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Purpose: Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) frequently develop arterial hyperoxaemia, which may be harmful. However, lower oxygen saturation targets may also lead to harmful episodes of hypoxaemia. Methods: In this registry-embedded, multicentre trial, we randomly assigned adult patients receiving VA-ECMO in an intensive care unit (ICU) to either a conservative (target SaO2 92–96%) or to a liberal oxygen strategy (target SaO2 97–100%) through controlled oxygen administration via the ventilator and ECMO gas blender. The primary outcome was the number of ICU-free days to day 28. Secondary outcomes included ICU-free days to day 60, mortality, ECMO and ventilation duration, ICU and hospital lengths of stay, and functional outcomes at 6 months. Results: From September 2019 through June 2023, 934 patients who received VA-ECMO were reported to the EXCEL registry, of whom 300 (192 cardiogenic shock, 108 refractory cardiac arrest) were recruited. We randomised 149 to a conservative and 151 to a liberal oxygen strategy. The median number of ICU-free days to day 28 was similar in both groups (conservative: 0 days [interquartile range (IQR) 0–13.7] versus liberal: 0 days [IQR 0–13.7], median treatment effect: 0 days [95% confidence interval (CI) – 3.1 to 3.1]). Mortality at day 28 (59/159 [39.6%] vs 59/151 [39.1%]) and at day 60 (64/149 [43%] vs 62/151 [41.1%] were similar in conservative and liberal groups, as were all other secondary outcomes and adverse events. The conservative group experienced 44 (29.5%) major protocol deviations compared to 2 (1.3%) in the liberal oxygen group (P < 0.001). Conclusions: In adults receiving VA-ECMO in ICU, a conservative compared to a liberal oxygen strategy, did not affect the number of ICU-free days to day 28. [ABSTRACT FROM AUTHOR]

Purpose: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an integral part of the management algorithm of patients with severe respiratory failure refractory to evidence-based conventional treatments. Right ventricular injury (RVI) pertaining to abnormalities in the dimensions and/or function of the right ventricle (RV) in the context of VV-ECMO significantly influences mortality. However, in the absence of a universally accepted RVI definition and evidence-based guidance for the management of RVI in this very high-risk patient cohort, variations in clinical practice continue to exist. Methods: Following a systematic search of the literature, an international Steering Committee consisting of eight healthcare professionals involved in the management of patients receiving ECMO identified domains and knowledge gaps pertaining to RVI definition and management where the evidence is limited or ambiguous. Using a Delphi process, an international panel of 52 Experts developed Expert position statements in those areas. The process also conferred RV-centric overarching open questions for future research. Consensus was defined as achieved when 70% or more of the Experts agreed or disagreed on a Likert-scale statement or when 80% or more of the Experts agreed on a particular option in multiple‐choice questions. Results: The Delphi process was conducted through four rounds and consensus was achieved on 31 (89%) of 35 statements from which 24 Expert position statements were derived. Expert position statements provided recommendations for RVI nomenclature in the setting of VV-ECMO, a multi-modal diagnostic approach to RVI, the timing and parameters of diagnostic echocardiography, and VV-ECMO settings during RVI assessment and management. Consensus was not reached on RV-protective driving pressure thresholds or the effect of prone positioning on patient-centric outcomes. Conclusion: The proposed definition of RVI in the context of VV-ECMO needs to be validated through a systematic aggregation of data across studies. Until further evidence emerges, the Expert position statements can guide informed decision-making in the management of these patients. [ABSTRACT FROM AUTHOR]

This article discusses the importance of protecting the diaphragm during invasive mechanical ventilation. Diaphragm dysfunction is a common issue in mechanically ventilated patients and can be caused by various factors. The article outlines a stepwise approach to diaphragm protection, including monitoring diaphragmatic effort, minimizing the duration of diaphragm inactivity, avoiding excessive respiratory drive and effort, maintaining patient-ventilator synchrony, and following evidence-based weaning strategies. It is important to note that the impact of diaphragm-protective ventilation on outcomes has not been established and further clinical trials are needed. [Extracted from the article]

The article discusses the relationship between acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) in critically ill patients. The study analyzed data from 10 randomized controlled trials conducted in the United States between 1996 and 2018. The authors found that AKI occurred in approximately 43.7% of patients with ARDS, with a higher incidence of AKI stage 3 and acute kidney disease (AKD) in patients with more severe AKI. The study also found that AKI was associated with higher mortality rates at 28 and 90 days. However, the study has some limitations, including the lack of consideration for certain variables and the heterogeneity of ARDS and AKI subphenotypes. Further research is needed to better understand the relationship between AKI and ARDS and to identify strategies for improving outcomes. [Extracted from the article]

This article discusses the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a treatment for acute myocardial infarction-related cardiogenic shock (AMI-CS). The article highlights that while there has been a significant increase in the use of VA-ECMO, there is a lack of evidence from randomized controlled trials (RCTs) to support its effectiveness. The article presents the findings of several RCTs and a meta-analysis, which suggest that routine VA-ECMO does not significantly reduce mortality in AMI-CS patients. The article also discusses the safety concerns associated with VA-ECMO, such as bleeding and peripheral ischemic complications. The limitations of the current evidence and the need for further research to identify specific patient subgroups that may benefit from VA-ECMO are also discussed. Overall, the article concludes that routine immediate VA-ECMO is not beneficial for the majority of AMI-CS patients, and further research is needed to determine its effectiveness in specific situations. [Extracted from the article]

