Cerebral outcome in adult patients treated with extracorporeal membrane oxygenation
ABSTRACT Extracorporeal membrane oxygenation (ECMO) carries a high risk of brain injury. The aim of this study was to determine the cerebral status in 28 adult survivors on average 5.0 (range, 0.5 to 12) years after ECMO treatment for severe cardiorespiratory failure.
All 28 patients were investigated at our institution. A comprehensive assessment protocol included a medical history, physical examination, neuropsychological assessment, electroencephalography, and neuroradiologic assessment.
All patients were ambulant unaided, and 43% were without any clinical findings. Impaired neuropsychological performance was found in 41%, neuroradiologic findings in 52%, and a pathologic electroencephalogram in 41% of the patients. There was a significant correlation between the cognitive outcome and neuroradiologic findings. The incidence of neuroradiologic findings (cerebral infarction, microemboli or hemorrhage) was significantly higher in the venoarterial group compared with the venovenous group (75% versus 17%). There was no correlation between the type of ECMO and neuropsychological impairment. Electroencephalography findings did not correlate with neuropsychological performance, nor with the neuroradiologic findings.
Late cerebral sequelae were frequently seen in patients treated on venoarterial ECMO. A significant correlation was found between cognitive impairment and neuroradiologic findings.
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ABSTRACT: Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome (ARDS) that characterized the 2009 influenza A (H1N1) pandemic have stimulated renewed interest in the use of veno-venous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R) to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to lung transplantation. The use of veno-arterial (VA) ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond post-cardiotomy failure. While technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.American Journal of Respiratory and Critical Care Medicine 07/2014; 190(5). DOI:10.1164/rccm.201404-0736CI · 11.99 Impact Factor
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ABSTRACT: The addition of an intra-aortic balloon pump (IABP) during peripheral venoarterial extracorporeal membrane oxygenation (VA ECMO) support has been shown to improve coronary bypass graft flows and cardiac function in refractory cardiogenic shock after cardiac surgery. The purpose of this study was to evaluate the impact of additional IABP support on the cerebral blood flow (CBF) in patients with peripheral VA ECMO following cardiac procedures. Twelve patients (mean age 60.40 +/- 9.80 years) received VA ECMO combined with IABP support for postcardiotomy cardiogenic shock after coronary artery bypass grafting. The mean CBF in the bilateral middle cerebral arteries was measured with and without IABP counterpulsation by transcranial Doppler. The patients provided their control values. The mean CBF data were divided into two groups (pulsatile pressure greater than 10 mmHg, P group; pulsatile pressure less than 10 mmHg, N group) based on whether the patients experienced cardiac stun. The mean cerebral blood flow in VA ECMO (IABP turned off) alone and VA ECMO with IABP support were compared using the paired t test. All of the patients were successfully weaned from VA ECMO, and eight patients survived to discharge. The addition of IABP to VA ECMO did not change the mean CBF (251.47 +/- 79.28 ml/min vs. 251.30 +/- 79.47 ml/min, P = 0.963). The mean CBF was higher in VA ECMO alone than in VA ECMO combined with IABP support in the N group (257.68 +/- 97.21 ml/min vs. 239.47 +/- 95.60, P = 0.00). The addition of IABP to VA ECMO support increased the mean CBF values significantly compared with VA ECMO alone (261.68 +/- 82.45 ml/min vs. 244.43 +/- 45.85 ml/min, P = 0.00) in the P group. These results demonstrate that an IABP significantly changes the CBF during peripheral VA ECMO, depending on the antegrade blood flow by spontaneous cardiac function. The addition of an IABP to VA ECMO support decreased the CBF during cardiac stun, and it increased CBF without cardiac stun.Journal of Translational Medicine 04/2014; 12(1):106. DOI:10.1186/1479-5876-12-106 · 3.99 Impact Factor
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ABSTRACT: Extracorporeal membrane oxygenation (ECMO) is a method of life support to maintain cardiopulmonary function. Its use as a medical application has increased since its inception to treat multiple conditions including acute respiratory distress syndrome, myocardial ischemia, cardiomyopathy, and septic shock. While complications including neurological and renal injury occur in patients on ECMO, bleeding and coagulopathy are most common. ECMO is associated with an inflammatory response promoting a hypercoagulable state, requiring anticoagulation to avoid thromboembolism originating in the nonendothelial surfaced circuit. However, excessive anticoagulation may result in bleeding complications including intracerebral hemorrhage. Monitoring anticoagulation for ECMO has its origins in cardiopulmonary bypass for cardiac surgery; however, there is no ideal level of anticoagulation, no standardized method to monitor anticoagulation, nor are all centers standardized on what is used for anticoagulation. Multiple blood products are used in an effort to decrease bleeding in the setting of anticoagulation, often in the setting of recent surgery, and this leads to significant increases in cost for patients on ECMO and transfusion-related complications. In this review article, we discuss the evolution of the various modalities of ECMO, indications, contraindications, and complications. Furthermore, we review the different strategies for anticoagulation and treatment of coagulopathy while on ECMO. Finally, we discuss the cost of ECMO and associated blood product transfusion.Anesthesia and analgesia 04/2014; 118(4):731-43. DOI:10.1213/ANE.0000000000000115 · 3.42 Impact Factor