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Venovenous extracorporeal membrane oxygenation in adult respiratory failure

View Article: PubMed Central - PubMed

ABSTRACT

Despite a potentially effective therapy for adult respiratory failure, a general agreement on venovenous extracorporeal membrane oxygenation (VV-ECMO) has not been reached among institutions due to its invasiveness and high resource usage. To establish consensus on the timing of intervention, large ECMO organizations have published the respiratory extracorporeal membrane oxygenation survival prediction (RESP) score and the ECMOnet score, which allow users to predict hospital mortality for candidates with their pre-ECMO presentations. This study was aimed to test the predictive powers of these published scores in a medium-sized cohort enrolling adults treated with VV-ECMO for acute respiratory failure, and develop an institutional prediction model under the framework of the 3 scores if a superior predictive power could be achieved. This retrospective study included 107 adults who received VV-ECMO for severe acute respiratory failure (a PaO2/FiO2 ratio <70 mm Hg) in a tertiary referral center from 2007 to 2015. Essential demographic and clinical data were collected to calculate the RESP score, the ECMOnet score, and the sequential organ failure assessment (SOFA) score before VV-ECMO. The predictive power of hospital mortality of each score was presented as the area under receiver-operating characteristic curve (AUROC). The multivariate logistic regression was used to develop an institutional prediction model. The surviving to discharge rate was 55% (n = 59). All of the 3 published scores had a real but poor predictive power of hospital mortality in this study. The AUROCs of RESP score, ECMOnet score, and SOFA score were 0.662 (P = 0.004), 0.616 (P = 0.04), and 0.667 (P = 0.003), respectively. An institutional prediction model was established from these score parameters and presented as follows: hospital mortality (Y) = −3.173 + 0.208 × (pre-ECMO SOFA score) + 0.148 × (pre-ECMO mechanical ventilation day) + 1.021 × (immunocompromised status). Compared with the 3 scores, the institutional model had a significantly higher AUROC (0.779; P < 0.001). The 3 published scores provide valuable information about the poor prognostic factors for adult respiratory ECMO. Among the score parameters, duration of mechanical ventilation, immunocompromised status, and severity of organ dysfunction may be the most important prognostic factors of VV-ECMO used for adult respiratory failure.

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Flow chart of patient distribution and managements during venovenous extracorporeal membrane oxygenation. ARF = acute respiratory failure, FiO2 = fraction of inspired oxygen, PaO2 = arterial oxygen tension, PEEP = positive end-expiratory pressure, PIP = peak inspiratory pressure;, RR = respiratory rate, SaO2 = arterial oxygen saturation, SpO2 = oxyhemoglobin saturation by pulse oximetry, VT = tidal volume, VV-ECMO = venovenous extracorporeal membrane oxygenation.
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Figure 1: Flow chart of patient distribution and managements during venovenous extracorporeal membrane oxygenation. ARF = acute respiratory failure, FiO2 = fraction of inspired oxygen, PaO2 = arterial oxygen tension, PEEP = positive end-expiratory pressure, PIP = peak inspiratory pressure;, RR = respiratory rate, SaO2 = arterial oxygen saturation, SpO2 = oxyhemoglobin saturation by pulse oximetry, VT = tidal volume, VV-ECMO = venovenous extracorporeal membrane oxygenation.

Mentions: We have thoroughly described our techniques and therapeutic protocol of VV-ECMO in our previous publications.[12,19,20]Figure 1 summarizes the major therapeutic goals of our VV-ECMO. We use the Capiox emergent bypass system (Terumo Inc., Tokyo, Japan) and the 2 cannula method (DLP Medtronic, Minneapolis, MN; femoral inflow cannula: 19–23 French, jugular outflow cannula: 17–21 French) to perform VV-ECMO via percutaneous cannulation. Initially, we maximize the sweep gas flow (10 L/min, pure oxygen) to rapidly remove the CO2, and gradually increase the ECMO pump flow to achieve a steady flow that carries the best pulse oximetry-detected oxyhemoglobin saturation (SpO2). To rest the lung on VV-ECMO, we change the setting of MV to a lung-protective level step by step. At first, we use a pressure-control mode with a PIP ≤35 cm H2O and a moderate PEEP (often 10–14 cm H2O) to obtain an estimated tidal volume ≤6 mL/kg/min on VV-ECMO. Then we take arterial and the postoxygenator blood samples to adjust the sweep gas flow and the MV FiO2. We also adjust the pump speed dynamically to provide a best SpO2 (>90%) and SaO2 (>85%) to gradually taper the PIP to 30 cm H2O and MV FiO2 to 0.4. The hemoglobin is kept at a level of ≥10 g/dL to increase the capacity of oxygenation. Keeping a modest anticoagulation on VV-ECMO with systemic heparinization is necessary except in the hemorrhagic patients. The therapeutic range of activated partial thromboplastin time is 40 to 55 seconds. In patients showing significant improvements, we would try to wean the patient from VV-ECMO as long as the arterial oxygenation could be maintained under the lung-protective ventilation, with a MV FiO2 ≤0.6.


