SCCM Resource Library-The Patient Weaned off ECMO, and Now?

Video Transcription

I'd like to thank the organizers of the Society of Critical Care Medicine Critical Care Congress for the opportunity to present during the session.  I'll be speaking about the patient Weindorf-Ekmo and now I think we all know this is about long-term outcomes.  These are my contact details and you'll find that my presentation is informed by my work in the pediatric intensive care unit environment.  These are my disclosures.  This is a report from the Extracorporeal Life Support Organization, the ELSO registry.  Established in 1989, you'll see that in the early 90s, there were only a handful of centers  using this invasive resource intensive support in a couple of handfuls of patients per year.  Given the successes in the neonatal and pediatric respiratory population,  ECMO support was extended to using cardiac and subsequently cardiopulmonary arrest, resuscitation situations, and has subsequently become effectively used in adult cardiac and  respiratory populations as well. The most recent year with complete data, 2020, shows that more than 500 centers were reporting  ECMO utilization to the ELSO registry and more than 18,000 individual ECMO runs were reported.  Now, this is particularly important for practitioners interested in critical care because each one of these ECMO runs occurs during an episode of care.  Indeed, an episode of critical care with most ECMO cannulations occurring at some stage into an episode of care, although some can occur in different centers or even in the field.  So the point of ECMO cannulation begins ECMO support, but the full duration of ECMO support  occurs within an episode of care with events before cannulation, during cannulation, during the ECMO support itself, and after ECMO support, all impacting patient outcomes.  In the pediatric ELSO registry report in 2016, we showed that there continued to be a difference in survival according to the indication for ECMO support.  So neonatal respiratory support with much better outcomes than patients supported in the context of ongoing cardiopulmonary arrest, whether they were neonates or children.  In this study, now more than a decade old by Dr. Zabrocki and colleagues, they showed that there  was an increase in complexity of the patient population supported on ECMO in that phase of  increased utilization. In this graphic, the lower portion represents in bar graph form the total  number of patients supported on ECMO, those in light gray being total population, and the black  graph representing patients with comorbidities at the time of ECMO cannulation. The upper portion  of the graphic shows survival outcomes for the patient population supported with the unbroken  line represented here, being the overall survival for the entire cohort, whereas the survival over  time for those patients without comorbidities at the time of ECMO cannulation represented here  with square line, and those with comorbidities represented here with triangular graphic,  show that there's a difference between the overall outcomes of patients according to the presence of  comorbidity at the time of ECMO cannulation, and over the course of the study period that  represented a difference in survival of 63% for those with no comorbidities compared to a survival  rate of 46% for those with comorbidities. So the patient indication for ECMO and underlying comorbidities can impact patient outcomes even before the patient is supported with ECMO.  The ECMO cannulation strategy itself can also have consequences after ECMO support. Dr. Teal  and colleagues noted early in this ELSO registry report that there was an association of carotid  artery cannulation and neurologic injury in pediatric patients supported with VA ECMO.  In the graphic on the left, they show that neonates and infants had higher rates of neurologic injury than older patients in the cohort, and in the graphic on the right,  they show that those patients cannulated with the carotid artery included had a higher rate  of neurologic injury than either those cannulated centrally or those cannulated via the femoral  artery. Indeed, in the study of almost 3,000 neonates and children supported on ECMO over  a two-year period, even after accounting for patient age and severity of illness prior to ECMO,  cannulation of the carotid artery was associated with the outcome of seizures, infarction, or CNS hemorrhage. So the way we cannulate patients to ECMO might impact their ongoing  outcomes. In this more granular study, single center study from Boston Children's Hospital,  the authors showed that in a 28-patient cohort with isolated single hemisphere lesion, the type of arterial ECMO cannulation was associated with the site of the injury.  I'm going to describe this graphic in just a minute. So the peripherally cannulated patients are represented on the left-hand graphic, centrally cannulated patients on the right.  The left cerebral hemisphere is represented in orange, and the right cerebral hemisphere is represented in blue. Anterior, middle, and posterior cerebral artery blood supply is  represented by the wedges as shown. What the authors found is that in those patients with  peripheral right carotid cannulation, there was an association with right hemispheric lesions, more so than left. And in those centrally cannulated patients,  the single hemisphere affected is more likely to be the left side than the right.  This isn't just in pediatric practice. The authors of this study showed that in patients with,  in an adult population, supported on VV ECMO with 31 French versus 27 French dual lumen cannulas,  intracranial hemorrhage was reported more frequently with the larger cannulation strategy.  So it looks like ECMO cannulation strategy matters to the overall sequalae of ECMO support.  In addition, the patient severity of illness and timing of ECMO support has implications for  outcomes. Those patients who were recognized as failing to improve in the context of escalating  conventional supports, and so are cannulated onto ECMO electively, have better outcomes than  those who crash onto ECMO in the context of either acute deterioration or ongoing failure to improve  with conventional supports. Those patients need post-resuscitation care in addition to the ECMO support that they're planned to receive. The timing and process of ECMO weaning and  decannulation also has implications for patient outcomes. Those with clear recovery of end organ  and primary organ function may be weaned slowly and progressively from ECMO versus those who have  a consequence of care that precipitates early decannulation or are decannulated for other  resource or patient factors, but are decannulated prior to recovery and so need ongoing intensive  care beyond that, have different outcomes. In addition, all of the episode of care that occurs  after ECMO support is included as ECMO outcomes. For example, in this study where we looked at  ECMO at the ELSO registry for patients who were decannulated from ECMO for organ recovery, those patients that we'd expect to survive ECMO care,  13% of patients were found to die within the first month after decannulation.  So even those patients who are decannulated from ECMO and expected to survive will only survive  under conditions of optimal ICU care for recovery and rehabilitation through discharge and beyond.  