Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury

Shou, Benjamin L.; Wilcox, Christopher S.; Florissi, Isabella; Kalra, Andrew; Caturegli, Giorgio; Zhang, Lucy Q.; Bush, Errol L.; Kim, Bo; Keller, Steven P.; Whitman, Glenn; Cho, Sung Min; Calligy, Kate; Brown, Patricia M.; Alejo, Diane; Anderson, Scott; Acton, Matthew; Rando, Hannah; Chang, Henry; Kerr, H. Dabney

doi:10.1007/s12028-022-01607-y

Cited by 20 publications

(11 citation statements)

References 35 publications

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“…Absence of pulsatile flow was associated with a higher frequency of IPH. Early low pulse pressure (< 20 mm Hg) has been associated with ABI in VA-ECMO patients, indicating low pulse pressure may serve as a marker of ABI risk, which is consistent with our TCD analysis [ 28 ]. However, this association needs to be interpreted carefully given the low number of patients with IPHs in our cohort.…”

Section: Discussionsupporting

confidence: 88%

Characterization of Cerebral Hemodynamics with TCD in Patients Undergoing VA-ECMO and VV-ECMO: a Prospective Observational Study

et al. 2022

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Background Extracorporeal membrane oxygenation has a high risk of acute brain injury and resultant mortality. Transcranial Doppler characterizes cerebral hemodynamics in real time, but limited data exist on its interpretation in ECMO. Here, we report TCD mean flow velocity and pulsatility index in a large ECMO population. Methods This was a prospective cohort study at a tertiary care center. The patients were adults on venoarterial ECMO or venovenous ECMO undergoing TCD studies. Results A total of 135 patients underwent a total of 237 TCD studies while on VA-ECMO ( n = 95, 70.3%) or VV-ECMO ( n = 40, 29.6%). MFVs were captured reliably (approximately 90%) and were similar to a published healthy cohort in all vessels except the internal carotid artery. Presence of a recordable PI was strongly associated with ECMO mode (57% in VA vs. 95% in VV, p < 0.001). Absence of TCD pulsatility was associated with intraparenchymal hemorrhage (14.7 vs. 1.6%, p = 0.03) in VA-ECMO patients. Conclusions Transcranial Doppler analysis in a single-center cohort of VA-ECMO and VV-ECMO patients demonstrates similar MFVs and PIs. Absence of PIs was associated with a higher frequency of intraparenchymal hemorrhage and a composite bleeding event. However, cautious interpretation and external validation is necessary for these findings with a multicenter study with a larger sample size. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01653-6.

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Section: Discussionsupporting

confidence: 88%

Characterization of Cerebral Hemodynamics with TCD in Patients Undergoing VA-ECMO and VV-ECMO: a Prospective Observational Study

et al. 2022

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“…Furthermore, even after ROSC, in refractory cardiac arrest supported by ECMO, the MAP generated by the heart, as indicated by the SAP-DAP differential, remains very low. 25…”

Section: Discussionmentioning

confidence: 99%

“…Serum ALB steadily decreased in the standard care group while remaining unchanged in the ALB group. A statistical difference was observed for T6 albuminemia between the standard care and ALB groups (9 [7][8][9][10][11] g/L vs. 25 [20][21][22][23][24][25][26] g/L, respectively, p < 0.001, Wilcoxon test) (Figure 2). No variation in plasma osmolality was induced by ALB perfusion compared to standard care.…”

Section: Plasma Albumin Concentrationsmentioning

confidence: 95%

“…Furthermore, even after ROSC, in refractory cardiac arrest supported by ECMO, the MAP generated by the heart, as indicated by the SAP-DAP differential, remains very low. 25 Additionally, the impact of ROSC on fluid resuscitation volumes during ECPR is still unknown. As previously observed in various studies, none of the animals in our study achieved ROSC.…”

Section: Study Limitationsmentioning

confidence: 99%

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Albumin Infusion Reduces Fluid Loading for Postresuscitation Syndrome in a Pig Model of Refractory Cardiac Arrest Resuscitated With Venoarterial Extra Corporeal Membrane Oxygenation

Lescroart,

Pequignot,

Orlowski

et al. 2023

ASAIO Journal

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Hemodynamic instability in postresuscitation syndrome worsens survival and neurological outcomes. Venoarterial extracorporeal membrane oxygenation (VA ECMO) for refractory cardiac arrest might improve outcomes. Hemodynamical support under VA ECMO relies on norepinephrine and crystalloids. The present work aims to assess the effects of albumin (ALB) infusion in a swine model of ischemic refractory cardiac arrest implanted by VA ECMO. Cardiac arrest was performed in 18 pigs and VA ECMO was initiated after 30 minutes cardiopulmonary resuscitation (CPR). Pigs were randomly assigned to standard care (norepinephrine + crystalloids) versus ALB group (ALB + standard care). Hemodynamical assessments were performed over 6 hours. Severe hypoalbuminemia was observed in the control group and could be reversed with ALB infusion. Total crystalloid load was significantly reduced with ALB infusion (1,000 [1,000–2,278] ml vs. 17,000 [10,000–19,000] ml, ALB versus control group, respectively, p < 0.001). There was no significant impact with regard to lactate clearance (29.16% [12.5–39.32] and 10.09% [6.78–29.36] for control versus ALB groups, respectively, p = 0.185), sublingual capillary microvascular parameters, or cerebral near-infrared spectrometer (NIRS) values. Compared to standard care, ALB infusion was highly effective in reducing fluid loading in a porcine model of postresuscitation syndrome after refractory cardiac arrest treated with VA ECMO.

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“…21 Arterial pulse pressure seems to hold important prognostic information in VA ECMO in cardiogenic shock and cardiac arrest. [22][23][24][25][26][27] In order to further clarify its role as a surrogate measure of cardiac contractility more research is needed in order to elucidate its intricate nature under VA ECMO. From a hemodynamic point of view, arterial pulse pressure is the result of left ventricular pulsatile flow combined to the VA ECMO flow infused into the aorta or one of its large branches.…”

Section: Assessment and Management Of Cardiac Functionmentioning

confidence: 99%

The physiology of venoarterial extracorporeal membrane oxygenation - A comprehensive clinical perspective

Fresiello,

Hermens,

Pladet

et al. 2024

Perfusion

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Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a standard of care for severe cardiogenic shock, refractory cardiac arrest and related impending multiorgan failure. The widespread clinical use of this complex temporary circulatory support modality is still contrasted by a lack of formal scientific evidence in the current literature. This might at least in part be attributable to VA ECMO related complications, which may significantly impact on clinical outcome. In order to limit adverse effects of VA ECMO as much as possible an indepth understanding of the complex physiology during extracorporeally supported cardiogenic shock states is critically important. This review covers all relevant physiological aspects of VA ECMO interacting with the human body in detail. This, to provide a solid basis for health care professionals involved in the daily management of patients supported with VA ECMO and suffering from cardiogenic shock or cardiac arrest and impending multiorgan failure for the best possible care.

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Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury

Cited by 20 publications

References 35 publications

Characterization of Cerebral Hemodynamics with TCD in Patients Undergoing VA-ECMO and VV-ECMO: a Prospective Observational Study

Characterization of Cerebral Hemodynamics with TCD in Patients Undergoing VA-ECMO and VV-ECMO: a Prospective Observational Study

Albumin Infusion Reduces Fluid Loading for Postresuscitation Syndrome in a Pig Model of Refractory Cardiac Arrest Resuscitated With Venoarterial Extra Corporeal Membrane Oxygenation

The physiology of venoarterial extracorporeal membrane oxygenation - A comprehensive clinical perspective

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