Patient selection for VV ECMO: have we found the crystal ball?

Ahuja, Abhilasha; Shekar, Kiran

doi:10.21037/jtd.2018.05.83

Cited by 8 publications

(14 citation statements)

References 9 publications

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“…6,9,10,13,[23][24][25][26][27] However, it should be highlighted that outcomes after VV-ECMO in ARDS are not dictated by the PaO 2 /FIO 2 ratio, but by multiple other factors related to the mechanical ventilation profile and extrapulmonary organ dysfunction. 33,37,38 Blood markers which have been associated with mortality include platelet count, hemoglobin or hematocrit, fibrinogen, bilirubin, and pH. 31,39 When VILI and hypercapnia rather than hypoxemia are the driving criteria for ECLS, the physiological rationale for implementation still relies on offloading the respiratory system by decreasing the intensity of mechanical ventilation.…”

Section: Gas Exchangementioning

confidence: 99%

How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation

Bullen

Teijeiro-Paradis

Fan

2020

Chest

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ARDS is a lethal form of acute respiratory failure, and because no specific treatments exist, supportive care remains the primary management strategy in these patients. Extracorporeal membrane oxygenation (ECMO) has emerged as an intervention in patients with severe ARDS to facilitate gas exchange and the delivery of more lung protective ventilation. Over the past 20 years, improvements in ECMO technology have increased its safety and transportability, making it far more available to this patient population globally. Deciding which patients with ARDS should be initiated on ECMO remains a challenging question. Numerous clinical and laboratory markers have been investigated, and multiple risk scores developed, to aid physicians in this decision-making process. However, they are still imperfect, and the choice is often based on institutional guidelines and the clinical impression of the treating physician. Given the potential risks and resource implications for this intervention, patient selection is critical and it is important to provide ECMO only to patients who have a reasonable chance for recovery or bridge to transplantation. In patients undergoing ECMO where there is no potential for recovery or transplant, the only option may be withdrawal of ECMO and palliation. These patients may be awake and interactive, which is often a very challenging scenario for patients, families, and the clinical team. In this article, we present a more controversial case and a review of the literature regarding the selection of patients with ARDS who should receive ECMO.

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Section: Gas Exchangementioning

confidence: 99%

How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation

Bullen

Teijeiro-Paradis

Fan

2020

Chest

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“…On the other hand, the substantial growth of patients treated with ECMO raises ethical issues regarding patient selection and when ECMO support should be halted. [51]. There is an increasing amount of studies demonstrating that careful patient selection is important to obtain the best results [51,52].…”

Section: Discussionmentioning

confidence: 99%

“…[51]. There is an increasing amount of studies demonstrating that careful patient selection is important to obtain the best results [51,52]. Moreover, resource utilisation should be justi ed to minimise the economic burden on the health system [52].…”

Section: Discussionmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation in Patients with Burns, Hero or Futile Medical Care? A Systematic Review and Meta-Analysis

Chiu¹,

Huang²,

Chen³

et al. 2020

Preprint

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Background Severely burned patients, particularly when compounded with inhalation injuries, are at high risk for cardiopulmonary failure. Recently, promising studies have stimulated interest in using extracorporeal membrane oxygenation (ECMO) as a potential therapy for burn patients with refractory cardiac and/or respiratory failure. Several observational studies have been reported, but the findings in these vary. Methods In this study, we conducted a systematic review and meta-analysis using standardized mortality ratios (SMRs) to elucidate the benefits associated with the use of ECMO in patients with burn and/or inhalation injuries. A literature search using PubMed, EMBASE, MEDLINE, and the Cochrane Library were performed from inception to October 20, 2020. Clinical outcomes in the selected studies were compared. Results 22 studies were included in the final review and analysis. 13 studies with a total of 75 patients were included in SMR quantitative analysis. The overall pooled mortality rate of burn patients receiving ECMO was 48%. The meta-analysis found that the observed mortality was significantly higher than the predicted mortality in patients receiving ECMO, with a pooled SMR of 2.07 (95% CI: 1.04–4.14). However, in the subgroup of burn patients with inhalation injuries, all patients receiving V-V ECMO had lower mortality rates compared to their predicted mortality rates, with a pooled SMR of 0.95 (95% CI: 0.52–1.73). Other subgroup analyses, including an adult group, pediatric group, V-V setting group, and a V-A setting group reported no benefits from ECMO; however, these results were not statistically significant. Interestingly, the pooled SMR values decreased as the selected patients’ revised Baux scores increased (R=-0.92), indicating that the potential benefits from the ECMO treatment increased as the severity of patients with burns increased, especially when the patients’ revised Baux scores exceeded 90. Conclusions Our meta-analysis revealed that burn patients receiving ECMO treatment were at a higher risk of death. However, select patients, including those with inhalation injuries and those with the revised Baux scores over 90, would benefit from ECMO treatment. We suggest that burn patients with inhalation injuries or with revised Baux scores exceeding 90 should be considered for ECMO treatment and early transfer to an ECMO centre.

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“…The most commonly used strategy to expand capacity of ECMO treatment and improve outcomes over the past decade has been risk stratification and mortality prediction models [1,[13][14][15]. Because ECMO is not only invasive but also very resource-intensive, it is often reserved for the sickest patients and only considered when other, less extreme treatment options have been exhausted [1,11].…”

mentioning

confidence: 99%

“…Determining which patients would most benefit from ECMO support and which require less invasive strategies can be difficult. Several risk stratification models exist to aid clinicians in making this determination [15]. The PREdiction of Survival on ECMO Therapy-Score, Predicting death for severe ARDS on VV-ECMO score, and the ECMOnet score have all shown moderate predictive value in determining which patients will benefit most from ECMO therapy [13][14][15].…”

mentioning

confidence: 99%

Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: How Do We Expand Capacity in the COVID-19 Era?

Peeler

Gleason

Cho

et al. 2021

Heart, Lung and Circulation

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Patient selection for VV ECMO: have we found the crystal ball?

Cited by 8 publications

References 9 publications

How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation

How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation

Extracorporeal Membrane Oxygenation in Patients with Burns, Hero or Futile Medical Care? A Systematic Review and Meta-Analysis

Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: How Do We Expand Capacity in the COVID-19 Era?

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