Dataset Information

Early Driving Pressure Changes Predict Outcomes during Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

ABSTRACT: Background:Extracorporeal membrane oxygenation (ECMO) serves as a rescue therapy when systemic hypoxia persists despite conventional care for severe acute respiratory distress syndrome (ARDS). Due to the extracorporeal gas exchange, the p aO2/F iO2 ratio cannot be used as the primary marker for disease severity and progression. Therefore, we performed a propensity score-matched analysis to identify other potential predictors of outcomes in patients supported by ECMO therapy. Results:Between December 2014 and May 2018, 105 patients underwent venovenous ECMO in our institution. From these patients, we identified 28 who died during ECMO therapy and assigned 28 control patients using propensity score matching based on the following criteria: age, ARDS severity, and SAPSII score at admission. A statistical evaluation of the patient characteristics, intensive care data, morbidities, respiratory system variables, and outcomes was performed. The baseline patient characteristics did not differ between groups and ECMO was placed on day 1 in all patients. The analyzed variables of respiratory mechanics, such as the plateau pressure, positive end-expiratory pressure, and tidal volume, did not differ between groups. The driving pressure before ECMO was equal between the nonsurvivors and the controls. Twelve hours after initiation of ECMO therapy, the driving pressure decreased by 40.8% in the survivors but by only 20.1% in the nonsurvivors. Conclusions:We report that very early driving pressure changes can serve as an indicator of disease severity and predict patient survival following ECMO therapy.

SUBMITTER: Magunia H

PROVIDER: S-EPMC7085355 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Early Driving Pressure Changes Predict Outcomes during Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

Magunia Harry H Haeberle Helene A HA Henn Philipp P Mehrländer Martin M Vlatten Peer O PO Mirakaj Valbona V Rosenberger Peter P Koeppen Michael M

Critical care research and practice 20200307

<h4>Background</h4>Extracorporeal membrane oxygenation (ECMO) serves as a rescue therapy when systemic hypoxia persists despite conventional care for severe acute respiratory distress syndrome (ARDS). Due to the extracorporeal gas exchange, the p aO2/F iO2 ratio cannot be used as the primary marker for disease severity and progression. Therefore, we performed a propensity score-matched analysis to identify other potential predictors of ou ...[more]

PMID: 32257436

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Project description:Patients on extracorporeal support for severe acute respiratory distress syndrome may require a prolonged period of deep sedation. In these patients, volatile sedation may represent a valid alternative to IV drugs. The aim of our study was to describe the feasibility of volatile sedation in a large cohort of acute respiratory distress syndrome patients undergoing venovenous extracorporeal membrane oxygenation and ultraprotective ventilation.DesignRetrospective monocentric study.SettingAdult ICU, ASST Monza, Italy.PatientsAdult patients who underwent volatile sedation with isoflurane during venovenous extracorporeal membrane oxygenation between 2009 and 2019.InterventionsIsoflurane was delivered via the AnaConDa system. The sedation level, hemodynamics, and laboratory tests were compared between the volatile sedation phase and the IV sedation phases before and after the isoflurane sedation period.Measurements and main resultsAbout 74 patients (50 yr [43-56 yr]) were included. Median duration of venovenous extracorporeal membrane oxygenation support was 22 days (14-51 d). Volatile sedation started on day 3 (2-6) of extracorporeal membrane oxygenation support, and its median duration was 7 days (4-13 d), ranging from 1 to 38 days. A total of 970 venovenous extracorporeal membrane oxygenation days were analyzed. During the volatile phase, the sedation level was slightly deeper (bispectral index 39 ± 6) compared with the IV phase before and after isoflurane (42 ± 8 and 43 ± 9, respectively, p < 0.001). Requirements of fentanyl and remifentanyl were reduced during the volatile phase. Minor differences in hemodynamics were observed during volatile sedation: mean arterial pressure was lower (75 ± 13 vs 79 ± 14 and 80 ± 15; p < 0.001), whereas cardiac output was higher (8.5 ± 1.9 vs 7.9 ± 1.8 and 8.0 ± 1.8; p = 0.003). Aspartate aminotransferase levels were lower during the volatile sedation phases (p < 0.001), whereas alanine aminotransferase, triglycerides, and creatine phosphokinase were more altered during the IV sedation phase before isoflurane (p < 0.001).ConclusionsVolatile sedation represents an alternative to IV agents to achieve long-term deep sedation in critically ill patients on extracorporeal membrane oxygenation undergoing ultraprotective ventilation.

