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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.

No MeSH data available.


Survival curve on venovenous extracorporeal membrane oxygenation (ECMO).
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Figure 2: Survival curve on venovenous extracorporeal membrane oxygenation (ECMO).

Mentions: The mean age of the 107 patients was 55 ± 16 years and 73% (n = 78) of them were male. Figure 1 shows the flowchart of patient distribution. The etiologies of ARF were categorized into 5 groups: bacterial pneumonia (n = 36; 3 were fungal pneumonia, and the top 3 bacteria were Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter baumannii); viral pneumonia (n = 18; all influenza A); trauma and inhalation injury (n = 21); aspiration pneumonitis (n = 3; 2 after surgeries of gastrointestinal tract and 1 had tracheoesophageal fistula); and others (n = 29; 16 were pneumonia without identifiable pathogens, 4 were pulmonary hemorrhage caused by autoimmune vasculitis, 7 were pulmonary edema in patients with chronic renal failure or after cardiac interventions, 1 was neurogenic pulmonary edema after cerebral aneurysm intervention, and 1 was pneumonitis after near-drowning). The median duration of MV before VV-ECMO was 3 (1–8) days. The mean values of pre-ECMO SOFA score, RESP score, and ECMOnet score were 11 ± 2, 0 ± 3, and 5 ± 2, respectively. Seventy-three per cent (n = 78) of the patients were weaned off VV-ECMO and 55% (n = 59) of them survived to hospital discharge. Eight patients died for the major hemorrhagic complications (intracranial hemorrhages in 3 patients, intra-abdominal/retroperitoneal hemorrhages in 2 patients, diffuse mucosal bleedings in 2 patients, and hemothorax in 1 patient) during the support of VV-ECMO. The other nonsurvivors (n = 40) showed a dependence on respiratory supports, either VV-ECMO or MV, and died with sepsis or multiple organ failure. The median values of ECMO stay and hospital stay were 9 (5–15) days and 43 (26–47) days, respectively. The actual survivals of RESP score were 75% in class I (score ≥6), 68% in class II (score 3–5), 63% in class III (score −1 to 2), 24% in class IV (score −5 to -2), and 38% in class V (score ≥−6) in this study. Figure 2 demonstrates the survival curve on VV-ECMO. Table 1 shows the results of univariate comparisons of the score parameters between the survivors and nonsurvivors. With ROC curve analysis, the discriminative powers on hospital mortality of the SOFA score, RESP score, and ECMOnet score were all significant but poor in our patients (AUROC: 0.667, 0.662, and 0.616, respectively).


Venovenous extracorporeal membrane oxygenation in adult respiratory failure
Survival curve on venovenous extracorporeal membrane oxygenation (ECMO).
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 2: Survival curve on venovenous extracorporeal membrane oxygenation (ECMO).
Mentions: The mean age of the 107 patients was 55 ± 16 years and 73% (n = 78) of them were male. Figure 1 shows the flowchart of patient distribution. The etiologies of ARF were categorized into 5 groups: bacterial pneumonia (n = 36; 3 were fungal pneumonia, and the top 3 bacteria were Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter baumannii); viral pneumonia (n = 18; all influenza A); trauma and inhalation injury (n = 21); aspiration pneumonitis (n = 3; 2 after surgeries of gastrointestinal tract and 1 had tracheoesophageal fistula); and others (n = 29; 16 were pneumonia without identifiable pathogens, 4 were pulmonary hemorrhage caused by autoimmune vasculitis, 7 were pulmonary edema in patients with chronic renal failure or after cardiac interventions, 1 was neurogenic pulmonary edema after cerebral aneurysm intervention, and 1 was pneumonitis after near-drowning). The median duration of MV before VV-ECMO was 3 (1–8) days. The mean values of pre-ECMO SOFA score, RESP score, and ECMOnet score were 11 ± 2, 0 ± 3, and 5 ± 2, respectively. Seventy-three per cent (n = 78) of the patients were weaned off VV-ECMO and 55% (n = 59) of them survived to hospital discharge. Eight patients died for the major hemorrhagic complications (intracranial hemorrhages in 3 patients, intra-abdominal/retroperitoneal hemorrhages in 2 patients, diffuse mucosal bleedings in 2 patients, and hemothorax in 1 patient) during the support of VV-ECMO. The other nonsurvivors (n = 40) showed a dependence on respiratory supports, either VV-ECMO or MV, and died with sepsis or multiple organ failure. The median values of ECMO stay and hospital stay were 9 (5–15) days and 43 (26–47) days, respectively. The actual survivals of RESP score were 75% in class I (score ≥6), 68% in class II (score 3–5), 63% in class III (score −1 to 2), 24% in class IV (score −5 to -2), and 38% in class V (score ≥−6) in this study. Figure 2 demonstrates the survival curve on VV-ECMO. Table 1 shows the results of univariate comparisons of the score parameters between the survivors and nonsurvivors. With ROC curve analysis, the discriminative powers on hospital mortality of the SOFA score, RESP score, and ECMOnet score were all significant but poor in our patients (AUROC: 0.667, 0.662, and 0.616, respectively).

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.