Purpose: Severe acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS. Methods: We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence. Results: Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59–0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57–0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66–0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63–1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72–1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals. Conclusions: In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain. [ABSTRACT FROM AUTHOR]

Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase. [ABSTRACT FROM AUTHOR]

This document, titled "Setting the ventilator in acute brain injury," discusses the use of a lung-protective strategy in patients with acute brain injury (ABI) who require invasive mechanical ventilation (IMV). Historically, ABI patients have received higher tidal volume and lower positive end expiratory pressure (PEEP) due to concerns about increased intra-cranial pressure (ICP) and impaired cerebral perfusion pressure. However, recent findings support the safety and efficacy of a protective ventilation strategy in most ABI patients. The document outlines a concise strategy for IMV settings, arterial blood gas targets, and management of concurrent ABI and acute respiratory distress syndrome (ARDS). It also emphasizes the importance of continuous monitoring and individualized approaches in specific clinical scenarios. [Extracted from the article]

This article discusses the concept of consumptive coagulopathy in patients undergoing extracorporeal life support (ECLS). Consumptive coagulopathy is a condition that leads to bleeding and thrombotic complications in these patients. The triggers for consumptive coagulopathy can be diverse, including endothelial cell activation/damage, malignancies, and foreign body contact activation. The article emphasizes the importance of using low-dose anticoagulants, such as low-dose unfractionated heparin, to prevent bleeding complications without significantly increasing the risk of thrombosis. It also suggests that running ECLS circuits without anticoagulant therapy should be critically evaluated, and further research is needed to reduce the burden of coagulopathy in ECLS patients. [Extracted from the article]

This document is a reply to a comment on a study about venoarterial extracorporeal membrane oxygenation (VA-ECMO) outcomes in immunocompromised patients. The authors discuss the challenges of determining the cause of death in critically ill patients, particularly those with refractory cardiogenic shock. They present data from their study, which found that multiple organ failure (MOF) was the most common cause of death in these patients. They also address concerns about the inclusion of immunocompromised patients in the study and the limitations of their retrospective design. The authors suggest that their findings can help inform decisions about the use of VA-ECMO in immunocompromised patients with cardiogenic shock. [Extracted from the article]

This document is a letter published in the journal Intensive Care Medicine. The authors conducted a study to evaluate the performance of a predictive survival model called the Survival after VA-ECMO (SAVE) score in immunocompromised patients with cardiogenic shock who were undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The study found that the SAVE score had limited discriminatory power and calibration, and did not outperform other intensive care unit (ICU) severity scores in predicting 90-day survival in this specific population. The authors suggest that the SAVE score should be recalibrated to include immunocompromised status and its underlying causes. [Extracted from the article]

This article discusses the importance of hemostasis testing in the intensive care unit (ICU) for critically ill patients who often experience bleeding and thrombotic complications. The article explores the utility of hemostasis testing in guiding clinical decisions and improving patient outcomes. It highlights the different coagulation abnormalities associated with underlying diseases such as sepsis-induced coagulopathy (SIC), disseminated intravascular coagulation (DIC), and COVID-19-associated coagulopathy. The article also emphasizes the significance of monitoring coagulation parameters during active bleeding and the use of anti-Xa monitoring in patients on extracorporeal membrane oxygenation (ECMO). Overall, the article suggests that a personalized approach to hemostasis testing can lead to more targeted and effective interventions, minimizing complications. [Extracted from the article]

Purpose: The outcomes of immunocompromised patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are seldom documented, making ECMO candidacy decisions challenging. This study aims (1) to report outcomes of immunocompromised patients treated with VA-ECMO, (2) to identify pre-ECMO predictors of 90-day mortality, (3) to assess the impact of immunodepression on 90-day mortality, and (4) to describe the main ECMO-related complications. Methods: This is a retrospective, propensity-weighted study conducted in two French experienced ECMO centers. Results: From January 2006 to January 2022, 177 critically ill immunocompromised patients (median (interquartile range, IQR) age 49 (32–60) years) received VA-ECMO. The main causes of immunosuppression were long-term corticosteroids/immunosuppressant treatment (29%), hematological malignancy (26%), solid organ transplant (20%), and solid tumor (13%). Overall 90-day and 1-year mortality were 70% (95% confidence interval (CI) 63–77%) and 75% (95% CI 65–79%), respectively. Older age and higher pre-ECMO lactate were independently associated with 90-day mortality. Across immunodepression causes, 1-year mortality ranged from 58% for patients with infection by human immunodeficiency virus (HIV) or asplenia, to 89% for solid organ transplant recipients. Hemorrhagic and infectious complications affected 39% and 54% of patients, while more than half the stay in intensive care unit (ICU) was spent on antibiotics. In a propensity score-weighted model comparing the 177 patients with 942 non-immunocompromised patients experiencing cardiogenic shock on VA-ECMO, immunocompromised status was independently associated with a higher 90-day mortality (odds ratio 2.53, 95% CI 1.72–3.79). Conclusion: Immunocompromised patients undergoing VA-ECMO treatment face an unfavorable prognosis, with higher 90-day mortality compared to non-immunocompromised patients. This underscores the necessity for thorough evaluation and careful selection of ECMO candidates within this frail population. [ABSTRACT FROM AUTHOR]

