Neurological Injury in Adults Treated With Extracorporeal Membrane Oxygenation
Department of Neurology, Johns Hopkins University, 600 N Wolfe St, Baltimore, MD 21287, USA. Archives of neurology
(Impact Factor: 7.42).
08/2011; 68(12):1543-9. DOI: 10.1001/archneurol.2011.209
Extracorporeal membrane oxygenation (ECMO) may be urgently used as a last resort form of life support when all other treatment options for potentially reversible cardiopulmonary injury have failed.
To examine the range and frequency of neurological injury in ECMO-treated adults.
Retrospective clinicopathological cohort study.
Mayo Clinic, Rochester, Minnesota.
A prospectively collected registry of all patients 15 years or older treated with ECMO for 12 or more hours from January 2002 to April 2010.
Patients were analyzed for potential risk factors for neurological events and death using logistic regression and Cox proportional hazards models.
Neurological diagnosis and/or death.
A total of 87 adults were treated (35 female [40%]; median age, 54 years [interquartile range, 31]; mean duration of ECMO, 91 hours [interquartile range, 100]; overall survival >7 days after ECMO, 52%). Neurological events occurred in 42 patients who received ECMO (50%; 95% confidence interval [CI], 39%-61%). Diagnoses included subarachnoid hemorrhage, ischemic watershed infarctions, hypoxic-ischemic encephalopathy, unexplained coma, and brain death. Death in patients who received ECMO who did not require antecedent cardiopulmonary resuscitation was associated with increased age (odds ratio, 1.24 per decade; 95% CI, 1.03-1.50; P = .02) and lower minimum arterial oxygen pressure (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .03). Although stroke was rarely diagnosed clinically, 9 of 10 brains studied at autopsy demonstrated hypoxic-ischemic and hemorrhagic lesions of vascular origin.
Severe neurological sequelae occur frequently in adult ECMO-treated patients with otherwise reversible cardiopulmonary injury (conservative estimate, 50%) and include a range of potentially fatal neurological diagnoses that may be due to the precipitating event and/or ECMO treatment.
Available from: PubMed Central
- "VA ECMO is effective for the treatment of acute cardiac failure, however, the neurological morbidity has become a significant concern for many patients . At one academic medical center, combined ischemic and hemorrhagic stroke affected 7% of the adult patients supported with ECMO and significantly increased the odds ratio of death . "
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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.
Available from: ejcts.oxfordjournals.org
- "Major factors such as bleeding (10–30%) and thrombembolic complications as well as infections impact on the primary outcome in this patient population . Also, neuronal injury, a common complication (up to 50%) in patients supported with extracorporeal devices, limits the outcome after ECLS . Predicting the neurological outcome, particularly after CPR, is relevant to extending/maintaining an elaborate extracorporeal therapy. "
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ABSTRACT: OBJECTIVES Extracorporeal life support (ECLS) is a rescue option in critically ill patients. Since fast available and appropriate for
respiratory and circulatory failure, it is frequently applied in resuscitation scenarios. Neurological injury is a complication
common in ECLS patients limiting outcome, particularly after resuscitation. In this study, the institutional ECLS database
was used to correlate neuron-specific enolase (NSE) serum peak values with outcome of patients supported with venoarterial
(VA) ECLS during cardiopulmonary resuscitation (CPR).
Available from: Yousef Abusabha
- "Currently,thestatusofanARFwithconsecutiveRVFshowsa poorprognosisforthepatient.Ifmechanicalventilationand intensivecaremanagementalonefailtoprovideadequateperfusionandsufficientgasexchange ,extracorporeallifesupport systemsarerecommendable.Despiterecentimprovementsin veno-venousECMOtherapyandtechnology,theoutcomefor patientssufferingacombinationofARFandRVFremainsunsatisfying.Therateofcomplicationsremainshigh:bleedingcomplications ,thrombo-embolicevents,neurologicalevents,capillary leaksyndromes,vesselsstenosisandinjuryarefrequently encountered.Inpurerespiratoryfailure,passivelydriven interventionallungassistsystemsofferacceptableoxygenation andgooddecarboxylationvialow-resistancedevices.Asthese systemsrequireasufficientcardiacoutputasdrivingforce,their useislimitedinconcomitantventricularfailure. Centralveno-arterialECMOiscurrentlythestandardtherapy infailingtheleftorrightmyocardium.Itavoidsordelaysirre- versiblemyocardialdamagewithsubsequentmultiorganfailure anddeath.Itstargetiseitherweaningofthedevicefollowing myocardialrecoveryorbridgingtotheimplantationofapermanentassistsystem .Incomparisonwithaveno-arterialECMO implantedviathefemoralvessels,centralECMOprovidesasafer oxygenationofthesupra-aorticvesselsandmightleadtoa higherdegreeofprotectiontothebrainandabettercoron- aryperfusion. ComparedwithcentralECMO,ouratrio-atrialapproachshows distinctadvantages:therightventricleiscompletelyunloaded byourdevice,andtherightventricularafterloadlosesitsthreat. "
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Right ventricular failure is often the final phase in acute and chronic respiratory failure. We combined right ventricular unloading with extracorporeal oxygenation in a new atrio-atrial extracorporeal membrane oxygenation (ECMO).METHODS
Eleven sheep (65 kg) were cannulated by a 28-Fr inflow cannula to the right atrium and a 25-Fr outflow cannula through the lateral left atrial wall. Both were connected by a serial combination of a microaxial pump (Impella Elect®, Abiomed Europe, Aachen, Germany) and a membrane oxygenator (Novalung(®)-iLA membrane oxygenator; Novalung GmbH, Hechingen, Germany). In four animals, three subsequent states were evaluated: normal circulation, apneic hypoxia and increased right atrial after load by pulmonary banding. We focused on haemodynamic stability and gas exchange.RESULTSAll animals reached the end of the study protocol. In the apnoea phase, the decrease in PaO2 (21.4 ± 3.6 mmHg) immediately recovered (179.1 ± 134.8 mmHg) on-device in continuous apnoea. Right heart failure by excessive after load decreased mean arterial pressure (59 ± 29 mmHg) and increased central venous pressure and systolic right ventricular pressure; PaO2 and SvO2 decreased significantly. On assist, mean arterial pressure (103 ± 29 mmHg), central venous pressure and right ventricular pressure normalized. The SvO2 increased to 89 ± 3% and PaO2 stabilized (129 ± 21 mmHg).CONCLUSIONS
We demonstrated the efficacy of a miniaturized atrio-atrial ECMO. Right ventricular unloading was achieved, and gas exchange was well taken over by the NovaLung. This allows an effective short- to mid-term treatment of cardiopulmonary failure, successfully combining right ventricular and respiratory bridging. The parallel bypass of the right ventricle and lung circulation permits full unloading of both systems as well as gradual weaning. Further pathologies (e.g. ischaemic right heart failure and acute lung injury) will have to be evaluated.
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