The outcomes most often associated with ECMO are survival to decannulation, hospital discharge,  but we all know that that really, what we're really talking about there is organ recovery  without new injury. Ravi Theodharajan and I have been looking at a Boston Children's Hospital cohort  of patients and have scored them according to organ dysfunction. We use the PSOFA score of  multi-organ dysfunction and when we looked at patients in the 12 hours before ECMO and scored them compared to the 12 hours after ECMO decannulation, we present the patients here  according to survivors versus non-survivors. You can see that although the multi-organ dysfunction  severity of illness as represented by PSOFA was equivalent in the survivors and non-survivors  before ECMO, in the post-ECMO decannulation cohorts, those who recovered end organ injury  and improved their PSOFA score over the duration of ECMO were more likely to survive than those  who did not improve their end organ function and resulted in a higher PSOFA score after ECMO.  And so our outcomes that we discussed then are survival to hospital discharge, recovery of organ function without additional burden of critical illness.  If we break up ECMO care into different aspects of care, for example anticoagulation, bleeding, clotting, hemodynamics and adequate organ perfusion and neurological function, we get  different outcomes that may be important to monitor different aspects of care including survival without new neurological injury and avoidance of hemocompatibility adverse events.  But we all know that when we're caring for an individual patient who's having an episode of critical care, which includes ECMO support, this invasive and resource intensive support,  that what we're aiming for with the patient and their families is return to usual daily activities.  So how do we go about improving ECMO outcomes, so-called ECMO outcomes? I think that these can  start at the institution, community and research community levels. At the institutional level,  it's important to identify and target processes for improvement and examples of these might  include from the neurological aspect of care, avoiding prolonged hypotension, hypoxemia or cardiopulmonary arrest in that pre-ECMO period before cannulation, timing of cannulation.  If the patient needs resuscitation, targeting post-resuscitation care to the particular ECMO  population cohort. Under optimal circumstances, the patient might be managed awake to facilitate  basic clinical examination. However, many patients will need to use surrogates including vital signs  such as NEARs, EEG and imaging for the babies, cranial ultrasounds for older children, CT brains  and certainly CTs in the context of concern for acute neurological events. We also surveilled patients using EEGs to identify either electroencephalographic or clinical seizures  and we manage those actively to try and prevent secondary injury. If we were thinking about optimising processes from a hemodynamic perspective,  as a cardiac intensivist, early left heart decompression and restoration of normal hemodynamics  is near and dear. We also target identification of residual lesions early so that they may be  resolved before the consequences of ECMO care become an issue for individual patients.  Where possible, we'd try to maintain cardiac ejection including lowering ECMO flow to reduce  afterload to the left ventricle as well as the use of low-dose inotropes if required and again that's balanced against the increased myocardial oxygen consumption  used in the context of inotropic support. So this is a genuine balance of processes. And we'd look to evaluate readiness for decannulation at the point where recovery  of function is apparent without inducing additional myocardial injury to facilitate that optimal weaning and decannulation to optimise outcomes post-ECMO. Because again,  all ECMO support happens in the context of an episode of critical care and any outcome of this  targeted support is dependent on pre-ECMO factors, the ECMO support and consequences of care  as well as optimal ICU care being delivered for recovery and rehabilitation beyond the ECMO support  and that should be targeted to the type of indication, type of organ failure that the patients had that precipitated ECMO support to start with. As a community, we'd look to  start with. As a community, we need to be invested in monitoring long-term outcomes.  These are the ELSO guidelines for follow-up after neonatal and pediatric ECMO reported out last year and I'd recommend review for anyone interested. The ELSO guidelines  identify pre-ECMO, on-ECMO and post-ECMO factors that all impact the long-term follow-up and  outcomes of our patients and the guidelines recommend domains of interest, assessments of  tests and action interventions according to age groups. So on this page, infancy and preschool,  this page school age and this page adolescents, all available in the manuscript for review.  Indeed, improving ECMO outcomes also comes with a description of the data elements that we're  using for our ECMO studies. We have to tell each other what our ECMO support looks like.  As a function of the Pediatric ECMO Anticoagulation Collaborative, Dr. Mazynski and I co-lead the Peace Consensus Series and we were invested in developing core research priorities  and common data elements for pediatric ECMO anticoagulation studies. We were thinking about this particularly in the context of some of the group's systematic reviews. This is group  one, the impact of ECMO circuit and components on anticoagulation management. This is the PICO  question that we used and the keywords that were addressed as part of the systematic review.  What we found was that while 29 papers met inclusion criteria of 32 years included,  of the studies identified, six papers didn't specify a cannulation mode, the A, the V, central or peripheral, simply not specified. An additional four papers appeared to include  VAD patients and patients supported with ECMO without actually identifying cannulation strategy  mode or whether or not an oxygenator was in place associated with outcomes. PUN technology wasn't  specified really and circuit coding, which is important for bleeding and clotting outcomes, as well as anticoagulant usage, weren't specified in more than half the population.  So as we move forward with research, it's important to consider how we want to think about core outcomes for ECMO studies. In the adult populations, the International ECMO Network  has identified domains and outcome measures associated as core for those patients supported  on ECMO. In the pediatric populations, there are multiple now core outcome sets for children according to the type of indication that the patients had for their critical illness.  This is one of those, a core outcome set for cardiac arrest in children. They address similar issues of the impact of the critical illness on their health, survival,  life impact, resource use, and economic impact, along with different domains.  And the core outcome sets already identified for critically ill children of different ideologies  target outcomes, measures, and methods for different populations. And as we move forward as a pediatric critical, as those practitioners invested in the care of children who are  critically ill, investing in outcome measures according to etiology may actually make more sense  for our populations. Because at the end of the day, we're all invested in the patient that we're  looking after as they move through their episode of critical illness, of which ECMO support may  be only a small portion to achieve the best possible outcomes for the patient and family. Thank you for your attention. I'm happy to be contacted about any part of the presentation.