Purpose: Venovenous extracorporeal membrane oxygenation (VV-ECMO) can be used to support patients with refractory acute respiratory failure, though guidance on patient selection is lacking. While age is commonly utilized as a factor in establishing the potential VV-ECMO candidacy of these patients, little is known regarding its association with outcome. We studied the association between increasing patient age and outcomes among patients with acute respiratory failure receiving VV-ECMO. Methods: In this registry-based cohort study, we used individual patient data from 144 centres. We included adult patients (≥ 18 years of age) receiving VV-ECMO from 2017 to 2022. The primary outcome was hospital mortality. Secondary outcomes included a composite of complications following initiation of VV-ECMO. We conducted Bayesian analyses to estimate the association between chronological age and outcomes. Results: We included 27,811 patients receiving VV-ECMO. Of these, 11,533 (41.5%) died in hospital. For the analysis conducted using weakly informed priors, and as compared to the reference category of age 18–29, the age brackets of 30–39 (odds ratio [OR] 1.17, 95% credible interval [CrI] 1.06–1.31), 40–49 (OR 1.65, 95% CrI 1.49–1.82), 50–59 (OR 2.39, 95% CrI 2.16–2.61), 60–69 (OR 3.29, 95% CrI 2.97–3.67), 70–79 (OR 4.57, 95% CrI 3.90–5.37), and ≥ 80 (OR 8.08, 95% CrI 4.85–13.74) were independently associated with increasing hospital mortality. Similar results were found between increasing age and post-ECMO complications. Conclusions: Among patients receiving VV-ECMO for acute respiratory failure, increasing age is significantly associated with poorer outcomes, and this association emerges as early as 30 years of age. [ABSTRACT FROM AUTHOR]

The article discusses the use of vasopressors and inotropes in patients undergoing extracorporeal membrane oxygenation (ECMO). It highlights the lack of guidelines in this area and emphasizes the importance of considering the clinical context and physiological changes associated with ECMO support. The article provides specific recommendations for the use of vasopressors and inotropes in both venoarterial ECMO (VA-ECMO) and venovenous ECMO (VV-ECMO) scenarios. It also discusses the potential risks and benefits of different medications and suggests the exploration of non-catecholaminergic agents in order to reduce the long-term exposure to catecholamines. [Extracted from the article]

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). The impact of ECMO on long-term outcomes of patients with severe ARDS is unclear. Methods: We searched electronic databases from inception to January 17th 2023. We selected clinical trials and observational studies reporting on long-term outcomes of patients supported with ECMO for ARDS. Health-related quality of life (HRQoL) was the primary outcome. Secondary outcomes included cognitive function, mental health, functional status, respiratory symptoms, and return to work. Results: Of the 7126 screened citations, 1 randomized clinical trial and 31 observational studies were included, of which 7 compared conventional mechanical ventilation (CMV) and ECMO. Overall quality of studies of the included studies was limited, with the majority being either low (45%) or fair (32%) quality. There was no significant difference in HRQoL measured with the SF-36 score between ECMO and CMV patients (physical component score [PCS]: mean difference 3.91 (− 6.22 to 14.05), mental component score [MCS] mean difference 1.33 (− 3.93 to 6.60)). There was no difference between cognitive function, mental health, functional status, and respiratory symptoms between ECMO and CMV, but data available for comparison were limited. There were high rates of disability for ECMO survivors with 49% of patients returning to work and 23% needing assistance at home on follow-up. Conclusion: Survivors of ECMO for ARDS experience significant disability in multiple domains. Further studies are needed to examine the effect of ECMO on long-term outcomes of patients compared to CMV. [ABSTRACT FROM AUTHOR]

Purpose: Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit. Methods: We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle–Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model. Results: We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C–E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33–0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46–0.66). Conclusion: In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence. [ABSTRACT FROM AUTHOR]

The article discusses the use of prone positioning (PP) during extracorporeal membrane oxygenation (ECMO) for patients with severe acute respiratory distress syndrome (ARDS). The authors explain that PP has been shown to improve oxygenation and respiratory mechanics in ARDS patients, and it may also help mitigate the risk of ventilator-induced lung injury. However, the evidence regarding the routine application of PP during ECMO is conflicting, and more research is needed. The authors conclude that while waiting for more conclusive data, PP remains a promising treatment option for ARDS patients in specialized ECMO centers. [Extracted from the article]

This article discusses a case study of a 44-year-old man who underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) after experiencing cardiac arrest. The patient showed signs of right atrial collapse, which initially suggested cardiac tamponade. However, further examination revealed that the collapse was actually induced by suction from the VA-ECMO drainage cannula. The article highlights the importance of accurately diagnosing pseudo-tamponade in VA-ECMO patients to avoid unnecessary surgical interventions. The authors recommend temporarily reducing ECMO flow to rule out pseudo-tamponade in cases of right atrial collapse without clear evidence of abundant pericardial effusion. [Extracted from the article]

Two sets of guidelines on the respiratory management of acute respiratory distress syndrome (ARDS) have been released by international experts. The guidelines, from the European Society of Intensive Care Medicine (ESICM) and the American Thoracic Society (ATS), aim to synthesize evidence from randomized trials and provide practical recommendations. While there are some differences between the two sets of guidelines, they both emphasize the importance of individualizing patient care and highlight areas of uncertainty that could be addressed through further research. The guidelines cover topics such as venovenous extracorporeal membrane oxygenation, positive end-expiratory pressure, and neuromuscular blockade. [Extracted from the article]

