIN RESULTS: The study included 3,293 patients: 743 (22.6%) were fully vaccinated (54.6% with booster), 166 (5.0%) were partially vaccinated, and 2,384 (72.4%) were unvaccinated. Unvaccinated patients were more likely to require invasive MV (78.4% vs 68.2%), vasopressor use (71.1% vs 66.6%), and extra-corporeal membrane oxygenation (2.1% vs 0.5%). In a propensity-matched analysis, in-hospital mortality was similar (31.8% vs 34.0%, adjusted odds ratio [OR], 1.25; 95% CI, 0.97-1.61), but median duration MV (7.6 vs 4.7 d; p < 0.001) and ICU LOS (6.6 vs 5.2 d; p < 0.001) were longer in unvaccinated compared to fully vaccinated patients. Among vaccinated patients, greater than or equal to 1 booster had lower in-hospital mortality (25.5% vs 40.9%; adjusted OR, 0.50; 95% CI, 0.0.36-0.68) and duration of MV (3.8 vs 5.6 d; p = 0.025). CONCLUSIONS: Nearly one in four patients admitted to the ICU with COVID-19 after widespread COVID-19 vaccine availability represented a vaccine-breakthrough case. Mortality risk remains substantial in vaccinated patients and similar between vaccinated and unvaccinated patients after the onset of critical illness. However, COVID-19 vaccination is associated with reduced ICU resource utilization and booster dosing may increase survivability from COVID-19-related critical illness. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Early studies of venovenous extracorporeal membrane oxygenation (ECMO) in COVID-19 have revealed similar outcomes to historical cohorts. Changes in the disease and treatments have led to differences in the patients supported on venovenous ECMO in the first and second waves. We aimed to compare these two groups in both the acute and follow-up phase. DESIGN: Retrospective single-center cohort study comparing mortality at censoring date (November 30, 2021) and decannulation, patient characteristics, complications and lung function and quality of life (QOL—by European Quality of Life 5 Dimensions 3 Level Version) at first follow-up in patients supported on venovenous ECMO between wave 1 and wave 2 of the COVID-19 pandemic. SETTING: Critical care department of a severe acute respiratory failure service. PATIENTS: Patients supported on ECMO for COVID-19 between wave 1 (March 17, 2020, to August 31, 2020) and wave 2 (January 9, 2020, to May 25, 2021). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-three patients were included in our analysis. Survival at censoring date (χ2, 6.35; p = 0.012) and decannulation (90.4% vs 70.0%; p < 0.001) was significantly lower in the second wave, while duration of ECMO run was longer (12.0 d [18.0–30.0 d] vs 29.5 d [15.5–58.3 d]; p = 0.005). Wave 2 patients had longer application of noninvasive ventilation (NIV) prior to ECMO and a higher frequency of barotrauma. Patient age and NIV use were independently associated with increased mortality (odds ratio 1.07 [1.01–1.14]; p = 0.025 and 3.37 [1.12–12.60]; p = 0.043, respectively). QOL and lung function apart from transfer coefficient of carbon monoxide corrected for hemoglobin was similar at follow-up across the waves. CONCLUSIONS: Most patients with COVID-19 supported on ECMO in both waves survived in the short and longer term. At follow-up patients had similar lung function and QOL across the two waves. This suggests that ECMO has an ongoing role in the management of a carefully selected group of patients with COVID-19. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Evidence of cerebrovascular complications in COVID-19 requiring venovenous extracorporeal membrane oxygenation (ECMO) is limited. Our study aims to characterize the prevalence and risk factors of stroke secondary to COVID-19 in patients on venovenous ECMO. DESIGN: We analyzed prospectively collected observational data, using univariable and multivariable survival modeling to identify risk factors for stroke. Cox proportional hazards and Fine-Gray models were used, with death and discharge treated as competing risks. SETTING: Three hundred eighty institutions in 53 countries in the COVID-19 Critical Care Consortium (COVID Critical) registry. PATIENTS: Adult COVID-19 patients who were supported by venovenous ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Five hundred ninety-five patients (median age [interquartile range], 51 yr [42–59 yr]; male: 70.8%) had venovenous ECMO support. Forty-three patients (7.2%) suffered strokes, 83.7% of which were hemorrhagic. In multivariable survival analysis, obesity (adjusted hazard ratio [aHR], 2.19; 95% CI, 1.05–4.59) and use of vasopressors before ECMO (aHR, 2.37; 95% CI, 1.08–5.22) were associated with an increased risk of stroke. Forty-eight-hour post-ECMO Pa co 2–pre-ECMO Pa co 2/pre-ECMO Pa co 2 (relative ΔPa co 2) of negative 26% and 48-hour post-ECMO Pa o 2–pre-ECMO Pa o 2/pre-ECMO Pa o 2 (relative ΔPa o 2) of positive 24% at 48 hours of ECMO initiation were observed in stroke patients in comparison to relative ΔPa co 2 of negative 17% and relative ΔPa o 2 of positive 7% in the nonstroke group. Patients with acute stroke had a 79% in-hospital mortality compared with 45% mortality for stroke-free patients. CONCLUSIONS: Our study highlights the association of obesity and pre-ECMO vasopressor use with the development of stroke in COVID-19 patients on venovenous ECMO. Also, the importance of relative decrease in Pa co 2 and moderate hyperoxia within 48 hours after ECMO initiation were additional risk factors. [ABSTRACT FROM AUTHOR]

