Safety and Feasibility of a Protocolized Daily Assessment of Readiness for Liberation From Venovenous Extracorporeal Membrane Oxygenation

Gannon, Whitney D.; Stokes, John W.; Bloom, Sarah; Sherrill, Wren H; Bacchetta, Matthew; Rice, Todd W.; Semler, Matthew W.; Casey, Jonathan D

doi:10.1016/j.chest.2021.05.066

Cited by 25 publications

(23 citation statements)

References 18 publications

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“…Signs of native lung recovery can be difficult to interpret when using imaging and measures of pulmonary compliance alone and may not accurately predict the likelihood of a patient's ability to be liberated from ECLS. Regular trials‐off V‐V ECLS in patients meeting certain safety criteria have been shown to be safe and feasible and may highlight patients that can be liberated sooner from ECLS than using clinical judgment alone 14 . However, it remains a risk that a V‐V ECLS trial‐off, which often involves temporarily reducing or stopping fresh gas flow may temporarily worsen the patient's condition.…”

Section: Discussionmentioning

confidence: 99%

Prediction of successful veno‐venous extracorporeal life support liberation using the oxygen challenge test

et al. 2022

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Background The oxygen challenge test (OCT) is an underutilized measure of lung recovery, easily performed prior to proceeding with a trial‐off V‐V ECLS as part of a weaning algorithm. Evidence‐based thresholds for OCT results which support continuing with V‐V ECLS weaning are lacking, making interpretation of these tests challenging in clinical practice. Methods We performed a retrospective review of patients commenced on V‐V ECLS as a bridge‐to‐recovery at Vancouver General Hospital from 2015–2019. The absolute PaO2 post‐OCT and change in PaO2 proportional to incremental FiO2 change on the ventilator (∆PaO2) were evaluated as predictive screening metrics for identifying conditions favorable for successful trial‐off of V‐V ECLS. Results An optimal cut‐off of PaO2 ≥ 240 mm Hg post‐OCT (AUC 0.77) and ∆PaO2 ≥ 250 mm Hg (AUC 0.76) was identified as a threshold for predicting successful trials‐off. A total of 26 and 24 patients achieved post‐OCT PaO2 and ∆PaO2 thresholds, and 100% of these patients were liberated successfully from ECLS during their admission. Conclusions The OCT can serve as an effective screen of shunt reduction and native lung recovery which can be used alongside other measures of ventilation to assess for suitability of liberation from V‐V ECLS prior to a trial‐off. Achieving a PaO2 ≥ 240 mm Hg post‐OCT is a strong prognostic indicator for successful liberation from V‐V ECLS during ICU admission.

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Section: Discussionmentioning

confidence: 99%

Prediction of successful veno‐venous extracorporeal life support liberation using the oxygen challenge test

et al. 2022

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“…1) Rate of ECMO weaning will be calculated according to date of ECMO weaning fulfilled. 2) Total length of ready for ECMO weaning refers to exact length in day till patients fulfill all the criteria of ready for ECMO weaning according to daily checkout records (14).…”

Section: Secondary Outcomesmentioning

confidence: 99%

“…Indeed, the successful weaning of ECMO is complex and multifactorial (13). ECMO weaning at the earliest possible time would be expected to improve outcomes, reduce cost, and optimize functional prognosis (14). This inspires us to hypothesize that if the medical rationale is based on its assumed benefits on cardiac function and oxygenation, then cardiopulmonary rehabilitation may subsequently contribute to earlier weaning of ECMO.…”

Section: Introductionmentioning

confidence: 99%

Can Cardiopulmonary Rehabilitation Facilitate Weaning of Extracorporeal Membrane Oxygenation (CaRe-ECMO)? Study Protocol for a Prospective Multidisciplinary Randomized Controlled Trial

Zheng

Sun

Mei

et al. 2022

Front. Cardiovasc. Med.