Project description:BackgroundProne positioning (PP) improves oxygenation and respiratory mechanics and is associated with lower mortality in patients with moderate to severe acute respiratory distress syndrome (ARDS). Despite this, some patients develop refractory hypoxemia and hypercapnia requiring venovenous extracorporeal membrane oxygenation (VV ECMO) support and are usually cared for in supine position. The physiologic and outcome benefits of routine PP of patients during VV ECMO remains unclear. Hence, we conducted the systematic review and meta-analysis to evaluate the outcome benefits of PP for patients with ARDS being treated with VV ECMO.MethodsAfter registration with PROSPERO (CRD42020199723), MEDLINE, EMBASE, Scopus and Cochrane databases were searched for relevant studies that reported PP in more than 10 adult patients supported with VV ECMO from origin to 1 March 2021. Studies were reviewed for quality using appropriate Joanna Briggs Institute (JBI) checklists, and certainty of evidence was assessed using the GRADE approach. The random-effects model (DerSimonian and Laird) was used. The primary outcome of interest was cumulative survival. Secondary outcomes were intensive care unit length of stay (ICU LOS) and ECMO duration. Changes in arterial blood gas (ABG) values, ventilator mechanics and complication rates were also studied.ResultsOf 812 potentially relevant publications, 12 studies (640 patients) met our inclusion criteria. Due to overlapping study populations, 11 studies were included in the final meta-analysis. Cumulative survival in patients that underwent PP was 57% (95% CI 41.9-71.4, high certainty). Patients that underwent PP had longer ICU LOS (+ 14.5 days, 95% CI 3.4-25.7, p = 0.01) and ECMO duration (+ 9.6 days, 95% CI 5.5-13.7, p < 0.0001). After PP, patients had significantly higher PaO2/FiO2 ratio, lower PaCO2 and reduced ventilator driving pressure, and no major complications were reported.ConclusionsPP during VV ECMO appears safe with a cumulative survival of 57% and may result in longer ECMO runs and ICU LOS. However, evidence from appropriately designed randomized trials is needed prior to widespread adoption of PP on VV ECMO.

Project description:BackgroundCarbon monoxide (CO) is an endogenous signaling molecule that activates cytoprotective programs implicated in the resolution of acute respiratory distress syndrome (ARDS) and survival of critical illness. Because CO levels can be measured in blood as carboxyhemoglobin, we hypothesized that carboxyhemoglobin percent (COHb%) may associate with mortality.ObjectivesTo examine the relationship between COHb% and outcomes in patients with ARDS requiring venovenous extracorporeal membrane oxygenation (ECMO), a condition where elevated COHb% is commonly observed.DesignRetrospective cohort study.SettingAcademic medical center ICU.PatientsPatients were included that had ARDS on venovenous ECMO.Measurements and main resultsWe examined the association between COHb% and mortality using a Cox proportional hazards model. Secondary outcomes including ECMO duration, ventilator weaning, and hospital and ICU length of stay were examined using both subdistribution and causal-specific hazard models for competing risks. We identified 109 consecutive patients for analysis. Mortality significantly decreased per 1 U increase in COHb% below 3.25% (hazard ratio [HR], 0.35; 95% CI, 0.15-0.80; p = 0.013) and increased per 1 U increase above 3.25% (HR, 4.7; 95% CI, 1.5-14.7; p = 0.007) reflecting a nonlinear association (p = 0.006). Each unit increase in COHb% was associated with reduced likelihood of liberation from ECMO and mechanical ventilation, and increased time to hospital and ICU discharge (all p < 0.05). COHb% was significantly associated with hemolysis but not with initiation of hemodialysis or blood transfusions.ConclusionsIn patients with ARDS on venovenous ECMO, COHb% is a novel biomarker for mortality exhibiting a U-shaped pattern. Our findings suggest that too little CO (perhaps due to impaired host signaling) or excess CO (perhaps due to hemolysis) is associated with higher mortality. Patients with low COHb% may exhibit the most benefit from future therapies targeting anti-oxidant and anti-inflammatory pathways such as low-dose inhaled CO gas.

Dataset Information

Early Driving Pressure Changes Predict Outcomes during Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

Publications

Early Driving Pressure Changes Predict Outcomes during Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome.

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