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Haemolysis, thrombosis and haemorrhage are well-documented complications of extracorporeal membrane oxygenation. This case report outlines an unusual case of haemolysis, thought secondary to a large mobile thrombus in the inferior vena cava. [ABSTRACT FROM AUTHOR]

Objective: The use of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrests (OHCA) has increased dramatically over the past decade. ECPR is resource intensive and costly, presenting challenges for policymakers. We sought to review the cost-effectiveness of ECPR compared with conventional cardiopulmonary resuscitation (CCPR) in OHCA.Methods: We searched Medline, Embase, Tufts CEA registry and NHS EED databases from database inception to 2021 or 2015 for NHS EED. Cochrane Covidence was used to screen and assess studies. Data on costs, effects and cost-effectiveness of included studies were extracted by two independent reviewers. Costs were converted to USD using purchasing power parities (OECD, 2022).1 The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist (Husereau et al., 2022)2 was used for reporting quality and completeness of cost-effectiveness studies; the review was registered on PROSPERO, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Results: Four studies met the inclusion criteria; three cost-effectiveness studies reported an incremental cost-effectiveness ratio (ICER) for OHCA compared with conventional care, and one reported the mean operating cost of ECPR. ECPR was more costly, accrued more life years (LY) and quality-adjusted life years (QALYs) than CCPR and was more cost-effective when compared with CCPR and other standard therapies. Overall study quality was rated as moderate.Conclusion: Few studies have examined the cost-effectiveness of ECPR for OHCA. Of those, ECPR for OHCA was cost-effective. Further studies are required to validate findings and assess the cost-effectiveness of establishing a new ECPR service or alternate ECPR delivery models. [ABSTRACT FROM AUTHOR]

Abstract Peripheral veno-arterial extra corporeal membrane oxygenation (VA-ECMO) is an established technique for short-to-medium support of patients with severe cardiac failure. However, in patients with concomitant respiratory failure, the residual native circulation will provide deoxygenated blood to the upper body, and may cause differential hypoxemia of the heart and brain. In this paper, we present a general computational framework for the identification of differential hypoxemia risk in VA-ECMO patients. A range of different VA-ECMO patient scenarios for a patient-specific geometry and vascular resistance were simulated using transient computational fluid dynamics simulations, representing a clinically relevant range of values of stroke volume and ECMO flow. For this patient, regardless of ECMO flow rate, left ventricular stroke volumes greater than 28 mL resulted in all aortic arch branch vessels being perfused by poorly-oxygenated systemic blood sourced from the lungs. The brachiocephalic artery perfusion was almost entirely derived from blood from the left ventricle in all scenarios except for those with stroke volumes less than 5 mL. Our model therefore predicted a strong risk of differential hypoxemia in nearly all situations with some residual cardiac function for this combination of patient geometry and vascular resistance. This simulation highlights the potential value of modelling for optimising ECMO design and procedures, and for the practical utility for personalised approaches in the clinical use of ECMO. [ABSTRACT FROM AUTHOR]

Background: The use of extracorporeal membrane oxygenation (ECMO) in refractory cardiac arrest (ECPR) has increased exponentially. ECPR is a resource intensive service and its cost effectiveness has yet to be demonstrated. We sought to complete a cost analysis with modelling of cost effectiveness and quality of life outcomes. We sought to complete a cost analysis with modelling of cost effectiveness and quality of life outcomes of patients who have undergone ECPR.Methods: Using data on all extracorporeal cardiopulmonary resuscitation (ECPR) patients at two ECMO centres in Sydney, Australia; we completed a costing analysis of ECPR patients. A Markov model of cost, quality of life and survival outcomes was developed to examine cost per QALY estimates and incremental cost effectiveness ratios (ICERs). Probabilistic sensitivity analysis (PSA) was completed to assess the probability of cost effectiveness for base case and variations.Results: Sixty-two consecutive ECPR patients were analysed; mean age of 51.9 ± 13.6 years, 38 (61%) were in hospital cardiac arrests (IHCA). Twenty-five patients (40%) survived to hospital discharge; all with a cerebral performance category (CPC) of 1 or 2. The mean cost per ECPR patient was AUD 75,165 (€50,535; ±AUD 75,737). Over 10 years ECPR was estimated to add a mean gain of 3.0 Quality Adjusted Life Years (QALYs) per patient with an incremental cost effectiveness ratio (ICER) of AUD 25,212 (€16,890) per QALY, increasing to 4.0 QALYs and an ICER of AUD 18,829 (€12,614) over a 15-year survival scenario. Mean cost per QALY did not differ significantly by OHCA or IHCA.Conclusions: ECMO support for refractory cardiac arrests is cost effective and compares favourably to accepted cost effectiveness thresholds. [ABSTRACT FROM AUTHOR]

Aim To describe the ECPR experience of two Australian ECMO centres, with regards to survival and neurological outcome, their predictors and complications. Methods Retrospective observational study of prospectively collected data on all patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR) at two academic ECMO referral centres in Sydney, Australia. Measurements and main results Thirty-seven patients underwent ECPR, 25 (68%) were for in-hospital cardiac arrests. Median age was 54 (IQR 47–58), 27 (73%) were male. Initial rhythm was ventricular fibrillation or pulseless ventricular tachycardia in 20 patients (54%), pulseless electrical activity ( n = 14, 38%), and asystole ( n = 3, 8%). 27 (73%) arrests were witnessed and 30 (81%) patients received bystander CPR. Median time from arrest to initiation of ECMO flow was 45 min (IQR 30–70), and the median time on ECMO was 3 days (IQR 1–6). Angiography was performed in 54% of patients, and 27% required subsequent coronary intervention (stenting or balloon angioplasty 24%). A total of 13 patients (35%) survived to hospital discharge (IHCA 33% vs. OHCA 37%). All survivors were discharged with favourable neurological outcome (Cerebral Performance Category 1 or 2). Pre-ECMO lactate level was predictive of mortality OR 1.35 (1.06–1.73, p = 0.016). Conclusions In selected patients with refractory cardiac arrest, ECPR may provide temporary support as a bridge to intervention or recovery. We report favourable survival and neurological outcomes in one third of patients and pre-ECMO lactate levels predictive of mortality. Further studies are required to determine optimum selection criteria for ECPR. [ABSTRACT FROM AUTHOR]