The article discusses the challenges in diagnosing non-occlusive mesenteric ischemia (NOMI), a rare condition that primarily affects critically ill patients in the intensive care unit (ICU). The lack of specific symptoms and established biomarkers makes it difficult to diagnose NOMI, leading to high mortality rates. Computed tomography angiography (CTA) is the standard diagnostic tool for acute mesenteric ischemia (AMI), but its accuracy is low for NOMI. The authors suggest that colonoscopy can be a useful complementary diagnostic tool for confirming or ruling out colon ischemia, particularly in ICU patients. [Extracted from the article]

The article discusses the use of prone positioning during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Randomized controlled trials (RCTs) are considered the gold standard for evaluating the efficacy and safety of medical interventions, but their results often contradict observational studies. The PRONECMO trial, which involved 170 COVID-19 patients on VV-ECMO, found that prone positioning during ECMO did not provide significant benefits compared to maintaining a supine position. These results contradict previous observational studies suggesting that prone positioning during ECMO can lead to accelerated weaning and lower mortality. The article emphasizes the need for further research to address critical questions regarding mechanical ventilation on ECMO. [Extracted from the article]

This article discusses the use of extracorporeal life support (ECLS) in patients with cardiogenic shock. Despite recommendations from medical societies, recent randomized controlled trials have shown no significant benefit of ECLS in terms of mortality or secondary outcomes. The article highlights the potential complications and risks associated with ECLS, including increased left ventricular (LV) loading conditions. Various strategies for left ventricular unloading have been developed, but their effectiveness and optimal timing are still being studied. The article suggests that future research should consider alternative composite endpoints that encompass both mortality and morbidity. [Extracted from the article]

A recent study published in the journal Intensive Care Medicine examined the use of prone positioning during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Previous observational studies have suggested that prone positioning can improve outcomes in ARDS patients, but the results of this randomized controlled trial (RCT) were negative. The trial focused on COVID-19-related ARDS and found no difference in rates of successful weaning from ECMO, mortality, or respiratory system compliance between the prone and supine groups. The authors suggest that further investigation is needed to determine if prone positioning may be beneficial for non-COVID-19-related ARDS. [Extracted from the article]

Purpose: Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can be used to support severely ill patients with cardiogenic shock. While age is commonly used in patient selection, little is known regarding its association with outcomes in this population. We sought to evaluate the association between increasing age and outcomes following V-A ECMO. Methods: We used individual-level patient data from 440 centers in the international Extracorporeal Life Support Organization registry. We included all adult patients receiving V-A ECMO from 2017 to 2019. The primary outcome was hospital mortality. Secondary outcomes included a composite of complications following initiation of V-A ECMO. We conducted Bayesian analyses of the relationship between increasing age and outcomes of interest. Results: We included 15,172 patients receiving V-A ECMO. Of these, 8172 (53.9%) died in hospital. For the analysis conducted using weakly informed priors, and as compared to the reference category of age 18–29, the age bracket of 30–39 (odds ratio [OR] 0.94, 95% credible interval [CrI] 0.79–1.10) was not associated with hospital mortality, but age brackets 40–49 (odds ratio [OR] 1.26, 95% CrI: 1.08–1.47), 50–59 (OR 1.78, 95% CrI: 1.55–2.06), 60–69 (OR 2.24, 95% CrI: 1.94–2.59), 70–79 (OR 2.90, 95% CrI: 2.49–3.39) and ≥ 80 (OR 4.02, 95% CrI: 3.13–5.20) were independently associated with increasing hospital mortality. Similar results were found in the analysis conducted with an informative prior, as well as between increasing age and post-ECMO complications. Conclusions: Among patients receiving V-A ECMO for cardiogenic shock, increasing age is strongly associated with increasing odds of death and complications, and this association emerges as early as 40 years of age. [ABSTRACT FROM AUTHOR]

Purpose: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a complex and high-risk life support modality used in severe cardiorespiratory failure. ECMO survival scores are used clinically for patient prognostication and outcomes risk adjustment. This study aims to create the first artificial intelligence (AI)-driven ECMO survival score to predict in-hospital mortality based on a large international patient cohort. Methods: A deep neural network, ECMO Predictive Algorithm (ECMO PAL) was trained on a retrospective cohort of 18,167 patients from the international Extracorporeal Life Support Organisation (ELSO) registry (2017–2020), and performance was measured using fivefold cross-validation. External validation was performed on all adult registry patients from 2021 (N = 5015) and compared against existing prognostication scores: SAVE, Modified SAVE, and ECMO ACCEPTS for predicting in-hospital mortality. Results: Mean age was 56.8 ± 15.1 years, with 66.7% of patients being male and 50.2% having a pre-ECMO cardiac arrest. Cross-validation demonstrated an inhospital mortality sensitivity and precision of 82.1 ± 0.2% and 77.6 ± 0.2%, respectively. Validation accuracy was only 2.8% lower than training accuracy, reducing from 75.5% to 72.7% [99% confidence interval (CI) 71.1–74.3%]. ECMO PAL accuracy outperformed the ECMO ACCEPTS (54.7%), SAVE (61.1%), and Modified SAVE (62%) scores. Conclusions: ECMO PAL is the first AI-powered ECMO survival score trained and validated on large international patient cohorts. ECMO PAL demonstrated high generalisability across ECMO regions and outperformed existing, widely used scores. Beyond ECMO, this study highlights how large international registry data can be leveraged for AI prognostication for complex critical care therapies. [ABSTRACT FROM AUTHOR]