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Background: Mortality of patients suffering from critical illness has been dramatically improved with advanced technological development of extracorporeal membrane oxygenation (ECMO) therapy. However, the majority of ECMO-supported patients failed to wean from ECMO therapy. As one of several options, cardiopulmonary rehabilitation serves as effective intervention in the improvement of cardiovascular and respiratory function in various major critical illness. Nonetheless, its role in facilitating ECMO weaning has not yet been explored. The purpose of this study is to investigate the effectiveness of cardiopulmonary rehabilitation on rate of ready for ECMO weaning in ECMO-supported patients (CaRe-ECMO).Methods: The CaRe-ECMO trial is a randomized controlled, parallel group, clinical trial. This trial will be performed in a minimum number of 366 ECMO-supported eligible patients. Patients will be randomly assigned to either: (1) the CaRe-ECMO group, which will be treated with usual care including pharmacotherapy, non-pharmacotherapy, and specific nursing for ECMO therapy and the CaRe-ECMO program; or (2) the control group, which will receive usual care only. The CaRe-ECMO program consists of protocolized positioning, passive range of motion (PROM) training, neuromuscular electrical stimulation (NMES), surface electrical phrenic nerve stimulation (SEPNS), and pulmonary rehabilitation. The primary outcome of the CaRe-ECMO trial is the rate of ready for ECMO weaning at CaRe-ECMO day 7 (refers to 7 days after the CaRe-ECMO program initiation). Secondary outcomes include rate of ECMO and mechanical ventilation weaning, total length in day of ready for ECMO weaning, ECMO weaning and mechanical ventilation, all-cause mortality, rate of major post-ECMO complications, ECMO unit length of stay (LOS) and hospital LOS, total cost for hospitalization, cerebral performance category (CPC), activities of daily living (ADL), and health-related quality of life (HRQoL).Discussion: The CaRe-ECMO is designed to answer the question “whether cardiopulmonary rehabilitation can facilitate weaning of ECMO (CaRe-ECMO).” Should the implementation of the CaRe-ECMO program result in superior primary and secondary outcomes as compared to the controls, specifically the add-on effects of cardiopulmonary rehabilitation to the routine ECMO practice for facilitating successful weaning, the CaRe-ECMO trial will offer an innovative treatment option for ECMO-supported patients and meaningfully impact on the standard care in ECMO therapy.Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT05035797.

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“…Recently, Al-Fares et al (9) showed that patients with higher TVs, heart rate, ventilatory ratio, and esophageal pressure swings during sweep gas off trials were less likely to achieve safe liberation from VV ECMO defined a priori as avoidance of ECMO recannulation, and increase MV support, need for rescue therapy, or hemodynamic instability within 48 hours after decannulation. Gannon et al conducted a prospective feasibility study in 26 patients highlighting the effectiveness of the use of protocolized daily assessment of readiness of liberation in VV ECMO (10). Both studies focused on liberation from ECMO as the primary outcome and not ICU LOS or liberation from MV (9, 10).…”

Section: Observational Studymentioning

confidence: 99%

Association of Respiratory Parameters at Venovenous Extracorporeal Membrane Oxygenation Liberation With Duration of Mechanical Ventilation and ICU Length of Stay: A Prospective Cohort Study

Thiara

Neto²,

Burrell

et al. 2022

Critical Care Explorations

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OBJECTIVES: Although the criteria for initiation of venovenous extracorporeal membrane oxygenation (VV ECMO) are well defined, the criteria and timing for VV ECMO decannulation are less certain. The aim of this study was to describe the ventilation and physiologic factors at the time of VV ECMO decannulation and to determine if these factors have association with mechanical ventilation or ICU length of stay after ECMO decannulation. DESIGN: Multicenter, prospective cohort study. SETTING: Eleven ICUs in Australia. PATIENTS: Adult patients treated with VV ECMO from March 19, 2019, to September 20, 2020. INTERVENTIONS: Liberation from VV ECMO. RESULTS: Of 87 patients receiving VV ECMO, the median age was 49 years (interquartile range, 37–59 yr), 61 of 87 (70%) were male, and 52/87 (60%) had a diagnosis of acute respiratory distress syndrome. There were 24 of 87 patients (28%) who died prior to day 90. No patient required a second run of VV ECMO. In a multivariate models, a higher partial pressure of arterial carbon dioxide (p < 0.01) and respiratory rate at the time of decannulation (p = 0.01) were predictive of a longer duration of mechanical ventilation and ICU length of stay postdecannulation in survivors. Higher positive end-expiratory pressure at ECMO decannulation was associated with shorter duration of ICU length of stay post-ECMO decannulation in survivors (p = 0.01). CONCLUSIONS: A higher partial pressure of arterial carbon dioxide and higher respiratory rate at ECMO decannulation were associated with increased duration of mechanical ventilation and increased duration of ICU stay postdecannulation, and increased positive end-expiratory pressure at decannulation was associated with decreased duration of ICU stay postdecannulation. Future research should further investigate these associations to establish the optimal ventilator settings and timing of liberation from VV ECMO.

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Safety and Feasibility of a Protocolized Daily Assessment of Readiness for Liberation From Venovenous Extracorporeal Membrane Oxygenation

Cited by 25 publications

References 18 publications

Prediction of successful veno‐venous extracorporeal life support liberation using the oxygen challenge test

Prediction of successful veno‐venous extracorporeal life support liberation using the oxygen challenge test

Can Cardiopulmonary Rehabilitation Facilitate Weaning of Extracorporeal Membrane Oxygenation (CaRe-ECMO)? Study Protocol for a Prospective Multidisciplinary Randomized Controlled Trial

Association of Respiratory Parameters at Venovenous Extracorporeal Membrane Oxygenation Liberation With Duration of Mechanical Ventilation and ICU Length of Stay: A Prospective Cohort Study

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