Video Summary

The speaker presents on the topic of long-term outcomes for patients receiving ECMO (extracorporeal membrane oxygenation) support. They discuss the growth and use of ECMO in various populations, including neonatal, pediatric, and adult patients. The speaker emphasizes the importance of considering patient factors, such as comorbidities, in predicting outcomes. They also highlight the impact of ECMO cannulation strategy on patient outcomes, particularly in relation to neurological injury. The timing and process of ECMO weaning and decannulation are also discussed as important factors in patient outcomes. The speaker suggests that improving ECMO outcomes requires a focus on institutional processes, such as avoiding prolonged hypotension and targeting post-resuscitation care, as well as community efforts in monitoring long-term outcomes. They also emphasize the need for standardized data elements and core outcome sets in ECMO research. Overall, the goal is to achieve optimal outcomes for patients and their families.

Asset Subtitle

Cardiovascular, Procedures, 2022

Asset Caption

Extracorporeal life support (ECLS) has been established as an advanced therapeutic alternative for respiratory failure, cardiogenic shock, and failure to wean off cardiopulmonary bypass. With a global increase in expertise, extracorporeal membrane oxygenation (ECMO) and other ECLS options have been explored in other patients’ indications. This session aims to increase understanding of future possibilities and indications for ECMO and ECLS toward improving individual outcomes.

Meta Tag

Content Type Presentation

Knowledge Area Cardiovascular

Knowledge Area Procedures

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Cardiothoracic Critical Care

Membership Level Select

Tag Shock

Tag Extracorporeal Membrane Oxygenation ECMO

Tag Cardiothoracic Critical Care

Year 2022

Keywords

ECMO

long-term outcomes

patient factors

neurological injury

ECMO weaning

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.