The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research. [ABSTRACT FROM AUTHOR]

Clinical delivery of aerosolized antibiotics Patients with and without cystic fibrosis bronchiectasis are affected by chronic bronchial infection frequently caused by I Pseudomonas aeruginosa. i Nebulisation of ciprofloxacin and aminoglycosides significantly delays the time to first exacerbation [[8]] and improves quality of life in non-cystic fibrosis patients [[8]]. Aerosol therapy in mechanically ventilated patients delivers drug particles driven by inspiratory gases. As aerosolised polymyxins and aminoglycosides are concentration-dependent antibiotics, the bactericidal effect is proportional to the delivered dose. [Extracted from the article]

This document is a reply to a comment made on an article about extracorporeal membrane oxygenation (ECMO) and positioning in the treatment of acute respiratory distress syndrome (ARDS). The authors acknowledge the concerns raised about study quality and missing data, but state that these issues were addressed in the discussion section of their paper. They also explain that a randomized trial comparing ECMO to prone positioning in severe ARDS is unlikely due to ethical considerations and practical challenges. The authors assert that their study provides the best estimates of the relative efficacy of ECMO, prone positioning, and low tidal volume for severe ARDS. [Extracted from the article]

This comment discusses a network meta-analysis comparing different treatments for severe hypoxemic acute respiratory distress syndrome (ARDS). The authors raise concerns about the inclusion of heterogeneous studies, the reliance on indirect comparisons, and the variability in definitions and durations of prone positioning. They also highlight the high rate of crossover in one study and the unclear methodology for handling missing data. The authors conclude that while the analysis provides important findings, the methodological limitations caution against overinterpretation and emphasize the need for more high-quality studies. [Extracted from the article]

A recent article in Intensive Care Medicine examined the outcomes of immunocompromised patients with cardiogenic shock who were treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). The study found that immunocompromised patients had a high 90-day mortality rate of 70%, and that being immunocompromised was independently associated with mortality. However, there are some uncertainties in the study's findings. The causes of death in the immunocompromised patients were unclear, and it is important to determine if VA-ECMO was associated with these deaths. Additionally, the variation in adjunctive therapy during VA-ECMO management was not evaluated, and there may have been selection bias in the study. Further research is needed to better understand the use of VA-ECMO in immunocompromised patients. [Extracted from the article]

The article discusses the impact of age on the outcomes of patients with cardiogenic shock who receive venoarterial extracorporeal membrane oxygenation (V-A ECMO) support. The authors conducted a Bayesian analysis of data from the Extracorporeal Life Support Organization (ELSO) registry, which included over 15,000 patients. They found that older age was associated with a higher risk of death, with patients over 40 years old experiencing increased mortality risk. However, there are limitations to the study, such as the lack of specificity in the variable of age and the potential impact of comorbidities on the relationship between age and mortality. The article emphasizes the need for cautious interpretation of the findings and highlights the uncertainty that clinicians still face in decision-making regarding age and ECMO support. [Extracted from the article]

Mechanical ventilation is provided to up to 20 million patients annually in intensive care units (ICUs) worldwide. 1, recent advances in invasive mechanical ventilation are characterized by the growing awareness that ARDS is a highly heterogeneous syndrome, and interventions to improve clinical outcomes need to be tailored to specific patient subgroups that share distinct clinical and possibly molecular phenotypes. Acute respiratory distress syndrome Most evidence surrounding ventilation strategies is based on studies in ARDS patients. Despite lung-protective mechanical ventilation strategies, the mortality of mechanically ventilated patients remains high, especially in patients with acute respiratory distress syndrome (ARDS). [Extracted from the article]

Second, we excluded ECPR patients, as severe post-cardiac arrest injury is frequent in this population leading to hypoxic brain injury, irrespective of ECMO support. In-hospital neurologic complications in adult patients undergoing venoarterial extracorporeal membrane oxygenation: results from the extracorporeal life support organization registry. The use of cerebral NIRS monitoring to identify acute brain injury in patients with VA-ECMO. First, all studies suggest that bedside repeatable non-invasive neuromonitoring is feasible in adult ECMO patients and variables derived from non-invasive neuromonitoring provide information on the occurrence of cerebral complications and are associated with functional outcomes. [Extracted from the article]

