Obesity as a Risk Factor for Failure to Wean from ECMO: A Systematic Review and Meta-Analysis

Zaidi, Syed Arsalan; Saleem, Kainat

doi:10.1155/2021/9967357

Cited by 19 publications

(14 citation statements)

References 37 publications

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“…However, this did include patients on VA support. 26 Additionally, a more recent 2022 ELSO study of more than 18,000 respiratory failure patients on ECMO (performed after our review was complete) shows that patients with BMIs of greater than or equal to 35 had decreased inpatient mortality and reduced hospital length of stays. 27 Based on our review, there does appear to be at least a trend toward reduced mortality among obese VV ECMO adults, but there is not a clear explanation.…”

Section: Mortalitymentioning

confidence: 84%

Outcomes in Obese Adult Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review

Reid,

Crespo Regalado,

Carlson

et al. 2023

ASAIO Journal

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Obesity is associated with an overall increased risk of morbidity and mortality. However, in patients with critical illness, sepsis, and acute respiratory distress syndrome, obesity may be protective, termed “the obesity paradox.” This is a systematic literature review of articles published from 2000 to 2022 evaluating complications and mortality in adults with respiratory failure on veno-venous extracorporeal membrane oxygenation (VV ECMO) based on body mass index (BMI). Eighteen studies with 517 patients were included. Common complications included acute renal failure (175/377, 46.4%), venous thrombosis (175/293, 59.7%), and bleeding (28/293, 9.6%). Of the six cohort studies, two showed improved mortality among obese patients, two showed a trend toward improved mortality, and two showed no difference. Comparing all patients in the studies with BMI of less than 30 to those with BMI of greater than or equal to 30, we noted decreased mortality with obesity (92, 37.1% of BMI <30 vs. 30, 11% of BMI ≥30, p ≤ 0.0001). Obesity may be protective against mortality in adult patients undergoing VV ECMO. Morbid and super morbid obesity should not be considered a contraindication to cannulation, with patients with BMI ≥ 80 surviving to discharge. Complications may be high, however, with higher rates of continuous renal replacement therapy and thrombosis among obese patients.

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Section: Mortalitymentioning

confidence: 84%

Outcomes in Obese Adult Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review

Reid,

Crespo Regalado,

Carlson

et al. 2023

ASAIO Journal

View full text Add to dashboard Cite

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“…Small case series found no survival difference with BMI dichotomized at 30 kg/m 2 [ 19 ], 35 kg/m 2 [ 20 ], or 40 kg/m 2 [ 11 ], as a continuous variable [ 8 , 9 , 35 ] or stratified by subcategories [ 9 , 10 , 12 ], although a trend toward improved survival was suggested for the highest BMI values [ 11 , 12 ]. A systematic review and meta-analysis of mixed cardiac and respiratory ECMO patients found no association of BMI ≥ 30 kg/m 2 with mortality [ 36 ]. Others observed lower mortality for patients with BMI ≥ 25 kg/m 2 [ 13 ] or BMI ≥ 40 kg/m 2 [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Impact of BMI on outcomes in respiratory ECMO: an ELSO registry study

