Modifiable Risk Factors and Mortality From Ischemic and Hemorrhagic Strokes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Organization Registry

Cho, Sung Min; Canner, Joe; Chiarini, Giovanni; Calligy, Kate; Caturegli, Giorgio; Rycus, Peter; Barbaro, Ryan P.; Tonna, Joseph E.; Lorusso, Roberto; Kilic, Ahmet; Choi, Chun Woo; Ziai, Wendy; Geocadin, Romergryko G.; Whitman, Glenn

doi:10.1097/ccm.0000000000004498

Cited by 75 publications

(54 citation statements)

References 40 publications

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“…A second prospective single-center analysis identified that hyperoxia (PO 2 > 300 mmHg) during the first hour after resuscitation was associated with a worse neurologic outcome at discharge [75]. A recent analysis of 10,342 VA-ECMO patients from the ELSO showed that all subtypes of ABI were more common in patients with hyperoxia, as measured by 24-hour ABG [76]. However, data on this for ECPR patients are limited.…”

Section: Clinical Research On "Hyperoxia" In Ecprmentioning

confidence: 99%

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Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

2021

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The addition of extracorporeal membrane oxygenation (ECMO) to conventional cardiopulmonary resuscitation (CPR), termed extracorporeal cardiopulmonary resuscitation (ECPR), has significantly improved survival in selected patient populations. Despite this advancement, significant neurological impairment persists in approximately half of survivors. ECPR represents a potential advancement for patients who experience refractory cardiac arrest (CA) due to a reversible etiology and do not regain spontaneous circulation. Important risk factors for acute brain injury (ABI) in ECPR include lack of perfusion, reperfusion, and altered cerebral autoregulation. The initial hypoxic-ischemic injury caused by no-flow and low-flow states after CA and during CPR is compounded by reperfusion, hyperoxia during ECMO support, and nonpulsatile blood flow. Additionally, ECPR patients are at risk for Harlequin syndrome with peripheral cannulation, which can lead to preferential perfusion of cerebral vessels with deoxygenated blood. Lastly, the oxygenator membrane is prothrombotic and requires systemic anticoagulation. The two competing phenomena result in thrombus formation, hemolysis, and thrombocytopenia, increasing the risk of ischemic and hemorrhagic ABI. In addition to clinical studies, we assessed available ECPR animal models to identify the mechanisms underlying ABI at the cellular level. Standardized multimodal neurological monitoring may facilitate early detection of and intervention for ABI. With the increasing use of ECPR, it is critical to understand the pathophysiology of ABI, its prevention, and the management strategies for improving the outcomes of ECPR. Translational and clinical research focusing on acute ABI immediately after ECMO cannulation and its short-and long-term neurological outcomes are warranted.

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Section: Clinical Research On "Hyperoxia" In Ecprmentioning

confidence: 99%

“…In addition to HIBIs, acute ischemic stroke (AIS) and intracranial hemorrhage (ICH) are major complications that increase mortality in patients supported with ECMO [76,84,85]. In patients treated with VA-ECMO, the prevalence of AIS is 3.3% and may be as high as 16% on autopsy [86,87].…”

Section: Ischemic Stroke and Intracranial Hemorrhage In Va-ecmomentioning

confidence: 99%

Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

2021

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“…However, neurologic injuries can occur while on ECMO and can be devastating. The reported incidence of such injuries ranges widely from 1 to 78% with a median of 13% [7][8][9][10]. As utilization of ECMO becomes more mainstream, the overall prevalence of associated neurologic injuries is also expected to increase.…”

Section: Introduction To Extracorporeal Membrane Oxygenationmentioning

confidence: 99%

Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review

Illum¹,

Odish²,

Minokadeh³

et al. 2021

Curr Treat Options Neurol

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Purpose Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists. Recent findingsThe most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death. These result from events prior to initiation of ECMO, failure of ECMO to provide adequate oxygen delivery, and/or complications that occur during ECMO. ECMO survivors also experience neurological and psychological sequelae similar to other survivors of critical illness. Summary Since many of the risk factors for neurologic injury cannot be easily mitigated, early diagnosis and intervention are crucial to limit morbidity and mortality from neurologic injury during ECMO.

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“…[1][2][3] Patients undergoing extracorporeal membrane oxygenation (ECMO) constitute a special population with a high risk of acute brain injury (ABI), up to 15.1% in patients undergoing veno-arterial (VA) ECMO, and 7.1% in patients undergoing veno-venous ECMO. 4 While evidence for improving neurological outcome with therapeutic hypothermia 32-36°C is well delineated in cardiac arrest, 1,[5][6][7][8][9] the effect of hypothermia in VA-ECMO is unknown. VA-ECMO patients are susceptible to reperfusion injury given their prolonged hypoperfusion preceding full restoration of cerebral blood flow, which may benefit from hypothermia.…”

Section: Introductionmentioning

confidence: 99%

Mild Hypothermia and Neurologic Outcomes in Patients undergoing Venoarterial Extracorporeal Membrane Oxygenation

Cho

Al‐Kawaz

Shou

et al. 2021

Preprint

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Background: Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 hours post-ECMO on neurological outcome in VA-ECMO patients. Methods: This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 hours post-ECMO. Primary outcome was good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates. Results: Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 hours of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 hours while 18 of those 88 patients (14.2%) had a mean temperature<36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (Odds Ratio [OR]=1.16, 95% Confidence Interval [CI]=1.04-1.31, p=0.01) after adjusting for age, severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-hour PaO . Neither duration of mild hypothermia (OR=0.93, CI=0.84-1.03, p=0.17) nor mean temperature (OR=0.78, CI=0.29-2.08, p=0.62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p=0.47) and mean 24-hour temperature (p=0.76) were not significantly associated with frequency of systemic hemorrhages. Conclusions: In this single center study, longer duration of mild hypothermia during the first 24 hours of ECMO support was significantly associated with improved neurological outcome. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.

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Modifiable Risk Factors and Mortality From Ischemic and Hemorrhagic Strokes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Organization Registry

Cited by 75 publications

References 40 publications

Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

Brain injury in extracorporeal cardiopulmonary resuscitation: translational to clinical research

Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review

Mild Hypothermia and Neurologic Outcomes in Patients undergoing Venoarterial Extracorporeal Membrane Oxygenation

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