Purpose: To provide an overview and evaluate the performance of mortality prediction models for patients requiring extracorporeal membrane oxygenation (ECMO) support for refractory cardiocirculatory or respiratory failure. Methods: A systematic literature search was undertaken to identify studies developing and/or validating multivariable prediction models for all-cause mortality in adults requiring or receiving veno-arterial (V-A) or veno-venous (V-V) ECMO. Estimates of model performance (observed versus expected (O:E) ratio and c-statistic) were summarized using random effects models and sources of heterogeneity were explored by means of meta-regression. Risk of bias was assessed using the Prediction model Risk Of BiAS Tool (PROBAST). Results: Among 4905 articles screened, 96 studies described a total of 58 models and 225 external validations. Out of all 58 models which were specifically developed for ECMO patients, 14 (24%) were ever externally validated. Discriminatory ability of frequently validated models developed for ECMO patients (i.e., SAVE and RESP score) was moderate on average (pooled c-statistics between 0.66 and 0.70), and comparable to general intensive care population-based models (pooled c-statistics varying between 0.66 and 0.69 for the Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Sequential Organ Failure Assessment (SOFA) score). Nearly all models tended to underestimate mortality with a pooled O:E > 1. There was a wide variability in reported performance measures of external validations, reflecting a large between-study heterogeneity. Only 1 of the 58 models met the generally accepted Prediction model Risk Of BiAS Tool criteria of good quality. Importantly, all predicted outcomes were conditional on the fact that ECMO support had already been initiated, thereby reducing their applicability for patient selection in clinical practice. Conclusions: A large number of mortality prediction models have been developed for ECMO patients, yet only a minority has been externally validated. Furthermore, we observed only moderate predictive performance, large heterogeneity between-study populations and model performance, and poor methodological quality overall. Most importantly, current models are unsuitable to provide decision support for selecting individuals in whom initiation of ECMO would be most beneficial, as all models were developed in ECMO patients only and the decision to start ECMO had, therefore, already been made. [ABSTRACT FROM AUTHOR]

Purpose: The impact of body mass index (BMI) on outcomes in respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) has been poorly described. We aimed to assess: (i) whether adults with class II obesity or more (BMI ≥ 35 kg/m2) have worse outcomes than lean counterparts, (ii) the form of the relationship between BMI and outcomes, (iii) whether a cutoff marking futility can be identified. Methods: A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry from 1/1/2010 to 31/12/2020 was conducted. Impact of BMI ≥ 35 kg/m2 was assessed with propensity-score (PS) matching, inverse propensity-score weighted (IPSW) and multivariable models (MV), adjusting for a priori identified confounders. Primary outcome was in-hospital mortality. The form of the relationship between BMI and outcomes was studied with generalized additive models. Outcomes across World Health Organisation (WHO)-defined BMI categories were compared. Results: Among 18,529 patients, BMI ≥ 35 kg/m2 was consistently associated with reduced in-hospital mortality [PS-matched: OR: 0.878(95%CI 0.798–0.966), p = 0.008; IPSW: OR: 0.899(95%CI 0.827–0.979), p = 0.014; MV: OR: 0.900(95%CI 0.834–0.971), p = 0.007] and shorter hospital length of stays. In patients with BMI ≥ 35 kg/m2, cardiovascular (17.3% versus 15.3%), renal (37% versus 30%) and device-related complications (25.7% versus 20.6%) increased, whereas pulmonary complications decreased (7.6% versus 9.3%). These findings were independent of confounders throughout PS-matched, IPSW and MV models. The relationship between BMI and outcomes was non-linear and no cutoff for futility was identified. Conclusion: Patients with obesity class II or more treated with ECMO for respiratory failure have lower mortality risk and shorter stays, despite increased cardiovascular, device-related, and renal complications. No upper limit of BMI indicating futility of ECMO treatment could be identified. BMI as single parameter should not be a contra-indication for respiratory ECMO. [ABSTRACT FROM AUTHOR]

Intensive care unit (ICU) patients with end-organ failure will require specialised machines or extracorporeal therapies to support the failing organs that would otherwise lead to death. ICU patients with severe acute kidney injury may require renal replacement therapy (RRT) to remove fluid and wastes from the body, and patients with severe cardiorespiratory failure will require extracorporeal membrane oxygenation (ECMO) to maintain adequate oxygen delivery whilst the underlying pathology is evaluated and managed. The presence of ECMO and RRT machines can further augment the existing pharmacokinetic (PK) alterations during critical illness. Significant changes in the apparent volume of distribution (Vd) and drug clearance (CL) for many important drugs have been reported during ECMO and RRT. Conventional antimicrobial dosing regimens rarely consider the impact of these changes and consequently, are unlikely to achieve effective antimicrobial exposures in critically ill patients receiving ECMO and/or RRT. Therefore, an in-depth understanding on potential PK changes during ECMO and/or RRT is required to inform antimicrobial dosing strategies in patients receiving ECMO and/or RRT. In this narrative review, we aim to discuss the potential impact of ECMO and RRT on the PK of antimicrobials and antimicrobial dosing requirements whilst receiving these extracorporeal therapies. The potential benefits of therapeutic drug monitoring (TDM) and dosing software to facilitate antimicrobial therapy for critically ill patients receiving ECMO and/or RRT are also reviewed and highlighted. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with severe respiratory failure and has received particular attention during the coronavirus disease 2019 (COVID-19) pandemic. Evidence from two key randomized controlled trials, a subsequent post hoc Bayesian analysis, and meta-analyses support the interpretation of a benefit of ECMO in combination with ultra-lung-protective ventilation for select patients with very severe forms of acute respiratory distress syndrome (ARDS). During the pandemic, new evidence has emerged helping to better define the role of ECMO for patients with COVID-19. Results from large cohorts suggest outcomes during the first wave of the pandemic were similar to those in non-COVID-19 cohorts. As the pandemic continued, mortality of patients supported with ECMO has increased. However, the precise reasons for this observation are unclear. Known risk factors for mortality in COVID-19 and non-COVID-19 patients are higher patient age, concomitant extra-pulmonary organ failures or malignancies, prolonged mechanical ventilation before ECMO, less experienced treatment teams and lower ECMO caseloads in the treating center. ECMO is a high resource-dependent support option; therefore, it should be used judiciously, and its availability may need to be constrained when resources are scarce. More evidence from high-quality research is required to better define the role and limitations of ECMO in patients with severe COVID-19. [ABSTRACT FROM AUTHOR]