et al. 2022

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Purpose The impact of body mass index (BMI) on outcomes in respiratory failure necessitating extracorporeal membrane oxygenation (ECMO) has been poorly described. We aimed to assess: (i) whether adults with class II obesity or more (BMI ≥ 35 kg/m 2 ) have worse outcomes than lean counterparts, (ii) the form of the relationship between BMI and outcomes, (iii) whether a cutoff marking futility can be identified. Methods A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry from 1/1/2010 to 31/12/2020 was conducted. Impact of BMI ≥ 35 kg/m 2 was assessed with propensity-score (PS) matching, inverse propensity-score weighted (IPSW) and multivariable models (MV), adjusting for a priori identified confounders. Primary outcome was in-hospital mortality. The form of the relationship between BMI and outcomes was studied with generalized additive models. Outcomes across World Health Organisation (WHO)-defined BMI categories were compared. Results Among 18,529 patients, BMI ≥ 35 kg/m 2 was consistently associated with reduced in-hospital mortality [PS-matched: OR: 0.878(95%CI 0.798–0.966), p = 0.008; IPSW: OR: 0.899(95%CI 0.827–0.979), p = 0.014; MV: OR: 0.900(95%CI 0.834–0.971), p = 0.007] and shorter hospital length of stays. In patients with BMI ≥ 35 kg/m 2 , cardiovascular (17.3% versus 15.3%), renal (37% versus 30%) and device-related complications (25.7% versus 20.6%) increased, whereas pulmonary complications decreased (7.6% versus 9.3%). These findings were independent of confounders throughout PS-matched, IPSW and MV models. The relationship between BMI and outcomes was non-linear and no cutoff for futility was identified. Conclusion Patients with obesity class II or more treated with ECMO for respiratory failure have lower mortality risk and shorter stays, despite increased cardiovascular, device-related, and renal complications. No upper limit of BMI indicating futility of ECMO treatment could be identified. BMI as single parameter should not be a contra-indication for respiratory ECMO. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06926-4.

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“…In this cohort of COVID-19 and non-COVID-19 VV ECMO patients at a high-volume ECMO referral center, BMI ≥ 40 was not associated with worse in-hospital mortality. Prior to the pandemic, regardless of VV ECMO indication, obesity was not considered a contraindication to VV ECMO, 12 , 21 and even patients with a BMI greater than 50 demonstrated similar outcomes compared to non-obese VV ECMO patients. 14 Whereas obesity can pose challenges for the ECMO management team, including cannulation, prone positioning, and ventilator management, these challenges have not translated to poor outcomes.…”

Section: Discussionmentioning

confidence: 99%

Body mass index does not impact survival in COVID-19 patients requiring veno-venous extracorporeal membrane oxygenation

et al. 2022

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Introduction With the increased demand for veno-venous extracorporeal membrane oxygenation (VV ECMO) during the COVID-19 pandemic, guidelines for patient candidacy have often limited this modality for patients with a body mass index (BMI) less than 40 kg/m2. We hypothesize that COVID-19 VV ECMO patients with at least class III obesity (BMI ≥ 40) have decreased in-hospital mortality when compared to non-COVID-19 and non-class III obese COVID-19 VV ECMO populations. Methods This is a single-center retrospective study of COVID-19 VV ECMO patients from January 1, 2014, to November 30, 2021. Our institution used BMI ≥ 40 as part of a multi-disciplinary VV ECMO candidate screening process in COVID-19 patients. BMI criteria were not considered for exclusion criteria in non-COVID-19 patients. Univariate and multivariable analyses were performed to assess in-hospital mortality differences. Results A total of 380 patients were included in our analysis: The COVID-19 group had a lower survival rate that was not statistically significant (65.7% vs.74.9%, p = .07). The median BMI between BMI ≥ 40 COVID-19 and non-COVID-19 patients was not different (44.5 vs 45.5, p = .2). There was no difference in survival between the groups (73.3% vs. 78.5%, p = .58), nor was there a difference in survival between the COVID-19 BMI ≥ 40 and BMI < 40 patients (73.3, 62.7, p= .29). Multivariable logistic regression with the outcome of in-hospital mortality was performed and BMI was not found to be significant (OR 0.99, 95% CI 0.89, 1.01; p = .92). Conclusion BMI ≥ 40 was not an independent risk factor for decreased in-hospital survival in this cohort of VV ECMO patients at a high-volume center. BMI should not be the sole factor when deciding VV ECMO candidacy in patients with COVID-19.

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Obesity as a Risk Factor for Failure to Wean from ECMO: A Systematic Review and Meta-Analysis

Cited by 19 publications

References 37 publications

Outcomes in Obese Adult Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review

Outcomes in Obese Adult Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review

Impact of BMI on outcomes in respiratory ECMO: an ELSO registry study

Body mass index does not impact survival in COVID-19 patients requiring veno-venous extracorporeal membrane oxygenation

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