Venovenous extracorporeal membrane oxygenation in adult respiratory failure
Flow chart of patient distribution and managements during venovenous extracorporeal membrane oxygenation. ARF = acute respiratory failure, FiO2 = fraction of inspired oxygen, PaO2 = arterial oxygen tension, PEEP = positive end-expiratory pressure, PIP = peak inspiratory pressure;, RR = respiratory rate, SaO2 = arterial oxygen saturation, SpO2 = oxyhemoglobin saturation by pulse oximetry, VT = tidal volume, VV-ECMO = venovenous extracorporeal membrane oxygenation.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4998339&req=5

Figure 1: Flow chart of patient distribution and managements during venovenous extracorporeal membrane oxygenation. ARF = acute respiratory failure, FiO2 = fraction of inspired oxygen, PaO2 = arterial oxygen tension, PEEP = positive end-expiratory pressure, PIP = peak inspiratory pressure;, RR = respiratory rate, SaO2 = arterial oxygen saturation, SpO2 = oxyhemoglobin saturation by pulse oximetry, VT = tidal volume, VV-ECMO = venovenous extracorporeal membrane oxygenation.
Mentions: We have thoroughly described our techniques and therapeutic protocol of VV-ECMO in our previous publications.[12,19,20]Figure 1 summarizes the major therapeutic goals of our VV-ECMO. We use the Capiox emergent bypass system (Terumo Inc., Tokyo, Japan) and the 2 cannula method (DLP Medtronic, Minneapolis, MN; femoral inflow cannula: 19–23 French, jugular outflow cannula: 17–21 French) to perform VV-ECMO via percutaneous cannulation. Initially, we maximize the sweep gas flow (10 L/min, pure oxygen) to rapidly remove the CO2, and gradually increase the ECMO pump flow to achieve a steady flow that carries the best pulse oximetry-detected oxyhemoglobin saturation (SpO2). To rest the lung on VV-ECMO, we change the setting of MV to a lung-protective level step by step. At first, we use a pressure-control mode with a PIP ≤35 cm H2O and a moderate PEEP (often 10–14 cm H2O) to obtain an estimated tidal volume ≤6 mL/kg/min on VV-ECMO. Then we take arterial and the postoxygenator blood samples to adjust the sweep gas flow and the MV FiO2. We also adjust the pump speed dynamically to provide a best SpO2 (>90%) and SaO2 (>85%) to gradually taper the PIP to 30 cm H2O and MV FiO2 to 0.4. The hemoglobin is kept at a level of ≥10 g/dL to increase the capacity of oxygenation. Keeping a modest anticoagulation on VV-ECMO with systemic heparinization is necessary except in the hemorrhagic patients. The therapeutic range of activated partial thromboplastin time is 40 to 55 seconds. In patients showing significant improvements, we would try to wean the patient from VV-ECMO as long as the arterial oxygenation could be maintained under the lung-protective ventilation, with a MV FiO2 ≤0.6.

View Article: PubMed Central - PubMed

ABSTRACT

Despite a potentially effective therapy for adult respiratory failure, a general agreement on venovenous extracorporeal membrane oxygenation (VV-ECMO) has not been reached among institutions due to its invasiveness and high resource usage. To establish consensus on the timing of intervention, large ECMO organizations have published the respiratory extracorporeal membrane oxygenation survival prediction (RESP) score and the ECMOnet score, which allow users to predict hospital mortality for candidates with their pre-ECMO presentations. This study was aimed to test the predictive powers of these published scores in a medium-sized cohort enrolling adults treated with VV-ECMO for acute respiratory failure, and develop an institutional prediction model under the framework of the 3 scores if a superior predictive power could be achieved. This retrospective study included 107 adults who received VV-ECMO for severe acute respiratory failure (a PaO2/FiO2 ratio <70 mm Hg) in a tertiary referral center from 2007 to 2015. Essential demographic and clinical data were collected to calculate the RESP score, the ECMOnet score, and the sequential organ failure assessment (SOFA) score before VV-ECMO. The predictive power of hospital mortality of each score was presented as the area under receiver-operating characteristic curve (AUROC). The multivariate logistic regression was used to develop an institutional prediction model. The surviving to discharge rate was 55% (n = 59). All of the 3 published scores had a real but poor predictive power of hospital mortality in this study. The AUROCs of RESP score, ECMOnet score, and SOFA score were 0.662 (P = 0.004), 0.616 (P = 0.04), and 0.667 (P = 0.003), respectively. An institutional prediction model was established from these score parameters and presented as follows: hospital mortality (Y) = −3.173 + 0.208 × (pre-ECMO SOFA score) + 0.148 × (pre-ECMO mechanical ventilation day) + 1.021 × (immunocompromised status). Compared with the 3 scores, the institutional model had a significantly higher AUROC (0.779; P < 0.001). The 3 published scores provide valuable information about the poor prognostic factors for adult respiratory ECMO. Among the score parameters, duration of mechanical ventilation, immunocompromised status, and severity of organ dysfunction may be the most important prognostic factors of VV-ECMO used for adult respiratory failure.

No MeSH data available.


Related in: MedlinePlus