The article discusses the use of femoral vessel cannulation for extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO) in adults. While this method offers advantages such as avoiding neurologic injury associated with carotid artery cannulation, it is also associated with complications that can lead to amputation or death. The article reviews data from the Extracorporeal Life Support Organization (ELSO) and concludes that bilateral femoral vessel cannulation is associated with fewer complications and lower mortality compared to unilateral cannulation. However, the article acknowledges limitations in the data and calls for further research on factors such as cannula size and monitoring methods to prevent complications. [Extracted from the article]

Objectives: To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes. Data Sources: PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population). Study Selection: Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support. Data Extraction: Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool. Data Synthesis: Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors. Conclusions: Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare. [ABSTRACT FROM AUTHOR]

Objectives: There has been a sustained increase in the utilization of venovenous extracorporeal membrane oxygenation (ECMO) over the last decade, further exacerbated by the COVID-19 pandemic. We set out to describe our institutional experience with extremely prolonged (> 50 d) venovenous ECMO support for recovery or bridge to lung transplant candidacy in patients with acute respiratory failure. Design: Retrospective cohort study. Setting: A large tertiary urban care center. Patients: Patients 18 years or older receiving venovenous ECMO support for greater than 50 days, with initial cannulation between January 2018 and January 2022. Interventions: None. Measurements and Main Results: One hundred thirty patients were placed on venovenous ECMO during the study period. Of these, 12 received prolonged (> 50 d) venovenous ECMO support. Eleven patients (92%) suffered from adult respiratory distress syndrome (ARDS) secondary to COVID-19, while one patient with prior bilateral lung transplant suffered from ARDS secondary to bacterial pneumonia. The median age of patients was 39 years (interquartile range [IQR], 35–51 yr). The median duration of venovenous ECMO support was 94 days (IQR, 70–128 d), with a maximum of 180 days. Median time from intubation to cannulation was 5 days (IQR, 2–14 d). Nine patients (75%) were successfully mobilized while on venovenous ECMO support. Successful weaning of venovenous ECMO support occurred in eight patients (67%); 6 (50%) were bridged to lung transplantation and 2 (17%) were bridged to recovery. Of those successfully weaned, seven patients (88%) were discharged from the hospital. All seven patients discharged from the hospital were alive 6 months post-decannulation; 83% (5/6) with sufficient follow-up time were alive 1-year after decannulation. Conclusions: Our experience suggests that extremely prolonged venovenous ECMO support to allow native lung recovery or optimization for lung transplantation may be a feasible strategy in select critically ill patients, further supporting the expanded utilization of venovenous ECMO for refractory respiratory failure. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the wholistic costs of systemic anticoagulation delivery in heparin versus bivalirudin-based maintenance of adult patients supported on extracorporeal membrane oxygenation (ECMO). DESIGN: Single-center retrospective cohort study. SETTING: Large academic ECMO center. PATIENTS: Adults on ECMO receiving heparin or bivalirudin for primary maintenance systemic anticoagulation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Electronic data were abstracted from a database maintained by our ECMO center, which transitioned to a preferred bivalirudin-based anticoagulation management in 2017. The pretransition group consisted of 126 patients (123 heparin and three bivalirudin), whereas the posttransition group included 275 patients (82 heparin and 193 bivalirudin). Drug costs were estimated using the wholesale acquisition cost, and laboratory assays costs were estimated using reimbursement fee schedules. Cost data were normalized to the duration of the ECMO run and reported in U.S. Dollar per ECMO day. Following the practice change, bivalirudin patients were less likely to receive AT supplementation (31.0 vs 12.4%; p < 0.0001) and had fewer coagulation assays ordered (6.1 vs 5.4 per ECMO day; p = 0.0004). After the transition, there was a dramatic decrease in costs related to AT assay assessments ($11.78 [interquartile range {IQR}, $9.48–$13.09] vs $1.03 [IQR, $0–$5.75]; p < 0.0001) and AT supplementation ($0 [IQR, $0–$312.82] vs $0 [IQR, $0–$0]; p < 0.0001) per ECMO day. Unadjusted survival at 28 days was higher posttransition (64.3 vs 74.9%; p = 0.0286). CONCLUSIONS: Antithrombin assays and supplementation compromise a significant proportion of heparin-based anticoagulation costs in ECMO patients and is substantially reduced when a bivalirudin-based anticoagulation strategy is deployed. A favorable association exists between the aggregate cost of administration of bivalirudin compared with heparin-based systemic anticoagulation in adults supported on ECMO driven by reductions in antithrombin activity assessments and the cost of antithrombin replacement. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the prevalence and outcomes associated with hemorrhage, disseminated intravascular coagulopathy, and thrombosis (HECTOR) complications in ICU patients with COVID-19. DESIGN: Prospective, observational study. SETTING: Two hundred twenty-nine ICUs across 32 countries. PATIENTS: Adult patients (≥ 16 yr) admitted to participating ICUs for severe COVID-19 from January 1, 2020, to December 31, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: HECTOR complications occurred in 1,732 of 11,969 study eligible patients (14%). Acute thrombosis occurred in 1,249 patients (10%), including 712 (57%) with pulmonary embolism, 413 (33%) with myocardial ischemia, 93 (7.4%) with deep vein thrombosis, and 49 (3.9%) with ischemic strokes. Hemorrhagic complications were reported in 579 patients (4.8%), including 276 (48%) with gastrointestinal hemorrhage, 83 (14%) with hemorrhagic stroke, 77 (13%) with pulmonary hemorrhage, and 68 (12%) with hemorrhage associated with extracorporeal membrane oxygenation (ECMO) cannula site. Disseminated intravascular coagulation occurred in 11 patients (0.09%). Univariate analysis showed that diabetes, cardiac and kidney diseases, and ECMO use were risk factors for HECTOR. Among survivors, ICU stay was longer (median days 19 vs 12; p < 0.001) for patients with versus without HECTOR, but the hazard of ICU mortality was similar (hazard ratio [HR] 1.01; 95% CI 0.92–1.12; p = 0.784) overall, although this hazard was identified when non-ECMO patients were considered (HR 1.13; 95% CI 1.02–1.25; p = 0.015). Hemorrhagic complications were associated with an increased hazard of ICU mortality compared to patients without HECTOR complications (HR 1.26; 95% CI 1.09–1.45; p = 0.002), whereas thrombosis complications were associated with reduced hazard (HR 0.88; 95% CI 0.79–0.99, p = 0.03). CONCLUSIONS: HECTOR events are frequent complications of severe COVID-19 in ICU patients. Patients receiving ECMO are at particular risk of hemorrhagic complications. Hemorrhagic, but not thrombotic complications, are associated with increased ICU mortality. [ABSTRACT FROM AUTHOR]

