Emergency Abdominal Surgery Outcomes of Critically Ill Patients on Extracorporeal Membrane Oxygenation: A Case‐Matched Study with a Propensity Score Analysis

Abstract

Brief title: Emergency abdominal surgery outcomes and ExtraCorporeal Membrane Oxygenation ABSTRACT Background: Extracorporeal membrane oxygenation (ECMO) induces coagulation disorders increasing the risk of bleeding during invasive procedures. We aimed to describe the outcomes of critically ill ECMO patients undergoing emergency abdominal surgery compared to nonECMO patients. Study Design: Retrospective case-matched single-center study with propensity score analysis in a tertiary ICU. All patients who underwent abdominal surgery were included. Results: From 2006 to 2014, 77 patients admitted in our ICU underwent emergency abdominal surgery, 35 were on ECMO. Surgery indications were comparable for ECMO and nonECMO patients: mostly intestinal ischemia (42%) and cholecystectomy (25%). Postoperative bleeding was significantly more frequent in ECMO group vs. nonECMO: 77% vs 40% transfused, with medians of 13 (6-22) vs. 3 (0-5) packed red blood cell; 9 (3-17) vs 0 (0-4) fresh-frozen plasma and 12 (3-22) vs 0 (0-8) platelet units (p<0.001 for all items). Reintervention for haemorrhagewas required in 20% vs 2% respectively, p = 0.02. At multivariable analysis, ECMO was strongly associated with bleeding (OR, 5.6 [95% CI, 2.0-15.4]; p = 0.001). ICU mortality was higher for ECMO-treated patients (69% vs. 33%; p = 0.003) but perioperative mortality remained comparable between groups (11% vs. 12%, NS). More frequent and severe bleeding was confirmed for highly comparable ECMO and nonECMO patients (21 each), propensity score-matched to be ECMO-implanted. Conclusions:Abdominal surgery procedures on ECMO-treated patients are associated with a higher risk of haemorrhage compared to nonECMO ICU patients. Further studies are needed to optimize ECMO-patient management during such interventions.

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“…There are case reports describing acute bowel ischemia during ECMO therapy. Presumably, non-occlusive or occlusive mesenteric ischemia is the cause of the bowel ischemia in these patients with ECMO therapy [39][40][41].…”

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“…Termination of pregnancy would have required a c‐section under ECMO therapy. Since abdominal surgery procedures under ECMO in critically ill patients are associated with a higher risk of hemorrhage, this approach was not recommended 19 . Continuation of pregnancy under ECMO support was excluded due to the severity of radiological pulmonary changes and the duration of ECMO therapy without improvement.…”

“…Since abdominal surgery procedures under ECMO in critically ill patients are associated with a higher risk of hemorrhage, this approach was not recommended. 19 Continuation of pregnancy under ECMO support was excluded due to the severity of radiological pulmonary changes and the duration of ECMO therapy without improvement. Long‐term ECMO support (≥2 weeks) in patients with severe acute respiratory failure is associated with significantly lower rates of complete pulmonary recovery.…”