Treatment of respiratory failure has improved dramatically since the polio epidemic in the 1950s with the use of invasive techniques for respiratory support: mechanical ventilation and extracorporeal respiratory support. However, respiratory support is only a supportive therapy, designed to "buy time" while the disease causing respiratory failure abates. It ensures viable gas exchange and prevents cardiorespiratory collapse in the context of excessive loads. Because the use of invasive modalities of respiratory support is also associated with substantial harm, it remains the responsibility of the clinician to minimize such hazards. Direct iatrogenic consequences of mechanical ventilation include the risk to the lung (ventilator-induced lung injury) and the diaphragm (ventilator-induced diaphragm dysfunction and other forms of myotrauma). Adverse consequences on hemodynamics can also be significant. Indirect consequences (e.g., immobilization, sleep disruption) can have devastating long-term effects. Increasing awareness and understanding of these mechanisms of injury has led to a change in the philosophy of care with a shift from aiming to normalize gases toward minimizing harm. Lung (and more recently also diaphragm) protective ventilation strategies include the use of extracorporeal respiratory support when the risk of ventilation becomes excessive. This review provides an overview of the historical background of respiratory support, pathophysiology of respiratory failure and rationale for respiratory support, iatrogenic consequences from mechanical ventilation, specifics of the implementation of mechanical ventilation, and role of extracorporeal respiratory support. It highlights the need for appropriate monitoring to estimate risks and to individualize ventilation and sedation to provide safe respiratory support to each patient. [ABSTRACT FROM AUTHOR]

This article discusses the need for personalized oxygen targets in patients undergoing extracorporeal membrane oxygenation (ECMO). The study mentioned in the article found no significant differences in outcomes between liberal and conservative approaches to oxygenation, but there are several aspects that warrant further investigation. Personalized oxygen strategies based on patient-specific factors, such as cardiac condition, may be more beneficial. Additionally, more detailed neurocognitive assessments and studies on hypoxia frequency and severity are needed to understand the long-term effects of different oxygenation targets on brain health. The article also highlights the importance of monitoring oxidative markers and lung injury markers to guide oxygenation strategies effectively. The link between oxygen usage and ECMO flow rate is another area that requires further study. Overall, the article emphasizes the need for individualized oxygenation strategies to better meet patient needs during ECMO. [Extracted from the article]

The article discusses a Bayesian re-analysis of the ECLS-SHOCK trial, which compared the use of extracorporeal life support (ECLS) with medical treatment in patients with acute myocardial infarction complicated by cardiogenic shock. The re-analysis used individual patient data to quantify the probabilities of benefits and harms. The results showed that the routine use of ECLS on mortality in this condition is likely to have no large benefit, and there is a high probability of bleeding and vascular complications. The authors recommend a cautious approach to using ECLS in these patients. [Extracted from the article]

The article discusses the routine use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the intensive care unit (ICU) and raises the question of whether patients are ready for it. While VA-ECMO is commonly used in managing critical patients with cardiac failure, recent trials have shown higher rates of complications such as limb ischemia and severe bleeding. The article highlights the psychological and emotional burden on patients and families, especially when patients remain in a state of non-improvement on ECMO. The decision to use VA-ECMO should involve shared responsibility and decision-making with patients, considering the limited evidence and divided opinions within the medical community. [Extracted from the article]

The article discusses the ventilatory management strategies for patients with acute brain injury (ABI) undergoing invasive mechanical ventilation (IMV). While the article provides valuable insights, it also highlights several potential flaws and caveats that need further discussion. These include the lack of robust evidence, concerns about increased intracranial pressure, the need for tailored approaches, limited data on driving pressure and mechanical power, and the dynamic nature of ABI and acute respiratory distress syndrome (ARDS). The article emphasizes the importance of personalized approaches, evidence-based practices, and the need for prospective studies to enhance treatment guidelines and outcomes for ABI patients. [Extracted from the article]

Purpose: Extracorporeal membrane oxygenation (ECMO) has become an established therapy for severe respiratory failure in coronavirus disease 2019 (COVID-19). The added benefit of receiving ECMO in COVID-19 remains uncertain. The aim of this study is to analyse the impact of receiving ECMO at specialist centres on hospital mortality. Methods: A multi-centre retrospective study was conducted in COVID-19 patients from 111 hospitals, referred to two specialist ECMO centres in the United Kingdom (UK) (March 2020 to February 2021). Detailed covariate data were contemporaneously curated from electronic referral systems. We analysed added benefit of ECMO treatment in specialist centres using propensity score matching techniques. Results: 1363 patients, 243 receiving ECMO, were analysed. The best matching technique generated 209 matches, with a marginal odds ratio (OR) for mortality of 0.44 (95% CI 0.29–0.68, p < 0.001) and absolute mortality reduction of 18.2% (44% vs 25.8%, p < 0.001) for treatment with ECMO in a specialist centre. Conclusion: We found ECMO provided at specialist centres conferred significant survival benefit. Where resources and specialism allow, ECMO should be widely offered. [ABSTRACT FROM AUTHOR]