The article discusses the management of heat-related illness and injury in the ICU, with a focus on gastrointestinal injury. The authors acknowledge the need for more studies on the gastrointestinal manifestations of heatstroke, as most of the available data come from retrospective observational studies or small case series. They highlight the reduction in splanchnic blood flow, increased intestinal permeability, and endotoxin leakage as potential complications of heatstroke. The article emphasizes the importance of prompt recognition and treatment of heatstroke symptoms in critically ill patients. [Extracted from the article]

The article discusses the importance of adhering to standardized nomenclature in the field of extracorporeal life support (ECLS), specifically focusing on the venopulmonary extracorporeal membrane oxygenation (ECMO) mode. The authors highlight the need for consistent terminology and abbreviations to improve communication and reduce ambiguity in scientific publications. They argue that the adoption of standardized nomenclature has been slow and call for journals to promote the use of the nomenclature developed by the Extracorporeal Life Support Organization (ELSO). The authors acknowledge their oversight in using inconsistent terminology in their own article and express agreement with the need for adherence to standardized nomenclature. [Extracted from the article]

This document discusses the importance of adhering to standardized nomenclature in the field of extracorporeal membrane oxygenation (ECMO). The authors argue that the use of nonstandardized abbreviations in ECMO publications makes it difficult to search and compare literature. They suggest that journals, such as Critical Care Medicine, should promote the consistent adoption of standardized nomenclature. The document also briefly mentions a study on heatstroke patients and suggests that certain issues need to be clarified in a related article. [Extracted from the article]

