Extracorporeal Life Support for 100 Adult Patients With Severe Respiratory Failure

Abstract

ObjectiveThe authors retrospectively reviewed their experience with extracorporeal life support (ECLS) in 100 adult patients with severe respiratory failure (ARF) to define techniques, characterize its efficacy and utilization, and determine predictors of outcome. Summary Background DataExtracorporeal life support maintains gas exchange during ARF, providing diseased lungs an optimal environment in which to heal. Extracorporeal life support has been successful in the treatment of respiratory failure in infants and children. In 1990, the authors instituted a standardized protocol for treatment of severe ARF in adults, which included ECLS when less invasive methods failed. MethodsFrom January 1990 to July 1996, the authors used ECLS for 100 adults with severe acute hypoxemic respiratory failure (n = 94): paO2/FiO2 ratio of 55.7 ± 15.9, transpulmonary shunt (Qs/Qt) of 52 ± 22%, or acute hypercarbic respiratory failure (n = 6): PaCO2 84.0 ± 31.5 mmHg, despite and after maximal conventional ventilation. The technique included venovenous percutaneous access, lung "rest," transport on ECLS, minimal anticoagulation, hemofiltration, and optimal systemic oxygen delivery. ResultsOverall hospital survival was 54%. The duration of ECLS was 271.9 ± 248.6 hours. Primary diagnoses included pneumonia (49 cases, 53% survived), adult respiratory distress syndrome (45 cases, 51 % survived), and airway support (6 cases, 83% survived). Multivariate logistic regression modeling identified the following pre-ECLS variables significant independent predictors of outcome: 1) pre-ECLS days of mechanical ventilation (p = 0.0003), 2) pre-ECLS PaO2/FiO2 ratio (p = 0.002), and 3) age (years) (p = 0.005).Modeling of variables during ECLS showed that no mechanical complications were independent predictors of outcome, and the only patient-related complications associated with outcome were the presence of renal failure (p < 0.0001) and significant surgical site bleeding (p = 0.0005). ConclusionsExtracorporeal life support provides life support for ARF in adults, allowing time for injured lungs to recover. In 100 patients selected for high mortality risk despite and after optimal 544 ECLS for Severe Respiratory Failure in Adults 545 conventional treatment, 54% survived. Extracorporeal life support is extraordinary but reasonable treatment in severe adult respiratory failure. Predictors of survival exist that may be useful for patient prognostication and design of future prospective studies.Extracorporeal circulation with a mechanical pump oxygenator provides temporary life support allowing cardiac operations. Modifications in the techniques and devices allow prolonged extracorporeal circulation in the intensive care unit (ICU), commonly referred to as extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS). For the past decade, ECLS has been standard treatment for newborn infants with severe respiratory failure (ARF) unresponsive to other methods of treatment. Extracorporeal life support has been used for >10,000 newborn inf...

Extracorporeal Membrane Oxygenation with Double Venous Drainage

“…Knight et al reported a lower mean percutaneous oxygen saturation in the venovenous ECMO but a higher intravascular thrombosis in the venoarterial ECMO system, while others reported frequent bleeding complication in venoarterial ECMO. 1,2) A study by Stohr, et al suggested a lower mortality rate in patients treated with venovenoarterial ECMO than in patients treated with venovenous or venoarterial ECMO. 3) Furthermore, Lazar, et al reported successful usage of bicaval dual-lumen catheter in neonates while Bonacchi, et al reported an "X-configuration" system for veno-venous bypass by the use of a self-modified inflow cannula.…”

Adición de un cortocircuito arterio-venoso durante el soporte vital extracorpóreo veno-arterial de un paciente con síndrome cardiopulmonar por Hantavirus: Caso clínico

“…Existen algunos criterios para decidir la conexión a ECLS (cortocircuito intrapulmonar >30% con FiO 2 >0,6, distensibilidad <0,5 ml/cmH 2 O/kg, hipercarbia incorregible con pH <7,0 y presión inspiratoria pico >40 cmH 2 O), sin embargo, el juicio clínico y el análisis caso a caso pueden influir en la decisión. En adultos, esta técnica no ha tenido la eficacia que ha mostrado en el escenario neonatal, sin embargo, siempre debe ser considerada como una herramienta más en pacientes cuya mortalidad estimada es mayor a 70% y poseen una probabilidad razonable de recuperación pulmonar 1,13,14 . El ECLS ofrece dos formas básicas de soporte: veno-venoso (ECLS/V-V) cuando el circuito se origina y termina en el compartimiento venoso y veno-arterial (ECLS/V-A) cuando se inicia en el lecho venoso y termina en el arterial 1,2,7 .…”

“…Los mejores resultados obtenidos con el uso de ECLS en los últimos años, se relacionan con el perfeccionamiento de la técnica y modificación de los criterios de selección de los pacientes 14 . Entre ellos destaca la implementación precoz del ECLS, es decir, antes que se instale el daño pulmonar inducido por ventilación mecánica 19 .…”

Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

“…This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5 There has been renewed interest in adult ECMO due to encouraging results from case series, 6,7 improved ECMO technology, 2 general advances in critical care, 3,8 and, most recently, the use of ECMO in H1N1 patients. 9,10 In fact, CESAR was published electronically in the same month period as a retrospective case review of ECMO in adult respiratory failure 11 and a meta-analysis of ECMO following adult cardiac arrest.…”