Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

Ortuno, Sofia; Delmas, Clément; Diehl, Jean‐Luc; Bailleul, Clotilde; Lancelot, Aymeric; Naili, Mahassen; Cholley, Bernard; Pirracchio, Romain; Aïssaoui, Nadia

doi:10.21037/acs.2018.08.05

Cited by 99 publications

(91 citation statements)

References 35 publications

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“…It is important to distinguish between weaning and survival [20]. The proportion of patients with refractory cardiogenic shock who are successfully weaned from VA-ECMO varies between 31% and 76%, depending on the underlying cause [5][6][7][21][22][23][24]. According to recent definitions, we specified successful weaning from VA-ECMO as not requiring further mechanical circulatory support within the following 30 days after VA-ECMO removal [21,22].…”

Section: Weaning Does Not Equal Survivalmentioning

confidence: 99%

“…The proportion of patients with refractory cardiogenic shock who are successfully weaned from VA-ECMO varies between 31% and 76%, depending on the underlying cause [5][6][7][21][22][23][24]. According to recent definitions, we specified successful weaning from VA-ECMO as not requiring further mechanical circulatory support within the following 30 days after VA-ECMO removal [21,22]. However, this clinician's perspective is quite subjective and, evidentially, 20% to 65% of patients weaned from VA-ECMO do not survive until hospital discharge due to insufficient myocardial recovery, primary or secondary (multi-)organ failure, neurological damage, and other comorbidities [6,8,22,24,25].…”

Section: Weaning Does Not Equal Survivalmentioning

confidence: 99%

“…In myocardial infarction, hibernating myocardium should be assessed properly and possibly recovered, for example [7,8]. Baseline MAP should be ≥ 60 mmHg in the absence or with low doses of catecholamines, and a pulsatile arterial waveform maintained for at least 24 h before starting weaning [6][7][8]22,46]. Hemodynamic instability, mechanical ventilation at maximum level with no prospect of de-escalation, catecholamines in high doses, or unchanged high volume and blood product requirements to maintain an adequate circulation advocate against a weaning attempt.…”

Section: Basic Requirements For Promising Weaning Attemptsmentioning

confidence: 99%

“…This is in contrast with renal function. There is an agreement that full recovery is not necessary, but thresholds are not clearly defined [21,22,44,48]. For example, recuperation of an acute tubular necrosis could take weeks, and persistence of anuria does not reflect organ perfusion.…”

Section: Basic Requirements For Promising Weaning Attemptsmentioning

confidence: 99%

“…A PaO 2 /FiO 2 ≥ 200 mmHg, an oxygen fraction delivered by the extracorporeal circuit ≤ 25%, and an oxygen fraction delivered by the ventilator circuit ≤ 60% are reasonable for weaning trials. These measurements should be made with VA-ECMO blood flow at 1.5 L/min and sweep gas flow rate of 1 L/min [7,8,22,42,45,49]. Of note, if the patient suffers from persistent pulmonary compromise but sufficient myocardial recovery could be achieved, switching to a VV-ECMO should be considered.…”

Section: Basic Requirements For Promising Weaning Attemptsmentioning

confidence: 99%

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Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

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Stremmel

Stark

et al. 2020

JCM

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Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.

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Section: Weaning Does Not Equal Survivalmentioning

confidence: 99%

Section: Weaning Does Not Equal Survivalmentioning

confidence: 99%

Section: Basic Requirements For Promising Weaning Attemptsmentioning

confidence: 99%

Section: Basic Requirements For Promising Weaning Attemptsmentioning

confidence: 99%

Section: Basic Requirements For Promising Weaning Attemptsmentioning

confidence: 99%

See 3 more Smart Citations

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

Lüsebrink

Stremmel

Stark

et al. 2020

JCM

View full text Add to dashboard Cite

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Predicting Parameters for Successful Weaning from Veno‐Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock

et al. 2020

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Aims Percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is utilized for patients with cardiogenic shock or cardiac arrest. However, the procedure protocol for weaning from VA-ECMO has not been well established. The present study aimed to determine the usefulness of echocardiographic and pulmonary artery catheter parameters for predicting successful weaning from VA-ECMO in patients with refractory cardiogenic shock. Methods and results We retrospectively studied 50 patients who were hospitalized and supported by VA-ECMO for >48 h between January 2013 and March 2017. Patients successfully weaned from VA-ECMO without reintroduction of VA-ECMO or left ventricular assist device implantation were defined as 30 day survivors. Echocardiographic and pulmonary artery catheter parameters were evaluated when ECMO flow was limited to a maximum of 1.5-2.0 L/min. Twenty-four patients were successfully weaned from VA-ECMO, whereas 26 were not. Fractional shortening, corrected left ventricular ejection time (LVETc, defined as LVET divided by the square root of heart rate), left ventricular outflow tract velocity time integral, and LVETc divided by pulmonary artery wedge pressure (PAWP) were significantly larger in the 30 day survivor groups. Multivariable analysis revealed LVETc∕PAWP as a significant independent predictor of successful weaning (LVETc∕PAWP, odds ratio 0.82, 95% confidence interval 0.71-0.94, P = 0.005). Receiver operating characteristic curve analysis revealed 15.9 as the optimal LVETc∕PAWP for predicting successful weaning (area under the curve 0.82). Conclusions The present findings indicate that LVETc∕PAWP is a potential predictor of successful weaning from VA-ECMO.

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Assessment of cardiac recovery in patients supported with venoarterial extracorporeal membrane oxygenation

et al. 2022

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Aims Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used to support patients in cardiogenic shock (CS). Early determination of disposition is paramount, as longer durations of support have been associated with worse outcomes. We describe a stepwise, bedside weaning protocol to assess cardiopulmonary recovery during VA-ECMO. Methods and resultsOver 1 year, we considered all patients on VA-ECMO for CS for the Weaning Protocol (WP) at our centre. During the WP, patients had invasive haemodynamic monitoring, echocardiography, and blood gas analysis while flow was reduced in 1 LPM decrements. Ultimately, the circuit was clamped for 30 min, and final measures were taken. Patients were described as having durable recovery (DR) if they were free of pharmacological and mechanical support at 30 days postdecannulation. Over 12 months, 34 patients had VA-ECMO for CS. Fourteen patients were eligible for the WP at 4-12 days. Ten patients tolerated full flow reduction and were successfully decannulated. Twenty-four per cent of the entire cohort demonstrated DR with no adverse events during the WP. Patients with DR had significantly higher ejection fraction, cardiac index, and smaller left ventricular size at lowest flow during the WP. Conclusions We describe a safe, stepwise, bedside weaning protocol to assess cardiac recovery during VA-ECMO. Early identification of patients more likely to recover may improve outcomes during ECMO support.

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Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

Cited by 99 publications

References 35 publications

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

Predicting Parameters for Successful Weaning from Veno‐Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock

Assessment of cardiac recovery in patients supported with venoarterial extracorporeal membrane oxygenation

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