The editorial titled "Venovenous Extracorporeal Membrane Oxygenation: In for a Penny, In for a Pound" discusses the impact of a recent study on the practice of venovenous extracorporeal membrane oxygenation (VV ECMO). The study challenges the traditional understanding of VV ECMO as a "bridge to recovery" and suggests that prolonged runs of VV ECMO may still result in good survival outcomes. The article highlights the need for better communication with patients and their families regarding the expected duration of VV ECMO and the possibility of additional procedures. It also emphasizes the importance of timely referral and transfer of patients on VV ECMO to a transplant center for lung transplantation. The article raises concerns about clinician burnout and resource allocation for patients with prolonged critical illness. It suggests that identifying variables associated with reduced VV ECMO time and optimizing functional recovery should be the focus of future studies. The article concludes by advocating for higher reimbursement for VV ECMO patients due to their continued survival. [Extracted from the article]

The utilization of venovenous extracorporeal membrane oxygenation (V-V ECMO) in patients with ARDS has increased tremendously over the last two decades and peaked massively during the COVID-19 pandemic. Keywords: acute respiratory distress syndrome; COVID-19; extracorporeal membrane oxygenation; intensive care; stroke EN acute respiratory distress syndrome COVID-19 extracorporeal membrane oxygenation intensive care stroke 1098 1100 3 07/20/23 20230801 NES 230801 Acute respiratory distress syndrome (ARDS) is characterized by bilateral chest radiographical opacities with severe hypoxemia due to noncardiogenic pulmonary edema ([1]). The conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure trial indicated that transferring ARDS patients to an ECMO center significantly decreased mortality or severe disability ([6]). [Extracted from the article]

OBJECTIVES: Prone positioning and venovenous extracorporeal membrane oxygenation (ECMO) are both useful interventions in acute respiratory distress syndrome (ARDS). Combining the two therapies is feasible and safe, but the effectiveness is not known. Our objective was to evaluate the potential survival benefit of prone positioning in venovenous ECMO patients cannulated for COVID-19–related ARDS. DESIGN: Retrospective analysis of a multicenter cohort. PATIENTS: Patients on venovenous ECMO who tested positive for severe acute respiratory syndrome coronavirus 2 by reverse transcriptase polymerase chain reaction or with a diagnosis on chest CT were eligible. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients on venovenous ECMO for respiratory failure in whom prone position status while on ECMO and in-hospital mortality were known were included. Of 647 patients in 41 centers, 517 were included. Median age was 55 (47–61), 78% were male and 95% were proned before cannulation. After cannulation, 364 patients (70%) were proned and 153 (30%) remained in the supine position for the whole ECMO run. There were 194 (53%) and 92 (60%) deaths in the prone and the supine groups, respectively. Prone position on ECMO was independently associated with lower in-hospital mortality (odds ratio = 0.49 [0.29–0.84]; p = 0.010). In 153 propensity score-matched pairs, mortality rate was 49.7% in the prone position group versus 60.1% in the supine position group (p = 0.085). Considering only patients alive at decannulation, propensity-matched proned patients had a significantly lower mortality rate (22.4% vs 37.8%; p = 0.029) than nonproned patients. CONCLUSIONS: Prone position may be beneficial in patients supported by venovenous ECMO for COVID-19–related ARDS but more data are needed to draw definitive conclusions. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To assess the association of timing to prone positioning (PP) during venovenous extracorporeal membrane oxygenation (V-V ECMO) with the probability of being discharged alive from the ICU at 90 days (primary endpoint) and the improvement of the respiratory system compliance (Cpl,rs). DESIGN: Pooled individual data analysis from five original observational cohort studies. SETTING: European extracorporeal membrane oxygenation (ECMO) centers. PATIENTS: Acute respiratory distress syndrome (ARDS) patients who underwent PP during ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Time to PP during V-V ECMO was explored both as a continuous and a categorical variable with Cox proportional hazard models. Three hundred patients were included in the analysis. The longer the time to PP during V-V ECMO, the lower the adjusted probability of alive ICU discharge (adjusted hazard ratio [HR] 0.90 for each day increase; 95% CI, 0.87–0.93). Two hundred twenty-three and 77 patients were included in the early PP (≤ 5 d) and late PP (> 5 d) groups, respectively. The cumulative 90-day probability of being discharged alive from the ICU was 61% in the early PP group vs 36% in the late PP group (log-rank test, p <0.001). This benefit was maintained after adjustment for confounders (adjusted HR, 2.52; 95% CI, 1.66–3.81; p <0.001). In the early PP group, PP was associated with a significant improvement of Cpl,rs (4 ± 9 mL/cm H2O vs 0 ± 12 in the late PP group, p =0.038). CONCLUSIONS: In a large cohort of ARDS patients on ECMO, early PP during ECMO was associated with a higher probability of being discharged alive from the ICU at 90 days and a greater improvement of Cpl,rs. [ABSTRACT FROM AUTHOR]