Purpose: The question of whether cancer patients with severe respiratory failure benefit from veno-venous extracorporeal membrane oxygenation (vv-ECMO) remains unanswered. We, therefore, analyzed clinical characteristics and outcomes of a large cohort of cancer patients treated with vv-ECMO with the aim to identify prognostic factors. Methods: 297 cancer patients from 19 German and Austrian hospitals who underwent vv-ECMO between 2009 and 2019 were retrospectively analyzed. A multivariable cox proportional hazards analysis for overall survival was performed. In addition, a propensity score-matched analysis and a latent class analysis were conducted. Results: Patients had a median age of 56 (IQR 44–65) years and 214 (72%) were males. 159 (54%) had a solid tumor and 138 (47%) a hematologic malignancy. The 60-day overall survival rate was 26.8% (95% CI 22.1–32.4%). Low platelet count (HR 0.997, 95% CI 0.996–0.999; p = 0.0001 per 1000 platelets/µl), elevated lactate levels (HR 1.048, 95% CI 1.012–1.084; p = 0.0077), and disease status (progressive disease [HR 1.871, 95% CI 1.081–3.238; p = 0.0253], newly diagnosed [HR 1.571, 95% CI 1.044–2.364; p = 0.0304]) were independent adverse prognostic factors for overall survival. A propensity score-matched analysis with patients who did not receive ECMO treatment showed no significant survival advantage for treatment with ECMO. Conclusion: The overall survival of cancer patients who require vv-ECMO is poor. This study shows that the value of vv-ECMO in cancer patients with respiratory failure is still unclear and further research is needed. The risk factors identified in the present analysis may help to better select patients who may benefit from vv-ECMO. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies support the potential efficacy of venovenous extracorporeal membrane oxygenation (vvECMO) for improving survival in severe acute respiratory distress syndrome (ARDS) cases. Prone positioning (PP) has been shown to improve the outcomes of moderate-to-severe ARDS patients. Few studies and no randomized controlled trials have evaluated the effect of PP performed in ECMO patients. Methods: We performed a systematic review and meta-analysis examining the effect of prone positioning for ARDS patients receiving vvECMO on survival. All authors were contacted to obtain complementary information not mentioned in the original articles. The main objective was to compare 28-day survival in vvECMO patients with PP to vvECMO patients without PP (controls). Results: Thirteen studies with a combined population of 1836 patients satisfied the inclusion criteria. PP was associated with a significant improvement in 28-day survival (503 survivors among 681 patients in the PP group [74%; 95% CI 71–77] vs. 450 survivors among 770 patients in the control group [58%, 95% CI 55–62]; RR 1.31 [95% CI 1.21–1.41]; I2 22% [95% CI 0–62%]; P < 0.0001). Survival was also improved in terms of other endpoints (60-day survival, 90-day survival, ICU survival, and hospital survival). In contrast, the duration of mechanical ventilation was increased in vvECMO patients with PP (mean difference 11.4 days [95% CI 9.2–13.5]; 0.64 [95% CI 0.50–0.78]; I2 8%; P < 0.0001). Conclusion: According to this meta-analysis, survival was improved when prone positioning was used in ARDS patients receiving vvECMO. The impact of this combination on survival should be investigated in prospective randomized controlled trials. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed at analyzing the prevalence, mortality association, and risk factors for bleeding and thrombosis events (BTEs) among adults supported with venovenous extracorporeal membrane oxygenation (VV-ECMO). Methods: We queried the Extracorporeal Life Support Organization registry for adults supported with VV-ECMO from 2010 to 2017. Multivariable logistic regression modeling was used to assess the association between BTEs and in-hospital mortality and the predictors of BTEs. Results: Among 7579 VV-ECMO patients meeting criteria, 40.2% experienced ≥ 1 BTE. Thrombotic events comprised 54.9% of all BTEs and were predominantly ECMO circuit thrombosis. BTE rates decreased significantly over the study period (p < 0.001). The inpatient mortality rate was 34.9%. Bleeding events (1.69 [1.49–1.93]) were more strongly associated with in-hospital mortality than thrombotic events (1.23 [1.08–1.41]) p < 0.01 for both. The BTEs most strongly associated with mortality were ischemic stroke (4.50 [2.55–7.97]) and medical bleeding, including intracranial (5.71 [4.02–8.09]), pulmonary (2.02 [1.54–2.67]), and gastrointestinal (1.54 [1.2–1.98]) hemorrhage, all p < 0.01. Risk factors for bleeding included acute kidney injury and pre-ECMO vasopressor support and for thrombosis were higher weight, multisite cannulation, pre-ECMO arrest, and higher PaCO2 at ECMO initiation. Longer time on ECMO, younger age, higher pH, and earlier year of support were associated with bleeding and thrombosis. Conclusions: Although decreasing over time, BTEs remain common during VV-ECMO and have a strong, cumulative association with in-hospital mortality. Thrombotic events are more frequent, but bleeding carries a higher risk of inpatient mortality. Differential risk factors for bleeding and thrombotic complications exist, raising the possibility of a tailored approach to VV-ECMO management. [ABSTRACT FROM AUTHOR]

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy. [ABSTRACT FROM AUTHOR]

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions 1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units? 2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment? 3. Which support should be used for extra-renal purification, in which conditions and environment? 4. Which haemodynamic support should be used, for which complications, and in which environment? 5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications? 6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment ...)? 7. What specific considerations should be taken into account in the intensive care unit? 8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)? 9. Which training is required for critical care doctors in charge of cancer patients? [ABSTRACT FROM AUTHOR]