Editorials

Should We “Rescue” Patients With 2009 Influenza A(H1N1) and Lung Injury From Conventional Mechanical Ventilation?

Survival of patients on ECMO has remained stable in every population. Laboratory values predictors of survival are required to improve patient care.

Clinical Looking Glass software was used to assess Electronic Medical Records (EMRs) of patients at Albert Einstein College of Medicine, Montefiore Medical Center (2007–2014).

Our population comprises of 166 adults and was divided in survivors and non-survivors, within 30 days. Indications for ECMO were cardiac (65%), respiratory (25%) and infectious diseases (< 10%). Eighty six patients (51.8%) survived the procedure. Gender, body weight, ejection fraction, diastolic blood pressure, and socio-economic status did not differ among survivors and non-survivors. In contrast, younger patients (45 yo vs 55 yo, p = 0.0001) and higher systolic blood pressure (115 mm Hg vs 103 mm Hg, p = 0.025) have favorable outcome. Univariate analysis shows that pre-cannulation values for creatinine (p = 0.0003), chloride (p = 0.009), bicarbonate (p = 0.015) and pH (p = 0.03) have prognostic value. Post-cannulation aPTT, pH, platelet and lymphocyte counts also have discriminative power. Notably, multiple logistic regressions for Multivariate Analysis identified chloride (OR 1.07; 95% CI 1.02–1.13; p = 0.004), pH (OR 3.35; 95% CI 1.89–5.9; p < 0.0001) and aPTT (OR 0.98; 95% CI 0.976–0.998; p = 0.024) as independent risk factors for 30-day mortality. These results imply that pre-existing renal conditions and hemostatic dysregulation contribute to poor outcome. Finally, patients on VV-ECMO have increase odds of survival (OR 1.88; 95% CI 1.06–3.34; p = 0.029).

Laboratory markers identified herein may guide the management of patients on ECMO.

The use of extracorporeal membrane oxygenation (ECMO) support for cardiac and respiratory failure has increased in recent years. Improvements in ECMO oxygenator and pump technologies have aided this increase in utilization. Additionally, reports of successful outcomes in supporting patients with respiratory failure during the 2009 H1N1 pandemic and reports of ECMO during cardiopulmonary resuscitation have led to increased uptake of ECMO. Patients requiring ECMO are a heterogenous group of critically ill patients with cardiac and respiratory failure. Bleeding and thrombotic complications remain a leading cause of morbidity and mortality in patients on ECMO. In this review, we describe the mechanisms and management of hemostatic, thrombotic and hemolytic complications during ECMO support.

The purpose of this review is to examine the indications of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). This technique of oxygenation has significantly increased worldwide with the H1N1 flu pandemic. The goal of ECMO is to maintain a safe level of oxygenation and controlled respiratory acidosis under protective ventilation. The enthusiasm for ECMO should not obscure the consideration for potential associated complications. Before widespread diffusion of ECMO, new trials should test the efficacy of early initiation or CO₂ removal in addition to, or even as an alternative to mechanical ventilation for severe ARDS.

L’objectif de cette revue est d’examiner les indications des membranes d’oxygénation extracorporelle (ECMO) lors d’un syndrome de détresse respiratoire aiguë (SDRA). Le recours à cette technique d’oxygénation a augmenté de manière significative à travers le monde depuis la pandémie grippale H1N1. Le but de l’ECMO est de maintenir un niveau acceptable d’oxygénation, ainsi que de contrôler l’acidose respiratoire sous ventilation protectrice. Cet enthousiasme pour l’ECMO ne doit pas faire négliger les complications potentielles associées à la technique. Avant d’élargir le recours à l’ECMO, de nouvelles études devront tester l’efficacité d’une utilisation précoce ou d’une épuration du CO₂ en complément ou à la place de la ventilation mécanique lors d’un SDRA sévère.

The events of the 2009 influenza pandemic sparked discussion regarding the need to optimize delivery of care to those most severely ill. We propose in this conceptual study that a tiered regionalization care system be instituted for patients with severe acute respiratory distress syndrome. Such system would be a component of national pandemic plans and could also be used in day-to-day operations.

The mortality and morbidity of patients with severe acute respiratory distress syndrome (ARDS) remains high despite the advances in intensive care practice. The low-tidal-volume ventilation strategy (ARDS net protocol) has been shown to be effective in improving survival. Unfortunately, however, some patients have such severe ARDS that they cannot be managed with the ARDS net strategy. In these patients, rescue therapies such as high-frequency ventilation, prone ventilation, nitric oxide, and extracorporeal membrane oxygenation (ECMO) are considered. The CESAR trial has shown that an ECMO-based protocol improved survival without severe disability as compared with conventional ventilation. The recent increased incidence of severe respiratory failure due to H1N1 influenza pandemic has led to an increased use of ECMO. Although several reports showed ECMO use to be encouraging, some scepticism remains. In this article, we reviewed the usefulness of ECMO in patients with severe ARDS in the light of current evidence.